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Osude N, Pagidipati NJ. A New Age for Secondary Prevention: Optimal Medical Therapy for Stable Ischemic Heart Disease Among Patients with Diabetes and/or Obesity. Med Clin North Am 2024; 108:469-487. [PMID: 38548458 DOI: 10.1016/j.mcna.2023.11.003] [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] [Indexed: 04/02/2024]
Abstract
Patients with type 2 diabetes and/or obesity and established cardiovascular disease are at increased risk for recurrent cardiovascular events. The indications of glucagon-like peptide-1 receptor agonists (GLP-1RAs) and sodium-glucose cotransporter-2 inhibitors have been expanded in the last decade due to benefit in cardiovascular outcome trials and are now considered guideline-recommended therapy for patients with type 2 diabetes and cardiovascular disease. Emerging data have begun to suggest that GLP-1RAs can decrease major adverse cardiovascular events among patients with obesity without diabetes. Overall, prescription of these agents remains low, despite being key to improve disparities in recurrent cardiovascular events. In this review, we discuss optimal medical therapy for secondary prevention for stable ischemic heart disease.
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Affiliation(s)
- Nkiru Osude
- Cardiovascular Division, Duke University, 2301 Erwin Road, Durham, NC 27710, USA.
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Rao VN, Sharma A, Stebbins A, Buse JB, Katona BG, Pagidipati NJ, Holman RR, Hernandez A, Mentz RJ, Lopes RD. Regional variation in cause of death in patients with type 2 diabetes: Insights from EXSCEL. Am Heart J 2024; 271:123-135. [PMID: 38395292 DOI: 10.1016/j.ahj.2024.02.013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/17/2024] [Accepted: 02/17/2024] [Indexed: 02/25/2024]
Abstract
AIMS Type 2 diabetes (T2D) is a risk factor for cardiovascular and non-cardiovascular mortality. However, global distribution of cause-specific deaths in T2D is poorly understood. We characterized cause-specific deaths by geographic region among individuals with T2D at risk for cardiovascular disease (CVD). METHODS AND RESULTS The international EXSCEL trial included 14,752 participants with T2D (73% with established CVD). We identified the proportion of deaths over 5-year follow-up attributed to cardiovascular and non-cardiovascular causes, and associated risk factors. During median 3.2-year follow-up, 1,091 (7.4%) participants died. Adjudicated causes of death were 723 cardiovascular (66.3% of deaths), including 252 unknown, and 368 non-cardiovascular (33.7%). Most deaths occurred in North America (N = 356/9.6% across region) and Eastern Europe (N = 326/8.1%), with fewest in Asia/Pacific (N = 68/4.4%). The highest proportional cause-specific deaths by region were sudden cardiac in Asia/Pacific (23/34% of regional deaths) and North America (86/24%); unknown in Eastern Europe (90/28%) and Western Europe (39/21%); and non-malignant non-cardiovascular in Latin America (48/31%). Cox proportional hazards model for adjudicated causes of death showed prognostic risk factors (hazard ratio [95% CI]) for cardiovascular and non-cardiovascular deaths, respectively: heart failure 2.04 (1.72-2.42) and 1.86 (1.46-2.39); peripheral artery disease 1.83 (1.54-2.18) and 1.78 (1.40-2.26); and current smoking status 1.61 (1.29-2.01) and 1.77 (1.31-2.40). CONCLUSIONS In a contemporary T2D trial population, with and without established CVD, leading causes of death varied by geographic region. Underlying mechanisms leading to variability in cause of death across geographic regions and its impact on clinical trial endpoints warrant future research.
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Affiliation(s)
- Vishal N Rao
- Division of Cardiovascular Medicine, Medical University of South Carolina and the Ralph H. Johnson Department of Veterans Affairs Medical Center, Charleston, SC
| | - Abhinav Sharma
- Division of Cardiology, McGill University Health Centre, Montreal, Quebec, Canada
| | - Amanda Stebbins
- Duke Clinical Research Institute, Duke University School of Medicine, Durham, NC
| | - John B Buse
- Department of Medicine, University of North Carolina School of Medicine, Chapel Hill, NC
| | | | - Neha J Pagidipati
- Duke Clinical Research Institute, Duke University School of Medicine, Durham, NC; Division of Cardiology, Duke University School of Medicine, Durham, NC
| | - Rury R Holman
- Diabetes Trials Unit, Radcliffe Department of Medicine, University of Oxford, Oxford, UK
| | - Adrian Hernandez
- Duke Clinical Research Institute, Duke University School of Medicine, Durham, NC; Division of Cardiology, Duke University School of Medicine, Durham, NC
| | - Robert J Mentz
- Duke Clinical Research Institute, Duke University School of Medicine, Durham, NC; Division of Cardiology, Duke University School of Medicine, Durham, NC
| | - Renato D Lopes
- Duke Clinical Research Institute, Duke University School of Medicine, Durham, NC; Division of Cardiology, Duke University School of Medicine, Durham, NC.
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Harrington J, Sattar N, Felker GM, Januzzi JL, Lam CSP, Pagidipati NJ, Pandey A, Van Spall HGC, McGuire DK. Putting More Weight on Obesity Trials in Heart Failure. Curr Heart Fail Rep 2024:10.1007/s11897-024-00655-z. [PMID: 38619690 DOI: 10.1007/s11897-024-00655-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 03/04/2024] [Indexed: 04/16/2024]
Abstract
PURPOSE OF REVIEW To review ongoing and planned clinical trials of weight loss among individuals with or at high risk of heart failure. RECENT FINDINGS Intentional weight loss via semaglutide among persons with heart failure and preserved ejection fraction and obesity significantly improves weight loss and health status as assessed by the KCCQ-CSS score and is associated with improvements in 6-min walk test. Ongoing and planned trials will explore the role of intentional weight loss with treatments such as semaglutide or tirzepatide for individuals with heart failure across the entire ejection fraction spectrum.
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Affiliation(s)
- Josephine Harrington
- Division of Cardiology, Department of Internal Medicine, Duke University Medical Center, Durham, NC, USA.
- Duke Clinical Research Institute, 300 W. Morris St, Durham, NC, 27701, USA.
| | - Naveed Sattar
- School of Cardiovascular and Metabolic Health, University of Glasgow, Glasgow, UK
| | - G Michael Felker
- Division of Cardiology, Department of Internal Medicine, Duke University Medical Center, Durham, NC, USA
- Duke Clinical Research Institute, 300 W. Morris St, Durham, NC, 27701, USA
| | - James L Januzzi
- Baim Institute for Clinical Research, Boston, MA, USA
- Cardiology Division, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Carolyn S P Lam
- Cardiology Division, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
- National Heart Centre Singapore and Duke-National University of Singapore, Bukit Merah, Singapore
| | - Neha J Pagidipati
- Division of Cardiology, Department of Internal Medicine, Duke University Medical Center, Durham, NC, USA
- Duke Clinical Research Institute, 300 W. Morris St, Durham, NC, 27701, USA
| | - Ambarish Pandey
- Division of Cardiology, Department of Internal Medicine, University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - Harriette G C Van Spall
- Baim Institute for Clinical Research, Boston, MA, USA
- Research Institute of St. Joe's, Hamilton, Canada
- McMaster University, Hamilton, Canada
| | - Darren K McGuire
- Division of Cardiology, Department of Internal Medicine, University of Texas Southwestern Medical Center, Dallas, TX, USA
- Parkland Health and Hospital System, Dallas, TX, USA
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Harrington J, Felker GM, Januzzi JL, Lam CSP, Lingvay I, Pagidipati NJ, Sattar N, Van Spall HGC, Verma S, McGuire DK. Worth Their Weight? An Update on New and Emerging Pharmacologic Agents for Obesity and Their Potential Role for Persons with Cardiac Conditions. Curr Cardiol Rep 2024; 26:61-71. [PMID: 38551786 DOI: 10.1007/s11886-023-02016-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 12/21/2023] [Indexed: 04/05/2024]
Abstract
PURPOSE OF REVIEW Obesity is associated with cardiovascular (CV) conditions, including but not limited to atherosclerotic disease, heart failure, and atrial fibrillation. Despite this, the impact of intentional weight loss on CV outcomes for persons with obesity and established CV conditions remains poorly studied. New and emerging pharmacologic therapies for weight loss primarily targeting the incretin/nutrient sensing axes induce substantial and sustained weight loss. The glucagon-like-peptide 1 receptor agonists (GLP-1 RA) liraglutide and semaglutide have US FDA approval for the treatment of obesity, and the application for an obesity indication for the dual GLP-1/glucose-dependent insulinotropic polypeptide (GIP) receptor agonist tirzepatide is presently under FDA review. Extensive phase II and IIIa randomized controlled trials are underway evaluating permutations of combined GLP-1 RA, GIP receptor agonist, GIP receptor antagonist, and glucagon receptor agonists. Clinical outcome trials of these therapies in persons with obesity at high risk of established CV conditions should make it possible to estimate the role of intentional weight loss in managing CV risk via these medications. RECENT FINDINGS High-dose once weekly injectable semaglutide (2.4 mg/week) use among persons with obesity and heart failure with preserved ejection fraction was effective at both reducing weight and improving health status; exercise capacity was also improved. Ongoing CV outcome trials of oral semaglutide and once weekly injectable tirzepatide will help to establish the role of these therapies among persons with other CV conditions. In addition to these two therapies targeting a CV claim or indication, many other new therapeutics for weight loss, as reviewed, are currently in development. The impact of pharmacologic-induced weight loss on CV conditions for persons with obesity and established CV conditions is currently under investigation for multiple agents. These therapies may offer new avenues to manage CV risk in persons with obesity and with established or at high risk for CV disease.
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Affiliation(s)
- Josephine Harrington
- Division of Cardiology, Department of Internal Medicine, Duke University Medical Center, Durham North Carolina, Durham, USA.
- Duke Clinical Research Institute, Durham, NC, USA.
| | - G Michael Felker
- Division of Cardiology, Department of Internal Medicine, Duke University Medical Center, Durham North Carolina, Durham, USA
- Duke Clinical Research Institute, Durham, NC, USA
| | - James L Januzzi
- Cardiology Division, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
- Baim Institute for Clinical Research, Boston, MA, USA
| | - Carolyn S P Lam
- Baim Institute for Clinical Research, Boston, MA, USA
- National Heart Centre Singapore and Duke-National University of Singapore, Singapore, Singapore
| | - Ildiko Lingvay
- Division of Endocrinology, Department of Internal Medicine, University of Texas Southwestern Medical Center, Dallas, TX, USA
- Peter O'Donnell Jr School of Public Health, University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - Neha J Pagidipati
- Division of Cardiology, Department of Internal Medicine, Duke University Medical Center, Durham North Carolina, Durham, USA
- Duke Clinical Research Institute, Durham, NC, USA
| | - Naveed Sattar
- School of Cardiovascular and Metabolic Health, University of Glasgow, Glasgow, UK
| | - Harriette G C Van Spall
- Baim Institute for Clinical Research, Boston, MA, USA
- Research Institute of St. Joseph's, Hamilton, Canada
- McMaster University Faculty of Health Sciences, Hamilton, Canada
| | - Subodh Verma
- Division of Cardiac Surgery, St Michael's Hospital of Unity Health Toronto, Toronto, ON, Canada
- Department of Surgery, and Pharmacology and Toxicology, University of Toronto, Toronto, ON, Canada
| | - Darren K McGuire
- Division of Cardiology, Department of Internal Medicine, University of Texas Southwestern Medical Center, Dallas, TX, USA
- Parkland Health, Dallas, TX, USA
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5
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Harrington J, Rao VN, Leyva M, Oakes M, Mentz RJ, Bosworth HB, Pagidipati NJ. Improving Guideline-Directed Medical Therapy for Patients With Heart Failure With Reduced Ejection Fraction: A Review of Implementation Strategies. J Card Fail 2024; 30:376-390. [PMID: 38142886 DOI: 10.1016/j.cardfail.2023.12.004] [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: 09/12/2023] [Revised: 12/08/2023] [Accepted: 12/12/2023] [Indexed: 12/26/2023]
Abstract
Despite recent advances in the use of guideline-directed medical therapy (GDMT) for patients with heart failure with reduced ejection fraction (HFrEF), achievement of target GDMT use and up-titration to goal dosages continue to be modest. In recent years, a number of interventional approaches to improve the usage of GDMT have been published, but many are limited by single-center experiences with small sample sizes. However, strategies including the use of multidisciplinary teams, dedicated GDMT titration algorithms and clinician audits with feedback have shown promise. There remains a critical need for large, rigorous trials to assess the utility of differing interventions to improve the use and titration of GDMT in HFrEF. Here, we review existing literature in GDMT implementation for those with HFrEF and discuss future directions and considerations in the field.
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Affiliation(s)
- Josephine Harrington
- Department of Medicine, Division of Cardiology Duke University, Durham, NC; Duke Clinical Research Institute, Durham, NC.
| | - Vishal N Rao
- Department of Medicine, Division of Cardiology Duke University, Durham, NC; Duke Clinical Research Institute, Durham, NC
| | - Monica Leyva
- Department of Population Health Sciences, Durham, NC
| | - Megan Oakes
- Department of Population Health Sciences, Durham, NC
| | - Robert J Mentz
- Department of Medicine, Division of Cardiology Duke University, Durham, NC; Duke Clinical Research Institute, Durham, NC
| | - Hayden B Bosworth
- Department of Medicine, Division of Cardiology Duke University, Durham, NC; Department of Population Health Sciences, Durham, NC
| | - Neha J Pagidipati
- Department of Medicine, Division of Cardiology Duke University, Durham, NC; Duke Clinical Research Institute, Durham, NC
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6
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Nelson AJ, Pagidipati NJ, Bosworth HB. Improving medication adherence in cardiovascular disease. Nat Rev Cardiol 2024:10.1038/s41569-023-00972-1. [PMID: 38172243 DOI: 10.1038/s41569-023-00972-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 11/27/2023] [Indexed: 01/05/2024]
Abstract
Non-adherence to medication is a global health problem with far-reaching individual-level and population-level consequences but remains unappreciated and under-addressed in the clinical setting. With increasing comorbidity and polypharmacy as well as an ageing population, cardiovascular disease and medication non-adherence are likely to become increasingly prevalent. Multiple methods for detecting non-adherence exist but are imperfect, and, despite emerging technology, a gold standard remains elusive. Non-adherence to medication is dynamic and often has multiple causes, particularly in the context of cardiovascular disease, which tends to require lifelong medication to control symptoms and risk factors in order to prevent disease progression. In this Review, we identify the causes of medication non-adherence and summarize interventions that have been proven in randomized clinical trials to be effective in improving adherence. Practical solutions and areas for future research are also proposed.
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Affiliation(s)
- Adam J Nelson
- Victorian Heart Institute, Melbourne, Victoria, Australia
- Duke Clinical Research Institute, Duke University, Durham, NC, USA
| | | | - Hayden B Bosworth
- Duke Clinical Research Institute, Duke University, Durham, NC, USA.
- Population Health Sciences, Duke University, Durham, NC, USA.
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7
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Harrington J, Felker GM, Lingvay I, Pagidipati NJ, Pandey A, McGuire DK. Managing Obesity in Heart Failure: A Chance to Tip the Scales? JACC Heart Fail 2024; 12:28-34. [PMID: 37897462 DOI: 10.1016/j.jchf.2023.09.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/08/2023] [Revised: 09/06/2023] [Accepted: 09/13/2023] [Indexed: 10/30/2023]
Abstract
Obesity is associated with incident heart failure (HF), independent of other cardiovascular risk factors. Despite rising rates of both obesity and incident HF, the associations remain poorly understood between: 1) obesity and HF outcomes; and 2) weight loss and HF outcomes. Evidence shows that patients with HF and obesity have high symptom burdens, lower exercise capacity, and higher rates of hospitalization for HF when compared with patients with HF without obesity. However, the impact of weight loss on these outcomes for patients with HF and obesity remains unclear. Recent advances in medical therapies for weight loss have offered a new opportunity for significant and sustained weight loss. Ongoing and recently concluded cardiovascular outcomes trials will offer new insights into the role of weight loss through these therapies in preventing HF and mitigating HF outcomes and symptom burdens among patients with established HF, particularly HF with preserved ejection fraction.
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Affiliation(s)
- Josephine Harrington
- Division of Cardiology, Department of Internal Medicine, Duke University Medical Center, Durham, North Carolina, USA; Duke Clinical Research Institute, Durham, North Carolina, USA
| | - G Michael Felker
- Division of Cardiology, Department of Internal Medicine, Duke University Medical Center, Durham, North Carolina, USA; Duke Clinical Research Institute, Durham, North Carolina, USA
| | - Ildiko Lingvay
- Division of Endocrinology, Department of Internal Medicine, University of Texas Southwestern Medical Center, Dallas, Texas, USA; Peter O'Donnell Jr School of Public Health, University of Texas Southwestern Medical Center, Dallas, Texas, USA
| | - Neha J Pagidipati
- Division of Cardiology, Department of Internal Medicine, Duke University Medical Center, Durham, North Carolina, USA; Duke Clinical Research Institute, Durham, North Carolina, USA
| | - Ambarish Pandey
- Division of Cardiology, Department of Internal Medicine, University of Texas Southwestern Medical Center, Dallas, Texas, USA
| | - Darren K McGuire
- Division of Cardiology, Department of Internal Medicine, University of Texas Southwestern Medical Center, Dallas, Texas, USA; Parkland Health and Hospital System, Dallas, Texas, USA.
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Kelsey MD, Pagidipati NJ. Should We "RESPECT EPA" More Now? EPA and DHA for Cardiovascular Risk Reduction. Curr Cardiol Rep 2023; 25:1601-1609. [PMID: 37812346 DOI: 10.1007/s11886-023-01972-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 09/24/2023] [Indexed: 10/10/2023]
Abstract
PURPOSE OF REVIEW There has been much debate surrounding the use of omega-3 fatty acids, eicosapentaenoic acid (EPA) and docosahexaenoic acid (DHA), for cardiovascular (CV) risk reduction. RECENT FINDINGS Recent trials of EPA and DHA have offered conflicting evidence. Some demonstrate reduction in CV risk using EPA alone in select populations. Others have demonstrated no benefit, with potential for side effects, such as new-onset atrial fibrillation. Both EPA and DHA have favorable impact on lipids and inflammation, suggesting some biological plausibility for CV risk reduction. However, clinical trials of these agents have produced mixed results. Based on available evidence, EPA may work better for CV risk than DHA and EPA combined. The benefit of EPA seems to be dose dependent, though higher doses may have more side effects. Further research is needed to define the role of EPA and DHA in the landscape of CV risk reduction.
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Affiliation(s)
- Michelle D Kelsey
- Division of Cardiology, Department of Medicine, Duke University School of Medicine, Durham, NC, USA.
- Duke Clinical Research Institute, 300 W Morgan St, Durham, NC, 27710, USA.
| | - Neha J Pagidipati
- Division of Cardiology, Department of Medicine, Duke University School of Medicine, Durham, NC, USA
- Duke Clinical Research Institute, 300 W Morgan St, Durham, NC, 27710, USA
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Foldyna B, Mayrhofer T, Lu MT, Karády J, Kolossváry M, Ferencik M, Shah SH, Pagidipati NJ, Douglas PS, Hoffmann U. Prognostic value of CT-derived coronary artery disease characteristics varies by ASCVD risk: insights from the PROMISE trial. Eur Radiol 2023; 33:4657-4667. [PMID: 36719496 PMCID: PMC10765563 DOI: 10.1007/s00330-023-09430-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/05/2022] [Revised: 11/15/2022] [Accepted: 01/07/2023] [Indexed: 02/01/2023]
Abstract
OBJECTIVES To compare the prognostic value of individual CT-derived coronary artery disease (CAD) characteristics across categories of clinical cardiovascular risk. METHODS The central core laboratory assessed coronary artery calcium (CAC), obstructive CAD (stenosis ≥ 50%), and high-risk plaque (HRP) in stable outpatients with suspected CAD enrolled in the PROMISE trial. Multivariable Cox regression models (endpoint: unstable angina, nonfatal myocardial infarction, or all-cause mortality; median follow-up: 2 years) were used to compare hazard ratios (HR) of the CT measures between low-borderline (< 7.5%) and moderate-high (≥ 7.5%) atherosclerotic cardiovascular disease (ASCVD) risk based on the pooled cohort equation. RESULTS Among 4356 included patients (aged 61 ± 8 years, 52% women), 67% had ASCVD risk ≥ 7.5%. Stratified by ASCVD risk, CAD ≥ 50% had nearly threefold greater HR in individuals with ASCVD < 7.5% (aHR, 6.85; 95% CI, 2.33-20.15; p < 0.001) vs. ASCVD ≥ 7.5% (aHR: 2.66, 95% CI: 1.67-4.25, p < 0.001; interaction p = 0.041). CAC predicted events solely in ASCVD ≥ 7.5% patients (aHR: 1.92, 95% CI: 1.01-3.63, p = 0.045; interaction p = 0.571), while HRP predicted events only in ASCVD < 7.5% (aHR: 3.11, 95% CI: 1.09-8.85, p = 0.034; interaction p = 0.034). CONCLUSIONS Prognostic values of CT-derived CAD characteristics differ by ASCVD risk categories. While CAD ≥ 50% has the highest prognostic value regardless of ASCVD risk, CAC is prognostic in high and HRP in low ASCVD risk. These findings suggest that CAD ≥ 50% and HRP detection rather than CAC scoring may better risk-stratify symptomatic low-risk patients and thus potentially improve downstream care. KEY POINTS • Prognostic value of individual CT-derived CAD characteristics differs by categories of cardiovascular risk. • Presence of obstructive coronary artery stenosis ≥ 50% has the highest prognostic value regardless of cardiovascular risk. • Coronary artery calcium is independently prognostic in high and high-risk plaque features in low cardiovascular risk.
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Affiliation(s)
- Borek Foldyna
- Cardiovascular Imaging Research Center, Massachusetts General Hospital, Harvard Medical School, 165 Cambridge Street, Suite 400, Boston, MA, 02114, USA.
| | - Thomas Mayrhofer
- Cardiovascular Imaging Research Center, Massachusetts General Hospital, Harvard Medical School, 165 Cambridge Street, Suite 400, Boston, MA, 02114, USA
- School of Business Studies, Stralsund University of Applied Sciences, Stralsund, Germany
| | - Michael T Lu
- Cardiovascular Imaging Research Center, Massachusetts General Hospital, Harvard Medical School, 165 Cambridge Street, Suite 400, Boston, MA, 02114, USA
| | - Júlia Karády
- Cardiovascular Imaging Research Center, Massachusetts General Hospital, Harvard Medical School, 165 Cambridge Street, Suite 400, Boston, MA, 02114, USA
- Cardiovascular Imaging Research Group, Heart and Vascular Center, Semmelweis University, Budapest, Hungary
| | - Márton Kolossváry
- Cardiovascular Imaging Research Center, Massachusetts General Hospital, Harvard Medical School, 165 Cambridge Street, Suite 400, Boston, MA, 02114, USA
| | - Maros Ferencik
- Knight Cardiovascular Institute, Oregon Health & Science University, Portland, OR, USA
| | - Svati H Shah
- Duke Clinical Research Institute, Duke University School of Medicine, Durham, NC, USA
| | - Neha J Pagidipati
- Duke Clinical Research Institute, Duke University School of Medicine, Durham, NC, USA
| | - Pamela S Douglas
- Duke Clinical Research Institute, Duke University School of Medicine, Durham, NC, USA
| | - Udo Hoffmann
- Innovative Imaging Consulting LLC, 163 Longfellow Rd, Waltham, MA, 02453, USA.
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10
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Kelsey MD, Mulder H, Chiswell K, Lampron ZM, Nilles E, Kulinski JP, Joshi PH, Jones WS, Chamberlain AM, Leucker TM, Hwang W, Milks MW, Paranjape A, Obeid JS, Linton MF, Kent ST, Peterson ED, O'Brien EC, Pagidipati NJ. Contemporary patterns of lipoprotein(a) testing and associated clinical care and outcomes. Am J Prev Cardiol 2023; 14:100478. [PMID: 37025553 PMCID: PMC10070377 DOI: 10.1016/j.ajpc.2023.100478] [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: 11/14/2022] [Revised: 02/13/2023] [Accepted: 02/25/2023] [Indexed: 03/06/2023] Open
Abstract
Objective Elevated lipoprotein(a) [Lp(a)] is associated with atherosclerotic cardiovascular disease, yet little is known about Lp(a) testing patterns in real-world practice. The objective of this analysis was to determine how Lp(a) testing is used in clinical practice in comparison with low density lipoprotein cholesterol (LDL-C) testing alone, and to determine whether elevated Lp(a) level is associated with subsequent initiation of lipid-lowering therapy (LLT) and incident cardiovascular (CV) events. Methods This is an observational cohort study, based on lab tests administered between Jan 1, 2015 and Dec 31, 2019. We used electronic health record (EHR) data from 11 United States health systems participating in the National Patient-Centered Clinical Research Network (PCORnet). We created two cohorts for comparison: 1) the Lp(a) cohort, of adults with an Lp(a) test and 2) the LDL-C cohort, of 4:1 date- and site-matched adults with an LDL-C test, but no Lp(a) test. The primary exposure was the presence of an Lp(a) or LDL-C test result. In the Lp(a) cohort, we used logistic regression to assess the relationship between Lp(a) results in mass units (< 50, 50-100, and > 100mg/dL) and molar units (<125, 125-250, > 250nmol/L) and initiation of LLT within 3 months. We used multivariable adjusted Cox proportional hazards regression to evaluate these Lp(a) levels and time to composite CV hospitalization, including hospitalization for myocardial infarction, revascularization and ischemic stroke. Results Overall, 20,551 patients had Lp(a) test results and 2,584,773 patients had LDL-C test results (82,204 included in the matched LDL-C cohort). Compared with the LDL-C cohort, the Lp(a) cohort more frequently had prevalent ASCVD (24.3% vs. 8.5%) and multiple prior CV events (8.6% vs. 2.6%). Elevated Lp(a) was associated with greater odds of subsequent LLT initiation. Elevated Lp(a) reported in mass units was also associated with subsequent composite CV hospitalization [aHR (95% CI): Lp(a) 50-100mg/dL 1.25 (1.02-1.53), p<0.03, Lp(a) > 100mg/dL 1.23 (1.08-1.40), p<0.01]. Conclusion Lp(a) testing is relatively infrequent in health systems across the U.S. As new therapies for Lp(a) emerge, improved patient and provider education is needed to increase awareness of the utility of this risk marker.
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Affiliation(s)
- Michelle D. Kelsey
- Division of Cardiology, Department of Medicine, Duke University Medical Center, Durham, NC, USA
- Duke Clinical Research Institute, Durham, NC, USA
| | | | | | | | - Ester Nilles
- Duke Clinical Research Institute, Durham, NC, USA
| | - Jacquelyn P. Kulinski
- Department of Medicine, Division of Cardiology, Medical College of Wisconsin, Milwaukee, USA
| | - Parag H. Joshi
- Department of Medicine, Division of Cardiology, University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - W. Schuyler Jones
- Division of Cardiology, Department of Medicine, Duke University Medical Center, Durham, NC, USA
- Duke Clinical Research Institute, Durham, NC, USA
| | - Alanna M. Chamberlain
- Department of Quantitative Health Sciences Research, Mayo Clinic, Rochester, MN, USA
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, MN
| | - Thorsten M. Leucker
- Johns Hopkins Ciccarone Center for the Prevention of Cardiovascular Disease, Baltimore, MD, USA
| | - Wenke Hwang
- Department of Public Health Sciences, Penn State Hershey Medical Center, The Pennsylvania State University, PA, USA
| | - M. Wesley Milks
- Division of Cardiovascular Medicine, Department of Internal Medicine, The Ohio State University Wexner Medical Center, Columbus, OH, USA
| | - Anuradha Paranjape
- Department of Medicine, Temple University Lewis Katz School of Medicine, Philadelphia, PA, USA
| | - Jihad S. Obeid
- Division of Biomedical Informatics, Department of Public Health Sciences, Medical University of South Carolina, Charleston, SC, USA
| | - MacRae F. Linton
- Division of Cardiovascular Medicine, Department of Medicine, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Shia T. Kent
- Center for Observational Research, Amgen Inc., Thousand Oaks, CA, USA
| | - Eric D. Peterson
- Department of Medicine, Division of Cardiology, University of Texas Southwestern Medical Center, Dallas, TX, USA
| | | | - Neha J. Pagidipati
- Division of Cardiology, Department of Medicine, Duke University Medical Center, Durham, NC, USA
- Duke Clinical Research Institute, Durham, NC, USA
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11
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Zhao E, Giamberardino SN, Pagidipati NJ, Voora D, Ginsburg GS, Hoffmann U, Karády J, Ferencik M, Douglas PS, Foldyna B, Shah SH. Branched-Chain Amino Acids in Computed Tomography-Defined Adipose Depots and Coronary Artery Disease: A PROMISE Trial Biomarker Substudy. J Am Heart Assoc 2023:e028410. [PMID: 37218594 PMCID: PMC10382003 DOI: 10.1161/jaha.122.028410] [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] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 05/24/2023]
Abstract
Background The interplay between branched-chain amino acid (BCAA) metabolism, an important pathway in adiposity and cardiometabolic disease, and visceral adipose depots such as hepatic steatosis (HS) and epicardial adipose tissue is unknown. We leveraged the PROMISE clinical trial with centrally adjudicated coronary computed tomography angiography imaging to determine relationships between adipose depots, BCAA dysregulation, and coronary artery disease (CAD). Methods and Results The PROMISE (Prospective Multicenter Imaging Study for Evaluation of Chest Pain) trial randomized 10 003 outpatients with stable chest pain to computed tomography angiography versus standard-of-care diagnostics. For this study, we included 1798 participants with available computed tomography angiography data and biospecimens. Linear and logistic regression were used to determine associations between a molar sum of BCAAs measured by nuclear magnetic resonance spectroscopy with body mass index, adipose traits, and obstructive CAD. Mendelian randomization was then used to determine if BCAAs are in the causal pathway for adipose depots or CAD. The study sample had a mean age of 60 years (SD, 8.0), body mass index of 30.6 (SD, 5.9), and epicardial adipose tissue volume of 57.3 (SD, 21.3) cm3/m2; 27% had HS, and 14% had obstructive CAD. BCAAs were associated with body mass index (multivariable beta 0.12 per SD increase in BCAA [95% CI, 0.08-0.17]; P=4×10-8). BCAAs were also associated with HS (multivariable odds ratio [OR], 1.46 per SD increase in BCAAs [95% CI, 1.28-1.67]; P=2×10-8), but BCAAs were associated only with epicardial adipose tissue volume (odds ratio, 1.18 [95% CI, 1.07-1.32]; P=0.002) and obstructive CAD (OR, 1.18 [95% CI, 1.04-1.34]; P=0.009) in univariable models. Two-sample Mendelian randomization did not support the role of BCAAs as within the causal pathways for HS or CAD. Conclusions BCAAs have been implicated in the pathogenesis of cardiometabolic diseases, and adipose depots have been associated with the risk of CAD. Leveraging a large clinical trial, we further establish the role of dysregulated BCAA catabolism in HS and CAD, although BCAAs did not appear to be in the causal pathway of either disease. This suggests that BCAAs may serve as an independent circulating biomarker of HS and CAD but that their association with these cardiometabolic diseases is mediated through other pathways.
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Affiliation(s)
| | | | - Neha J Pagidipati
- Division of Cardiology, Department of Medicine Duke University Medical Center Durham NC
- Duke Clinical Research Institute Durham NC
| | - Deepak Voora
- Cardiovascular Imaging Research Center Massachusetts General Hospital-Harvard Medical School Boston MA
| | - Geoffrey S Ginsburg
- Division of Cardiology, Department of Medicine Duke University Medical Center Durham NC
| | - Udo Hoffmann
- Cardiovascular Imaging Research Center Massachusetts General Hospital-Harvard Medical School Boston MA
| | - Júlia Karády
- Cardiovascular Imaging Research Center Massachusetts General Hospital-Harvard Medical School Boston MA
| | - Maros Ferencik
- Knight Cardiovascular Institute Oregon Health and Science University Portland OR
| | - Pamela S Douglas
- Division of Cardiology, Department of Medicine Duke University Medical Center Durham NC
| | - Borek Foldyna
- Cardiovascular Imaging Research Center Massachusetts General Hospital-Harvard Medical School Boston MA
| | - Svati H Shah
- Duke Molecular Physiology Institute Duke University School of Medicine Durham NC
- Division of Cardiology, Department of Medicine Duke University Medical Center Durham NC
- Duke Clinical Research Institute Durham NC
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12
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Pagidipati NJ, Nelson AJ, Kaltenbach LA, Leyva M, McGuire DK, Pop-Busui R, Cavender MA, Aroda VR, Magwire ML, Richardson CR, Lingvay I, Kirk JK, Al-Khalidi HR, Webb L, Gaynor T, Pak J, Senyucel C, Lopes RD, Green JB, Granger CB. Coordinated Care to Optimize Cardiovascular Preventive Therapies in Type 2 Diabetes: A Randomized Clinical Trial. JAMA 2023; 329:1261-1270. [PMID: 36877177 PMCID: PMC9989955 DOI: 10.1001/jama.2023.2854] [Citation(s) in RCA: 17] [Impact Index Per Article: 17.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/21/2023] [Accepted: 02/16/2023] [Indexed: 03/07/2023]
Abstract
Importance Evidence-based therapies to reduce atherosclerotic cardiovascular disease risk in adults with type 2 diabetes are underused in clinical practice. Objective To assess the effect of a coordinated, multifaceted intervention of assessment, education, and feedback vs usual care on the proportion of adults with type 2 diabetes and atherosclerotic cardiovascular disease prescribed all 3 groups of recommended, evidence-based therapies (high-intensity statins, angiotensin-converting enzyme inhibitors [ACEIs] or angiotensin receptor blockers [ARBs], and sodium-glucose cotransporter 2 [SGLT2] inhibitors and/or glucagon-like peptide 1 receptor agonists [GLP-1RAs]). Design, Setting, and Participants Cluster randomized clinical trial with 43 US cardiology clinics recruiting participants from July 2019 through May 2022 and follow-up through December 2022. The participants were adults with type 2 diabetes and atherosclerotic cardiovascular disease not already taking all 3 groups of evidence-based therapies. Interventions Assessing local barriers, developing care pathways, coordinating care, educating clinicians, reporting data back to the clinics, and providing tools for participants (n = 459) vs usual care per practice guidelines (n = 590). Main Outcomes and Measures The primary outcome was the proportion of participants prescribed all 3 groups of recommended therapies at 6 to 12 months after enrollment. The secondary outcomes included changes in atherosclerotic cardiovascular disease risk factors and a composite outcome of all-cause death or hospitalization for myocardial infarction, stroke, decompensated heart failure, or urgent revascularization (the trial was not powered to show these differences). Results Of 1049 participants enrolled (459 at 20 intervention clinics and 590 at 23 usual care clinics), the median age was 70 years and there were 338 women (32.2%), 173 Black participants (16.5%), and 90 Hispanic participants (8.6%). At the last follow-up visit (12 months for 97.3% of participants), those in the intervention group were more likely to be prescribed all 3 therapies (173/457 [37.9%]) vs the usual care group (85/588 [14.5%]), which is a difference of 23.4% (adjusted odds ratio [OR], 4.38 [95% CI, 2.49 to 7.71]; P < .001) and were more likely to be prescribed each of the 3 therapies (change from baseline in high-intensity statins from 66.5% to 70.7% for intervention vs from 58.2% to 56.8% for usual care [adjusted OR, 1.73; 95% CI, 1.06-2.83]; ACEIs or ARBs: from 75.1% to 81.4% for intervention vs from 69.6% to 68.4% for usual care [adjusted OR, 1.82; 95% CI, 1.14-2.91]; SGLT2 inhibitors and/or GLP-1RAs: from 12.3% to 60.4% for intervention vs from 14.5% to 35.5% for usual care [adjusted OR, 3.11; 95% CI, 2.08-4.64]). The intervention was not associated with changes in atherosclerotic cardiovascular disease risk factors. The composite secondary outcome occurred in 23 of 457 participants (5%) in the intervention group vs 40 of 588 participants (6.8%) in the usual care group (adjusted hazard ratio, 0.79 [95% CI, 0.46 to 1.33]). Conclusions and Relevance A coordinated, multifaceted intervention increased prescription of 3 groups of evidence-based therapies in adults with type 2 diabetes and atherosclerotic cardiovascular disease. Trial Registration ClinicalTrials.gov Identifier: NCT03936660.
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Affiliation(s)
| | - Adam J. Nelson
- Duke Clinical Research Institute, Durham, North Carolina
- Victorian Heart Institute, Monash University, Melbourne, Australia
| | | | - Monica Leyva
- Duke Clinical Research Institute, Durham, North Carolina
| | - Darren K. McGuire
- University of Texas Southwestern Medical Center, Dallas
- Parkland Health and Hospital System, Dallas, Texas
| | | | | | | | | | | | | | - Julienne K. Kirk
- School of Medicine, Wake Forest University, Winston-Salem, North Carolina
| | | | - Laura Webb
- Duke Clinical Research Institute, Durham, North Carolina
| | - Tanya Gaynor
- Boehringer Ingelheim Pharmaceuticals, Inc, Ridgefield, Connecticut
| | - Jonathan Pak
- Boehringer Ingelheim Pharmaceuticals, Inc, Ridgefield, Connecticut
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13
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Rao VN, Pagidipati NJ. Long-Term Outcomes Following Behavioral Weight Management Programs: Worth the Weight. Circ Cardiovasc Qual Outcomes 2023; 16:e009965. [PMID: 36974899 PMCID: PMC10487370 DOI: 10.1161/circoutcomes.123.009965] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 03/29/2023]
Affiliation(s)
- Vishal N. Rao
- Division of Cardiology, Duke University School of Medicine, Durham, NC (V.N.R.)
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14
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Nanna MG, Nelson AJ, Haynes K, Shambhu S, Eapen Z, Cziraky MJ, Calvert SB, Pagidipati NJ, Granger CB. Lipid-lowering treatment among older patients with atherosclerotic cardiovascular disease. J Am Geriatr Soc 2023; 71:1243-1249. [PMID: 36538393 PMCID: PMC10089944 DOI: 10.1111/jgs.18172] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/01/2022] [Revised: 11/10/2022] [Accepted: 11/16/2022] [Indexed: 12/24/2022]
Abstract
BACKGROUND The contemporary uptake of lipid-lowering therapies (LLT), including more intensive treatment with high-intensity statins and non-statin LLT, among U.S. older adults (≥75 years old) with ASCVD is unknown. METHODS In this multicenter retrospective cohort study of a large geographically diverse sample of commercially insured U.S. older adults with ASCVD, we assessed treatment with LLT. Secondary measures included LDL-C above target ≥70 mg/dl, persistence and adherence to therapy. RESULTS Treatment with statins, high-intensity statins, ezetimibe, and PCSK9 inhibitors was assessed in 194,503 older adults (49.9% female) with known ASCVD on January 31st, 2019. 49.3% of older adults with ASCVD were on any statin, with 16.6% receiving a high-intensity statin and 32.7% on low-or moderate-intensity statins. Treatment with ezetimibe (2.4%) or PCSK9 inhibitors (0.24%) was rare and 62.6% of the overall cohort had an LDL-C above target at ≥70 mg/dl. Patients on high-intensity statins were more frequently male, had a diagnosis of coronary artery disease, and were more frequently seen by a cardiologist compared with those on low-or moderate-intensity statins and untreated individuals (p < 0.0001). The majority of older adults on high-intensity statins remained on therapy at 12 months (91.9%) and 85.7% had ≥75% adherence to treatment. CONCLUSIONS Less than half of eligible older adults with ASCVD are on statins and only a minority of patients are receiving more intensive lipid-lowering to improve outcomes.
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Affiliation(s)
- Michael G Nanna
- Section of Cardiovascular Medicine, Yale School of Medicine, New Haven, Connecticut, USA
| | - Adam J Nelson
- Duke Clinical Research Institute, Durham, North Carolina, USA
| | | | | | - Zubin Eapen
- Element Science, San Francisco, California, USA
| | | | - Sara B Calvert
- Duke Clinical Research Institute, Durham, North Carolina, USA
- Clinical Trials Transformation Initiative, Durham, North Carolina, USA
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15
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Pagidipati NJ, Mulder H, Chiswell K, Lampron Z, Jones WS, Machineni S, Waitman LR, Mongraw-Chaffin M, Waterman F, Kumar N, Ramasamy A, Smolarz G, Peterson ED, O'Brien E. Evaluation of weight change and cardiometabolic risk factors in a real-world population of US adults with overweight or obesity. Prev Med 2023; 170:107496. [PMID: 36997096 DOI: 10.1016/j.ypmed.2023.107496] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/24/2022] [Revised: 03/26/2023] [Accepted: 03/27/2023] [Indexed: 04/01/2023]
Abstract
Whether individuals in real-world settings are able to lose weight and improve cardiometabolic risk factors over time is unclear. We aimed to determine the management of and degree of body weight change over 2 years among individuals with overweight or obesity, and to assess associated changes in cardiometabolic risk factors and clinical outcomes. Using data from 11 large health systems within the Patient-Centered Outcomes Research Network in the U.S., we collected the following data on adults with a recorded BMI ≥25 kg/m2 between January 1, 2016 and December 31, 2016: body-mass index (BMI), systolic blood pressure (SBP), diastolic blood pressure (DBP), low-density lipoprotein cholesterol (LDL-C), high-density lipoprotein cholesterol (HDLC), triglycerides and glycated hemoglobin (HbA1c). We found that among 882,712 individuals with BMI ≥25 kg/m2 (median age 59 years; 56% female), 52% maintained stable weight over 2 years and 1.3% utilized weight loss pharmacotherapy. Weight loss of 10% was associated with small but significant lowering of mean SBP (-2.69 mmHg [95% CI -2.88, -2.50]), DBP (-1.26 mmHg [95% CI -1.35, -1.18]), LDL-C (-2.60 mg/dL [95% CI -3.14, -2.05]), and HbA1c (-0.27% [95% CI -0.35, -0.19]) in the same 12 months. However, these changes were not sustained over the following year. In this study of adults with BMI ≥25 kg/m2, the majority had stable weight over 2 years, pharmacotherapies for weight loss were under-used, and small changes in cardiometabolic risk factors with weight loss were not sustained, possibly due to failure to maintain weight loss.
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Affiliation(s)
- Neha J Pagidipati
- Duke Clinical Research Institute, Durham, NC, United States of America.
| | - Hillary Mulder
- Duke Clinical Research Institute, Durham, NC, United States of America
| | - Karen Chiswell
- Duke Clinical Research Institute, Durham, NC, United States of America
| | - Zachary Lampron
- Duke Clinical Research Institute, Durham, NC, United States of America
| | - William S Jones
- Duke Clinical Research Institute, Durham, NC, United States of America
| | - Sriram Machineni
- University of North Carolina School of Medicine, Chapel Hill, NC, United States of America
| | - Lemuel R Waitman
- University of Missouri School of Medicine, Columbia, MO, United States of America
| | | | | | | | | | | | - Eric D Peterson
- University of Texas Southwestern School of Medicine, Dallas, TX, United States of America
| | - Emily O'Brien
- Duke Clinical Research Institute, Durham, NC, United States of America
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16
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Harrington J, Nguyen M, Green J, Sattar N, Pagidipati NJ, Hernandez AF, Mentz RJ, Sourij H, Holman RR, Shah S. PROTEOMIC MARKERS OF CARDIAC FIBROSIS AND ENDOTHELIAL FUNCTION ASSOCIATED WITH HEART FAILURE IN PATIENTS WITH DIABETES: AN EXSCEL BIOMARKER SUB-STUDY. J Am Coll Cardiol 2023. [DOI: 10.1016/s0735-1097(23)00755-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 03/06/2023]
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17
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Khedagi A, Hoke C, Kelsey M, Coviello A, Jones WS, Jackson LR, Patel MR, McGarrah RW, Pagidipati NJ, Shah NP. Call to action: Understanding the differences in the use of SGLT-2 inhibitors and GLP-1 receptor agonists. Am J Prev Cardiol 2023; 13:100477. [PMID: 36915710 PMCID: PMC10006446 DOI: 10.1016/j.ajpc.2023.100477] [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: 12/27/2022] [Revised: 02/14/2023] [Accepted: 02/21/2023] [Indexed: 03/05/2023] Open
Abstract
Cardiovascular disease remains one of the most prominent global health problems and has been demonstrated to disproportionally affect certain communities. Despite an increasing collective effort to improve health inequalities, a multitude of disparities continue to affect cardiovascular outcomes. Among the most prominent disparities within cardiovascular disease prevention are with the use and distribution of sodium-glucose cotransporter-2 (SGLT-2) inhibitors and glucagon-like peptide 1 (GLP-1) receptor agonists. Several landmark trials have demonstrated the efficacy of these novel agents, not only in cardiovascular disease prevention among those with diabetes, but also in heart failure and chronic kidney disease. However, the use of these agents remains limited by disparities in certain racial/ethnic, sex, and socioeconomic groups. This review works to highlight and understand these differences on the use and prescribing patterns of pivotal agents in cardiovascular disease prevention, SGLT-2 inhibitors and GLP-1 agonists. Our aim is to enrich understanding and to inspire efforts to end disparities in cardiovascular morbidity and mortality due to race, sex and income inequality.
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Affiliation(s)
- Apurva Khedagi
- Department of Medicine, Duke University School of Medicine, Durham, NC
| | - Cara Hoke
- Division of Cardiology, Duke University School of Medicine, Durham, NC
| | - Michelle Kelsey
- Division of Cardiology, Duke University School of Medicine, Durham, NC
| | - Andrea Coviello
- Division of Endocrinology, Metabolism, and Nutrition, Duke University School of Medicine
| | - W. Schuyler Jones
- Division of Cardiology, Duke University School of Medicine, Durham, NC
| | - Larry R. Jackson
- Division of Cardiology, Duke University School of Medicine, Durham, NC
| | - Manesh R Patel
- Division of Cardiology, Duke University School of Medicine, Durham, NC
| | - Rob W. McGarrah
- Division of Cardiology, Duke University School of Medicine, Durham, NC
| | - Neha J Pagidipati
- Division of Cardiology, Duke University School of Medicine, Durham, NC
| | - Nishant P. Shah
- Division of Cardiology, Duke University School of Medicine, Durham, NC
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18
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Nelson AJ, Pagidipati NJ, Kelsey MD, Ardissino M, Aroda VR, Cavender MA, Lopes RD, Al-Khalidi HR, Braceras R, Gaynor T, Kaltenbach LA, Kirk JK, Lingvay I, Magwire ML, O'Brien EC, Pak J, Pop-Busui R, Richardson CR, Levya M, Senyucel C, Webb L, McGuire DK, Green JB, Granger CB. Coordinating Cardiology clinics randomized trial of interventions to improve outcomes (COORDINATE) - Diabetes: rationale and design. Am Heart J 2023; 256:2-12. [PMID: 36279931 DOI: 10.1016/j.ahj.2022.10.079] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/04/2022] [Revised: 10/13/2022] [Accepted: 10/18/2022] [Indexed: 06/16/2023]
Abstract
Several medications that are proven to reduce cardiovascular events exist for individuals with type 2 diabetes mellitus (T2DM) and atherosclerotic cardiovascular disease, however they are substantially underused in clinical practice. Clinician, patient, and system-level barriers all contribute to these gaps in care; yet, there is a paucity of high quality, rigorous studies evaluating the role of interventions to increase utilization. The COORDINATE-Diabetes trial randomized 42 cardiology clinics across the United States to either a multifaceted, site-specific intervention focused on evidence-based care for patients with T2DM or standard of care. The multifaceted intervention comprised the development of an interdisciplinary care pathway for each clinic, audit-and-feedback tools and educational outreach, in addition to patient-facing tools. The primary outcome is the proportion of individuals with T2DM prescribed three key classes of evidence-based medications (high-intensity statin, angiotensin converting enzyme inhibitor or angiotensin receptor blocker, and either a sodium/glucose cotransporter-2 inhibitor (SGLT-2i) inhibitor or glucagon-like peptide 1 receptor agonist (GLP-1RA) and will be assessed at least 6 months after participant enrollment. COORDINATE-Diabetes aims to identify strategies that improve the implementation and adoption of evidence-based therapies.
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Affiliation(s)
| | | | | | | | | | | | | | | | | | - Tanya Gaynor
- Boehringer Ingelheim Pharmaceuticals, Inc. Ridgefield, CT
| | | | - Julienne K Kirk
- Wake Forest University School of Medicine, Winston Salem, NC
| | - Ildiko Lingvay
- University of Texas Southwestern Medical Center, Dallas, TX
| | | | | | - Jonathan Pak
- Boehringer Ingelheim Pharmaceuticals, Inc. Ridgefield, CT
| | | | | | | | | | - Laura Webb
- Duke Clinical Research Institute, Durham, NC
| | - Darren K McGuire
- University of Texas Southwestern Medical Center, Dallas, TX; Parkland Health and Hospital System, Dallas, TX
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19
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Shah NP, Page C, Green CL, Gao M, Cavalier J, McGarrah RW, DeWald TA, Sangvai D, Patel MR, Pagidipati NJ. Bending the Cardiovascular Event Curve by Evaluating the Potential Impact of Achieving Low-Density Lipoprotein Cholesterol Goal Across a Large Health System Among Secondary Prevention Patients. Am J Cardiol 2023; 186:91-99. [PMID: 36371856 PMCID: PMC10725565 DOI: 10.1016/j.amjcard.2022.10.033] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/19/2022] [Revised: 10/05/2022] [Accepted: 10/14/2022] [Indexed: 11/12/2022]
Abstract
Guidelines recommend aggressive low-density lipoprotein cholesterol (LDL-C) lowering in patients with atherosclerotic cardiovascular disease (ASCVD). However, the recommended threshold of LDL-C ≤70 mg/dL is often not achieved. We used data from the Duke University Health System electronic health record to characterize patterns of lipid levels and lipid management in patients with ASCVD to estimate the number of clinical events that could be prevented by achieving LDL-C ≤70 mg/dL . A multivariable logistic regression model was developed to predict the 1-year composite of all-cause mortality, myocardial infarction, stroke, or coronary revascularization and was validated through bootstrapping. The number needed to treat to prevent an event was then determined. Among 56,230 patients with ASCVD, the median (quartile 1, quartile 3) age was 68.6 years (59.9, 76.2), 47% were women, and 27% were non-Hispanic Black. LDL-C was >70 mg/dL in 39,566 of patients (70%); these patients were more frequently female (51% vs 36%), non-Hispanic Black (28% vs 23%), and less frequently on statin therapy (67% vs 91%) than those with LDL-C ≤70 mg/dL . A predictive model with reasonable discrimination (c-index 0.77, 95% confidence interval 0.760 to 0.77) and calibration (slope 0.99) determined that if the overall population achieved an LDL-C ≤70 mg/dL, 734 clinical events (455 myocardial infarctions, 186 strokes, and 93 coronary revascularizations) could be prevented in a year. Achieving LDL-C ≤70 mg/dL in patients with ASCVD across a health system could prevent significant clinical events within a single year. In conclusion, this study quantifies the potential benefit of a system-wide effort to achieve guideline-based LDL-C goals.
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Affiliation(s)
- Nishant P Shah
- Divisions of Cardiology, Duke University Hospital, Durham, North Carolina; Duke Clinical Research Institute, Durham, North Carolina.
| | - Courtney Page
- Duke Clinical Research Institute, Durham, North Carolina
| | - Cynthia L Green
- Duke Clinical Research Institute, Durham, North Carolina; Department of Biostatistics & Bioinformatics, Duke University School of Medicine, Durham, North Carolina
| | - Michael Gao
- Divisions of Cardiology, Duke University Hospital, Durham, North Carolina
| | - Joanna Cavalier
- Divisions of Cardiology, Duke University Hospital, Durham, North Carolina
| | - Robert W McGarrah
- Divisions of Cardiology, Duke University Hospital, Durham, North Carolina
| | - Tracy A DeWald
- Divisions of Cardiology, Duke University Hospital, Durham, North Carolina; Divisions of Clinical Pharmacology, Duke University Hospital, Durham, North Carolina
| | - Devdutta Sangvai
- Duke Population Health Management Office, Durham, North Carolina
| | - Manesh R Patel
- Divisions of Cardiology, Duke University Hospital, Durham, North Carolina; Duke Clinical Research Institute, Durham, North Carolina
| | - Neha J Pagidipati
- Divisions of Cardiology, Duke University Hospital, Durham, North Carolina; Duke Clinical Research Institute, Durham, North Carolina
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20
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Pagidipati NJ, Peterson ED. Can System Solutions Be Scaled to Control High Blood Pressure and Lipids? JAMA Cardiol 2023; 8:21-22. [PMID: 36350615 DOI: 10.1001/jamacardio.2022.4015] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Affiliation(s)
- Neha J Pagidipati
- Duke Clinical Research Institute, Duke University, Durham, North Carolina
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21
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Nelson AJ, Pagidipati NJ, Granger CB. Reply: High-Dose Statins Increase Adverse Events and Do Not Improve Survival. J Am Coll Cardiol 2022; 80:e127. [PMID: 36229096 DOI: 10.1016/j.jacc.2022.08.741] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/26/2022] [Accepted: 08/01/2022] [Indexed: 06/16/2023]
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22
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Kolossváry M, Mayrhofer T, Ferencik M, Karády J, Pagidipati NJ, Shah SH, Nanna MG, Foldyna B, Douglas PS, Hoffmann U, Lu MT. Are risk factors necessary for pretest probability assessment of coronary artery disease? A patient similarity network analysis of the PROMISE trial. J Cardiovasc Comput Tomogr 2022; 16:397-403. [PMID: 35393245 PMCID: PMC9452442 DOI: 10.1016/j.jcct.2022.03.006] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/22/2021] [Revised: 03/05/2022] [Accepted: 03/22/2022] [Indexed: 11/26/2022]
Abstract
BACKGROUND Pretest probability (PTP) calculators utilize epidemiological-level findings to provide patient-level risk assessment of obstructive coronary artery disease (CAD). However, their limited accuracies question whether dissimilarities in risk factors necessarily result in differences in CAD. Using patient similarity network (PSN) analyses, we wished to assess the accuracy of risk factors and imaging markers to identify ≥50% luminal narrowing on coronary CT angiography (CCTA) in stable chest-pain patients. METHODS We created four PSNs representing: patient characteristics, risk factors, non-coronary imaging markers and calcium score. We used spectral clustering to group individuals with similar risk profiles. We compared PSNs to a contemporary PTP score incorporating calcium score and risk factors to identify ≥50% luminal narrowing on CCTA in the CT-arm of the PROMISE trial. We also conducted subanalyses in different age and sex groups. RESULTS In 3556 individuals, the calcium score PSN significantly outperformed patient characteristic, risk factor, and non-coronary imaging marker PSNs (AUC: 0.81 vs. 0.57, 0.55, 0.54; respectively, p < 0.001 for all). The calcium score PSN significantly outperformed the contemporary PTP score (AUC: 0.81 vs. 0.78, p < 0.001), and using 0, 1-100 and > 100 cut-offs provided comparable results (AUC: 0.81 vs. 0.81, p = 0.06). Similar results were found in all subanalyses. CONCLUSION Calcium score on its own provides better individualized obstructive CAD prediction than contemporary PTP scores incorporating calcium score and risk factors. Risk factors may not be able to improve the diagnostic accuracy of calcium score to predict ≥50% luminal narrowing on CCTA.
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Affiliation(s)
- Márton Kolossváry
- Cardiovascular Imaging Research Center, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA.
| | - Thomas Mayrhofer
- Cardiovascular Imaging Research Center, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA; School of Business Studies, Stralsund University of Applied Sciences, Stralsund, Germany
| | - Maros Ferencik
- Cardiovascular Imaging Research Center, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA; Knight Cardiovascular Institute, Oregon Health and Science University, Portland, OR, USA
| | - Júlia Karády
- Cardiovascular Imaging Research Center, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Neha J Pagidipati
- Duke Clinical Research Institute, Duke University School of Medicine, Durham, NC, USA
| | - Svati H Shah
- Duke Clinical Research Institute, Duke University School of Medicine, Durham, NC, USA
| | - Michael G Nanna
- Section of Cardiovascular Medicine, Yale School of Medicine, New Haven, CT, USA
| | - Borek Foldyna
- Cardiovascular Imaging Research Center, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Pamela S Douglas
- Duke Clinical Research Institute, Duke University School of Medicine, Durham, NC, USA
| | - Udo Hoffmann
- Cardiovascular Imaging Research Center, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Michael T Lu
- Cardiovascular Imaging Research Center, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
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Grant JK, Snow S, Kelsey M, Rymer J, Schaffer AE, Patel MR, McGarrah RW, Pagidipati NJ, Shah NP. Lipid-Lowering Therapy in Woman of Childbearing Age: a Review and Stepwise Clinical Approach. Curr Cardiol Rep 2022; 24:1373-1385. [PMID: 35904667 DOI: 10.1007/s11886-022-01751-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 07/17/2022] [Indexed: 11/28/2022]
Abstract
PURPOSE OF REVIEW Women are less often recognized to have cardiovascular disease (CVD) risk and are underrepresented in randomized trials of lipid-lowering therapy. Here, we summarize non-pharmacologic and pharmacologic strategies for lipid-lowering in women of childbearing age, lipid changes during pregnancy and lactation, discuss sex-specific outcomes in currently available literature, and discuss future areas of research. RECENT FINDINGS While lifestyle interventions form the backbone of CVD prevention, some women of reproductive age have an indication for pharmacologic lipid-lowering. Sex-based evidence is limited but suggests that both statin and non-statin lipid-lowering agents are beneficial regardless of sex, especially at high cardiovascular risk. Pharmacologic lipid-lowering therapies, both during the pregnancy period and during lactation, have historically been and continue to be limited by safety concerns. This oftentimes limits lipid-lowering options in women of childbearing age. In this review, we summarize lipid-lowering strategies in women of childbearing age and the impact of therapies during pregnancy and lactation. The limited sex-specific data regarding efficacy, adverse events, and cardiovascular outcomes underscore the need for a greater representation of women in randomized controlled trials. More data on lipid-lowering teratogenicity are needed, and through increased clinician awareness and reporting to incidental exposure registries, more data can be harvested.
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Affiliation(s)
- Jelani K Grant
- Division of Cardiology, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Sarah Snow
- Division of Cardiology, Duke University School of Medicine, 2301 Erwin Rd, Durham, NC, 27705, USA
| | - Michelle Kelsey
- Division of Cardiology, Duke University School of Medicine, 2301 Erwin Rd, Durham, NC, 27705, USA
| | - Jennifer Rymer
- Division of Cardiology, Duke University School of Medicine, 2301 Erwin Rd, Durham, NC, 27705, USA
| | - Anna E Schaffer
- Division of Endocrinology, Metabolism, and Nutrition, Duke University School of Medicine, Durham, NC, USA
| | - Manesh R Patel
- Division of Cardiology, Duke University School of Medicine, 2301 Erwin Rd, Durham, NC, 27705, USA
| | - Robert W McGarrah
- Division of Cardiology, Duke University School of Medicine, 2301 Erwin Rd, Durham, NC, 27705, USA
| | - Neha J Pagidipati
- Division of Cardiology, Duke University School of Medicine, 2301 Erwin Rd, Durham, NC, 27705, USA
| | - Nishant P Shah
- Division of Cardiology, Duke University School of Medicine, 2301 Erwin Rd, Durham, NC, 27705, USA.
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24
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Nelson AJ, Haynes K, Shambhu S, Eapen Z, Cziraky MJ, Nanna MG, Calvert SB, Gallagher K, Pagidipati NJ, Granger CB. High-Intensity Statin Use Among Patients With Atherosclerosis in the U.S. J Am Coll Cardiol 2022; 79:1802-1813. [PMID: 35512860 PMCID: PMC9344279 DOI: 10.1016/j.jacc.2022.02.048] [Citation(s) in RCA: 46] [Impact Index Per Article: 23.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/16/2021] [Revised: 01/26/2022] [Accepted: 02/23/2022] [Indexed: 12/20/2022]
Abstract
BACKGROUND Preventive therapy among patients with established atherosclerotic cardiovascular disease (ASCVD) is generally underused. Whether new guideline recommendations and a focus on implementation have improved the use of high-intensity statins is unknown. OBJECTIVES This study sought to evaluate the patterns and predictors of statin use among patients with ASCVD. METHODS In this retrospective cohort study, pharmacy and medical claims data from a commercial health plan were queried for patients with established ASCVD between January 31, 2018, and January 31, 2019. Statin use on an index date of January 31, 2019, was evaluated, as was 12-month adherence and discontinuation. Multivariable logistic regression was used to determine independent associations with statin use of varying intensities. RESULTS Of the 601,934 patients with established ASCVD, 41.7% were female, and the mean age was 67.5 ± 13.3 years. Overall, 22.5% of the cohort were on a high-intensity statin, 27.6% were on a low- or moderate-intensity statin, and 49.9% were not on any statin. In multivariable analysis, younger patients, female patients, and those with higher Charlson comorbidity score were less likely to be prescribed any statin. Among statin users, female patients, older patients, and those with peripheral artery disease were less likely to be on a high-intensity formulation, whereas a cardiology encounter in the prior year increased the odds. The majority of high-intensity stain users achieved high levels of adherence. CONCLUSIONS Substantial underuse of statins persists in a large, insured, and contemporary cohort of patients with ASCVD from the United States. In particular, concerning gaps in appropriate statin use remain among younger patients, women, and those with noncoronary ASCVD.
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Affiliation(s)
- Adam J Nelson
- Duke Clinical Research Institute, Durham, North Carolina, USA
| | | | | | - Zubin Eapen
- Element Science, San Francisco, California, USA
| | | | - Michael G Nanna
- Section of Cardiovascular Medicine, Yale School of Medicine, New Haven, Connecticut, USA
| | - Sara B Calvert
- Duke Clinical Research Institute, Durham, North Carolina, USA; Clinical Trials Transformation Initiative, Durham, North Carolina, USA
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Kelsey MD, Nelson AJ, Green JB, Granger CB, Peterson ED, McGuire DK, Pagidipati NJ. Guidelines for Cardiovascular Risk Reduction in Patients With Type 2 Diabetes: JACC Guideline Comparison. J Am Coll Cardiol 2022; 79:1849-1857. [PMID: 35512864 DOI: 10.1016/j.jacc.2022.02.046] [Citation(s) in RCA: 21] [Impact Index Per Article: 10.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/07/2022] [Accepted: 02/22/2022] [Indexed: 12/12/2022]
Abstract
Cardiovascular disease is a leading cause of morbidity and mortality in individuals with type 2 diabetes mellitus. These high-risk patients benefit from aggressive risk factor management, with blood pressure and low-density lipoprotein-cholesterol treatment, glycemic control, kidney protection, and lifestyle intervention. There are several recommendation and guideline documents across cardiology, endocrinology, nephrology, and general medicine professional societies from the United States and Europe with recommendations for cardiovascular risk reduction in patients with type 2 diabetes mellitus. Although there are some noteworthy differences, particularly in risk stratification, low-density lipoprotein-cholesterol and blood pressure treatment targets, and the use of sodium-glucose cotransporter-2 inhibitors and glucagon-like peptide-1 receptor agonists, overall there is considerable alignment across recommendations from different professional societies.
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Affiliation(s)
- Michelle D Kelsey
- Division of Cardiology, Department of Medicine, Duke University Medical Center, Durham, North Carolina, USA; Duke Clinical Research Institute, Durham, North Carolina, USA.
| | - Adam J Nelson
- Duke Clinical Research Institute, Durham, North Carolina, USA. https://twitter.com/ajnelson
| | - Jennifer B Green
- Duke Clinical Research Institute, Durham, North Carolina, USA; Division of Endocrinology, Department of Medicine, Duke University Medical Center, Durham, North Carolina, USA
| | - Christopher B Granger
- Division of Cardiology, Department of Medicine, Duke University Medical Center, Durham, North Carolina, USA; Duke Clinical Research Institute, Durham, North Carolina, USA
| | - Eric D Peterson
- Division of Cardiology, Department of Medicine, University of Texas Southwestern Medical Center, and Parkland Health and Hospital System, Dallas, Texas, USA
| | - Darren K McGuire
- Division of Cardiology, Department of Medicine, University of Texas Southwestern Medical Center, and Parkland Health and Hospital System, Dallas, Texas, USA
| | - Neha J Pagidipati
- Division of Cardiology, Department of Medicine, Duke University Medical Center, Durham, North Carolina, USA; Duke Clinical Research Institute, Durham, North Carolina, USA
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Lowenstern A, Alexander KP, Pagidipati NJ, Hill CL, Pellikka PA, Cooper LS, Alhanti B, Hoffmann U, Mark DB, Douglas PS. Presenting Symptoms in Patients Undergoing Coronary Artery Disease Evaluation: Association With Noninvasive Test Results and Clinical Outcomes in the PROMISE Trial. Circ Cardiovasc Qual Outcomes 2022; 15:e008298. [PMID: 35369715 PMCID: PMC9117448 DOI: 10.1161/circoutcomes.121.008298] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND Patients evaluated for coronary artery disease have a range of symptoms and underlying risk. The relationships between patient-described symptoms, clinician conclusions, and subsequent clinical management and outcomes remain incompletely described. METHODS In this secondary analysis, we examined the association between 4 types of presenting symptoms (substernal/left-sided chest pain, other chest/neck/arm pain, dyspnea, and other symptoms) and patient risk, noninvasive test results, clinical management, and outcomes for stable outpatients randomized in the PROMISE (Prospective Multicenter Imaging Study for Evaluation of Chest Pain) trial. Multivariable regression models were used to evaluate differences in noninvasive test result, all-cause death/myocardial infarction/unstable angina hospitalization and cardiovascular death/myocardial infarction by symptom type. RESULTS Among 9996 patients, most presented with chest pain (47.2% substernal, 29.2% other), followed by dyspnea (14.9%), and other symptoms (8.7%). Patients with dyspnea were older (median age 63 versus 60, P≤0.02) with higher baseline risk (78.2% with atherosclerotic cardiovascular disease >7.5% versus 67.6%, P≤0.02). Using patients with substernal chest pain as a reference, there was no difference in noninvasive test positivity across symptom groups (all P>0.05), but test-positive patients with dyspnea (adjusted odds ratio, 0.66 [95% CI, 0.51-0.85]) or other symptoms (adjusted odds ratio, 0.65 [95% CI, 0.47-0.90]) were less likely to be referred for cardiac catheterization. While symptom type alone was not associated with outcomes, symptom presentation with chest pain or dyspnea did modify the association between a positive noninvasive test and clinical outcome (interaction P=0.025 for both all-cause death/myocardial infarction/unstable angina hospitalization and cardiovascular death/MI). CONCLUSIONS Among low-risk outpatients evaluated for coronary artery disease, typicality of symptoms was not closely associated with higher baseline risk but was related to differences in processes of care and the prognostic value of a positive test. Adverse events were not associated with clinician risk estimates or symptoms alone. These unexpected findings highlight the limitation of relying solely on symptom presentation or clinician risk estimation to evaluate patients for suspected coronary artery disease. REGISTRATION URL: https://www. CLINICALTRIALS gov; Unique identifier: NCT01174550.
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Affiliation(s)
- Angela Lowenstern
- Duke Clinical Research Institute, Duke University School of Medicine, Durham, NC (A.L., K.P.A., N.J.P., C.L.H., B.A., D.B.M., P.S.D.).,Vanderbilt University Medical Center (A.L.)
| | - Karen P Alexander
- Duke Clinical Research Institute, Duke University School of Medicine, Durham, NC (A.L., K.P.A., N.J.P., C.L.H., B.A., D.B.M., P.S.D.)
| | - Neha J Pagidipati
- Duke Clinical Research Institute, Duke University School of Medicine, Durham, NC (A.L., K.P.A., N.J.P., C.L.H., B.A., D.B.M., P.S.D.)
| | - C Larry Hill
- Duke Clinical Research Institute, Duke University School of Medicine, Durham, NC (A.L., K.P.A., N.J.P., C.L.H., B.A., D.B.M., P.S.D.)
| | | | - Lawton S Cooper
- National Heart, Lung, and Blood Institute, Bethesda, MD (L.S.C.)
| | - Brooke Alhanti
- Duke Clinical Research Institute, Duke University School of Medicine, Durham, NC (A.L., K.P.A., N.J.P., C.L.H., B.A., D.B.M., P.S.D.)
| | - Udo Hoffmann
- Massachusetts General Hospital, Harvard Medical School, Boston (U.H.)
| | - Daniel B Mark
- Duke Clinical Research Institute, Duke University School of Medicine, Durham, NC (A.L., K.P.A., N.J.P., C.L.H., B.A., D.B.M., P.S.D.)
| | - Pamela S Douglas
- Duke Clinical Research Institute, Duke University School of Medicine, Durham, NC (A.L., K.P.A., N.J.P., C.L.H., B.A., D.B.M., P.S.D.)
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Foldyna B, Lu MT, Ferencik M, Karady J, Mayrhofer T, Shah S, Pagidipati NJ, Douglas PS, Hoffmann U. PREDICTIVE VALUE OF INDIVIDUAL CORONARY CT-DERIVED CAD CHARACTERISTICS VARIES ACROSS ASCVD RISK STRATA: RESULTS FROM THE PROMISE TRIAL. J Am Coll Cardiol 2022. [DOI: 10.1016/s0735-1097(22)02200-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
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Kelsey MD, Nelson AJ, Green JB, Granger CB, Peterson ED, McGuire DK, Pagidipati NJ. TROPONIN ELEVATION AS A MANIFESTATION OF COVID-19 MYOCARDIAL INFLAMMATION ASSOCIATED WITH INCREASED MORTALITY. J Am Coll Cardiol 2022. [PMID: 35512864 PMCID: PMC8972581 DOI: 10.1016/s0735-1097(22)02840-6] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Affiliation(s)
- Michelle D Kelsey
- Division of Cardiology, Department of Medicine, Duke University Medical Center, Durham, North Carolina, USA; Duke Clinical Research Institute, Durham, North Carolina, USA.
| | - Adam J Nelson
- Duke Clinical Research Institute, Durham, North Carolina, USA. https://twitter.com/ajnelson
| | - Jennifer B Green
- Duke Clinical Research Institute, Durham, North Carolina, USA; Division of Endocrinology, Department of Medicine, Duke University Medical Center, Durham, North Carolina, USA
| | - Christopher B Granger
- Division of Cardiology, Department of Medicine, Duke University Medical Center, Durham, North Carolina, USA; Duke Clinical Research Institute, Durham, North Carolina, USA
| | - Eric D Peterson
- Division of Cardiology, Department of Medicine, University of Texas Southwestern Medical Center, and Parkland Health and Hospital System, Dallas, Texas, USA
| | - Darren K McGuire
- Division of Cardiology, Department of Medicine, University of Texas Southwestern Medical Center, and Parkland Health and Hospital System, Dallas, Texas, USA
| | - Neha J Pagidipati
- Division of Cardiology, Department of Medicine, Duke University Medical Center, Durham, North Carolina, USA; Duke Clinical Research Institute, Durham, North Carolina, USA
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Affiliation(s)
- Vishal N. Rao
- Division of Cardiology, Duke University Medical Center, Durham, NC
| | | | | | | | - Terry A. Fortin
- Division of Cardiology, Duke University Medical Center, Durham, NC
| | - Marat Fudim
- Division of Cardiology, Duke University Medical Center, Durham, NC
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Nelson AJ, O’Brien EC, Kaltenbach LA, Green JB, Lopes RD, Morse CG, Al-Khalidi HR, Aroda VR, Cavender MA, Gaynor T, Kirk JK, Lingvay I, Magwire ML, McGuire DK, Pak J, Pop-Busui R, Richardson CR, Senyucel C, Kelsey MD, Pagidipati NJ, Granger CB. Use of Lipid-, Blood Pressure-, and Glucose-Lowering Pharmacotherapy in Patients With Type 2 Diabetes and Atherosclerotic Cardiovascular Disease. JAMA Netw Open 2022; 5:e2148030. [PMID: 35175345 PMCID: PMC8855234 DOI: 10.1001/jamanetworkopen.2021.48030] [Citation(s) in RCA: 27] [Impact Index Per Article: 13.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/15/2022] Open
Abstract
IMPORTANCE Based on contemporary estimates in the US, evidence-based therapies for cardiovascular risk reduction are generally underused among patients with type 2 diabetes and atherosclerotic cardiovascular disease (ASCVD). OBJECTIVE To determine the use of evidence-based cardiovascular preventive therapies in a broad US population with diabetes and ASCVD. DESIGN, SETTING, AND PARTICIPANTS This multicenter cohort study used health system-level aggregated data within the National Patient-Centered Clinical Research Network, including 12 health systems. Participants included patients with diabetes and established ASCVD (ie, coronary artery disease, cerebrovascular disease, and peripheral artery disease) between January 1 and December 31, 2018. Data were analyzed from September 2020 until January 2021. EXPOSURES One or more health care encounters in 2018. MAIN OUTCOMES AND MEASURES Patient characteristics by prescription of any of the following key evidence-based therapies: high-intensity statin, angiotensin-converting enzyme inhibitor (ACEI) or angiotensin-receptor blocker (ARB) and sodium glucose cotransporter-2 inhibitors (SGLT2I) or glucagon-like peptide-1 receptor agonist (GLP-1RA). RESULTS The overall cohort included 324 706 patients, with a mean (SD) age of 68.1 (12.2) years and 144 169 (44.4%) women and 180 537 (55.6%) men. A total of 59 124 patients (18.2% ) were Black, and 41 470 patients (12.8%) were Latinx. Among 205 885 patients with specialized visit data from the prior year, 17 971 patients (8.7%) visited an endocrinologist, 54 330 patients (26.4%) visited a cardiologist, and 154 078 patients (74.8%) visited a primary care physician. Overall, 190 277 patients (58.6%) were prescribed a statin, but only 88 426 patients (26.8%) were prescribed a high-intensity statin; 147 762 patients (45.5%) were prescribed an ACEI or ARB, 12 724 patients (3.9%) were prescribed a GLP-1RA, and 8989 patients (2.8%) were prescribed an SGLT2I. Overall, 14 918 patients (4.6%) were prescribed all 3 classes of therapies, and 138 173 patients (42.6%) were prescribed none. Patients who were prescribed a high-intensity statin were more likely to be men (59.9% [95% CI, 59.6%-60.3%] of patients vs 55.6% [95% CI, 55.4%-55.8%] of patients), have coronary atherosclerotic disease (79.9% [95% CI, 79.7%-80.2%] of patients vs 73.0% [95% CI, 72.8%-73.3%] of patients) and more likely to have seen a cardiologist (40.0% [95% CI, 39.6%-40.4%] of patients vs 26.4% [95% CI, 26.2%-26.6%] of patients). CONCLUSIONS AND RELEVANCE In this large cohort of US patients with diabetes and ASCVD, fewer than 1 in 20 patients were prescribed all 3 evidence-based therapies, defined as a high-intensity statin, either an ACEI or ARB, and either an SGLT2I and/or a GLP-1RA. These findings suggest that multifaceted interventions are needed to overcome barriers to the implementation of evidence-based therapies and facilitate their optimal use.
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Affiliation(s)
- Adam J. Nelson
- Duke Clinical Research Institute, Durham, North Carolina
| | | | | | | | | | - Caryn G. Morse
- Wake Forest School of Medicine, Winston-Salem, North Carolina
| | | | | | | | - Tanya Gaynor
- Boehringer Ingelheim Pharmaceuticals, Ridgefield, Connecticut
| | | | | | | | - Darren K. McGuire
- University of Texas Southwestern Medical Center, Dallas
- Parkland Health and Hospital System, Dallas, Texas
| | - Jonathan Pak
- Boehringer Ingelheim Pharmaceuticals, Ridgefield, Connecticut
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Pagidipati NJ, Phelan M, Page C, Clowse M, Henao R, Peterson ED, Goldstein BA. The importance of weight stabilization amongst those with overweight or obesity: Results from a large health care system. Prev Med Rep 2021; 24:101615. [PMID: 34976671 PMCID: PMC8684020 DOI: 10.1016/j.pmedr.2021.101615] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2021] [Revised: 10/14/2021] [Accepted: 10/22/2021] [Indexed: 10/28/2022] Open
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Taron J, Foldyna B, Mayrhofer T, Osborne MT, Meyersohn N, Bittner DO, Puchner SB, Emami H, Lu MT, Ferencik M, Pagidipati NJ, Douglas PS, Hoffmann U. Risk Stratification With the Use of Coronary Computed Tomographic Angiography in Patients With Nonobstructive Coronary Artery Disease. JACC Cardiovasc Imaging 2021; 14:2186-2195. [PMID: 33865792 PMCID: PMC8497643 DOI: 10.1016/j.jcmg.2021.03.019] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/28/2020] [Revised: 02/24/2021] [Accepted: 03/12/2021] [Indexed: 12/28/2022]
Abstract
OBJECTIVES The purpose of this study was to develop a risk prediction model for patients with nonobstructive CAD. BACKGROUND Among stable chest pain patients, most cardiovascular (CV) events occur in those with nonobstructive coronary artery disease (CAD). Thus, developing tailored risk prediction approaches in this group of patients, including CV risk factors and CAD characteristics, is needed. METHODS In PROMISE (Prospective Multicenter Imaging Study for Evaluation of Chest Pain) computed tomographic angiography patients, a core laboratory assessed prevalence of CAD (nonobstructive 1% to 49% left main or 1% to 69% stenosis any coronary artery), degree of stenosis (minimal: 1% to 29%; mild: 30% to 49%; or moderate: 50% to 69%), high-risk plaque (HRP) features (positive remodeling, low-attenuation plaque, and napkin-ring sign), segment involvement score (SIS), and coronary artery calcium (CAC). The primary end point was an adjudicated composite of unstable angina pectoris, nonfatal myocardial infarction, and death. Cox regression analysis determined independent predictors in nonobstructive CAD. RESULTS Of 2,890 patients (age 61.7 years, 46% women) with any CAD, 90.4% (n = 2,614) had nonobstructive CAD (mean age 61.6 yrs, 46% women, atherosclerotic cardiovascular disease [ASCVD] risk 16.2%). Composite events were independently predicted by ASCVD risk (hazard ratio [HR]: 1.03; p = 0.001), degree of stenosis (30% to 69%; HR: 1.91; p = 0.011), and presence of ≥2 HRP features (HR: 2.40; p = 0.008). Addition of ≥2 HRP features to: 1) ASCVD and CAC; 2) ASCVD and SIS; or 3) ASCVD and degree of stenosis resulted in a statistically significant improvement in model fit (p = 0.0036; p = 0.0176; and p = 0.0318; respectively). Patients with ASCVD ≥7.5%, any HRP, and mild/moderate stenosis had significantly higher event rates than those who did not meet those criteria (3.0% vs. 6.2%; p = 0.007). CONCLUSIONS Advanced coronary plaque features have incremental value over total plaque burden for the discrimination of clinical events in low-risk stable chest pain patients with nonobstructive CAD. This may be a first step to improve prevention in this cohort with the highest absolute risk for CV events.
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Affiliation(s)
- Jana Taron
- Cardiovascular Imaging Research Center, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA; Department of Radiology, University Hospital Freiburg, Freiburg, Germany.
| | - Borek Foldyna
- Cardiovascular Imaging Research Center, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Thomas Mayrhofer
- Cardiovascular Imaging Research Center, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA; School of Business Studies, Stralsund University of Applied Sciences, Stralsund, Germany
| | - Michael T Osborne
- Cardiovascular Imaging Research Center, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA; Cardiology Division, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Nandini Meyersohn
- Cardiovascular Imaging Research Center, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Daniel O Bittner
- Department of Cardiology, University Hospital Erlangen, Friedrich-Alexander University Erlangen-Nürnberg, Erlangen, Germany
| | - Stefan B Puchner
- Cardiovascular Imaging Research Center, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA; Department of Biomedical Imaging and Image-guided Therapy, Medical School of Vienna, Vienna, Austria
| | - Hamed Emami
- Cardiovascular Center, University of Michigan, Ann Arbor, USA
| | - Michael T Lu
- Cardiovascular Imaging Research Center, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Maros Ferencik
- Cardiovascular Imaging Research Center, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA; Knight Cardiovascular Institute, Oregon Health and Science University, Portland, Oregon, USA
| | - Neha J Pagidipati
- Duke Clinical Research Institute, Duke University School of Medicine, Durham, North Carolina, USA
| | - Pamela S Douglas
- Duke Clinical Research Institute, Duke University School of Medicine, Durham, North Carolina, USA
| | - Udo Hoffmann
- Cardiovascular Imaging Research Center, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA
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Samsky MD, Mentz RJ, Stebbins A, Lokhnygina Y, Aday AW, Pagidipati NJ, Jones WS, Katona BG, Patel MR, Holman RR, Hernandez AF, Gutierrez JA. Polyvascular disease and increased risk of cardiovascular events in patients with type 2 diabetes: Insights from the EXSCEL trial. Atherosclerosis 2021; 338:1-6. [PMID: 34741929 DOI: 10.1016/j.atherosclerosis.2021.10.011] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/07/2021] [Revised: 10/12/2021] [Accepted: 10/29/2021] [Indexed: 11/26/2022]
Abstract
BACKGROUND AND AIMS Polyvascular disease is an independent predictor of major adverse cardiovascular events (MACE). The relationship between the number of diseased arterial beds and MACE is unknown. How MACE risk changes in individuals with type 2 diabetes (T2D) is also understudied. Furthermore, it is unknown whether heart failure (HF) status and hemoglobin A1c (HbA1c) levels influence outcomes in polyvascular disease. This analysis from the Exenatide Study of Cardiovascular Event Lowering trial (EXSCEL) aimed to examine the risk associated with increasing number of diseased arterial beds on MACE and all-cause mortality (ACM). METHODS Cox models were used to test associations between the number of diseased arterial beds and MACE and ACM. Prespecified interaction testing between number of diseased arterial beds with baseline HF, HbA1c (≤8% vs. >8%), and treatment assignment was performed. RESULTS Overall, 14,751 participants were included; 26.5% were without atherosclerosis, 58.9% had 1-bed, 12.3% had 2-bed, and 2.3% had 3-bed disease. An increasing burden of atherosclerotic disease was associated with increasing risk of MACE (adjusted HR [aHR] 1.71 [95% CI 1.46-2.02]; 2.61 [2.17-3.15]; 3.46 [2.69-4.45] for 1, 2, and 3 beds, respectively, p < 0.001 for all) and ACM (1.94 [1.56-2.42]; 3.03 [2.33-3.95]; 3.66 [2.59-5.18] for 1, 2, and 3 beds, respectively, p < 0.001 for all). Prespecified interaction testing did not reveal any significant associations. CONCLUSIONS In patients with T2D, compared to those without atherosclerotic vascular disease, risk of MACE and ACM increases incrementally with each additional diseased arterial bed.
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Affiliation(s)
- Marc D Samsky
- Department of Medicine, Duke University School of Medicine, Durham, NC, USA; Duke Clinical Research Institute, Duke University School of Medicine, Durham, NC, USA.
| | - Robert J Mentz
- Department of Medicine, Duke University School of Medicine, Durham, NC, USA; Duke Clinical Research Institute, Duke University School of Medicine, Durham, NC, USA
| | - Amanda Stebbins
- Duke Clinical Research Institute, Duke University School of Medicine, Durham, NC, USA
| | - Yuliya Lokhnygina
- Duke Clinical Research Institute, Duke University School of Medicine, Durham, NC, USA
| | - Aaron W Aday
- Division of Cardiovascular Medicine, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Neha J Pagidipati
- Department of Medicine, Duke University School of Medicine, Durham, NC, USA; Duke Clinical Research Institute, Duke University School of Medicine, Durham, NC, USA
| | - W Schuyler Jones
- Department of Medicine, Duke University School of Medicine, Durham, NC, USA; Duke Clinical Research Institute, Duke University School of Medicine, Durham, NC, USA
| | | | - Manesh R Patel
- Department of Medicine, Duke University School of Medicine, Durham, NC, USA; Duke Clinical Research Institute, Duke University School of Medicine, Durham, NC, USA
| | - Rury R Holman
- Diabetes Trials Unit, Radcliffe Department of Medicine, University of Oxford, Oxford, UK
| | - Adrian F Hernandez
- Department of Medicine, Duke University School of Medicine, Durham, NC, USA; Duke Clinical Research Institute, Duke University School of Medicine, Durham, NC, USA
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Weissler EH, Clare RM, Lokhnygina Y, Buse JB, Goodman SG, Katona B, Iqbal N, Pagidipati NJ, Sattar N, Holman RR, Hernandez AF, Mentz RJ, Patel MR, Jones WS. Predicting major adverse limb events in individuals with type 2 diabetes: Insights from the EXSCEL trial. Diabet Med 2021; 38:e14552. [PMID: 33690915 PMCID: PMC8429063 DOI: 10.1111/dme.14552] [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] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/28/2020] [Revised: 03/01/2021] [Accepted: 03/09/2021] [Indexed: 02/06/2023]
Abstract
AIMS Although models exist to predict amputation among people with type 2 diabetes with foot ulceration or infection, we aimed to develop a prediction model for a broader range of major adverse limb events (MALE)-including gangrene, revascularization and amputation-among individuals with type 2 diabetes. METHODS In a post-hoc analysis of data from the Exenatide Study of Cardiovascular Event Lowering (EXSCEL) trial, we compared participants who experienced MALE with those who did not. A multivariable model was constructed and translated into a risk score. RESULTS Among the 14,752 participants with type 2 diabetes in EXSCEL, 3.6% experienced MALE. Characteristics associated with increased risk of MALE were peripheral artery disease (PAD) (HRadj 4.83, 95% CI: 3.94-5.92), prior foot ulcer (HRadj 2.16, 95% CI: 1.63-2.87), prior amputation (HRadj 2.00, 95% CI: 1.53-2.64), current smoking (HRadj 2.00, 95% CI: 1.54-2.61), insulin use (HRadj 1.86, 95% CI: 1.52-2.27), coronary artery disease (HRadj 1.67, 95% CI: 1.38-2.03) and male sex (HRadj 1.64, 95% CI: 1.31-2.06). Cerebrovascular disease, former smoking, age, glycated haemoglobin, race and neuropathy were also associated significantly with MALE after adjustment. A risk score ranging from 6 to 96 points was constructed, with a C-statistic of 0.822 (95% CI: 0.803-0.841). CONCLUSIONS The majority of MALE occurred among participants with PAD, but participants without a history of PAD also experienced MALE. A risk score with good performance was generated. Although it requires validation in an external dataset, this risk score may be valuable in identifying patients requiring more intensive care and closer follow-up.
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Affiliation(s)
- E. Hope Weissler
- Division of Vascular Surgery, Duke University School of Medicine, Durham, NC
| | - Robert M. Clare
- Duke Clinical Research Institute, Duke University School of Medicine, Durham, NC
| | - Yuliya Lokhnygina
- Duke Clinical Research Institute, Duke University School of Medicine, Durham, NC
| | - John B. Buse
- Division of Endocrinology, University of North Carolina School of Medicine, Chapel Hill, NC
| | - Shaun G. Goodman
- Canadian VIGOUR Centre, University of Alberta, Edmonton, Alberta, and St. Michael's Hospital, Department of Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Brian Katona
- BioPharmaceuticals R&D, AstraZeneca, Gaithersburg, MD USA
| | - Nayyar Iqbal
- BioPharmaceuticals R&D, AstraZeneca, Gaithersburg, MD USA
| | - Neha J. Pagidipati
- Duke Clinical Research Institute, Duke University School of Medicine, Durham, NC
- Division of Cardiology, Duke University School of Medicine, Durham, NC
| | - Naveed Sattar
- Institute of Cardiovascular and Medical Sciences, University of Glasgow, Glasgow, UK
| | - Rury R. Holman
- Diabetes Trials Unit, Radcliffe Department of Medicine, University of Oxford, Oxford, UK
| | - Adrian F. Hernandez
- Duke Clinical Research Institute, Duke University School of Medicine, Durham, NC
- Division of Cardiology, Duke University School of Medicine, Durham, NC
| | - Robert J. Mentz
- Duke Clinical Research Institute, Duke University School of Medicine, Durham, NC
- Division of Cardiology, Duke University School of Medicine, Durham, NC
| | - Manesh R. Patel
- Duke Clinical Research Institute, Duke University School of Medicine, Durham, NC
- Division of Cardiology, Duke University School of Medicine, Durham, NC
| | - W. Schuyler Jones
- Duke Clinical Research Institute, Duke University School of Medicine, Durham, NC
- Division of Cardiology, Duke University School of Medicine, Durham, NC
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McGuire DK, Pagidipati NJ. GLP1 receptor agonists: from antihyperglycaemic to cardiovascular drugs. Lancet Diabetes Endocrinol 2021; 9:640-641. [PMID: 34425084 DOI: 10.1016/s2213-8587(21)00212-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/22/2021] [Accepted: 07/28/2021] [Indexed: 11/21/2022]
Affiliation(s)
- Darren K McGuire
- Division of Cardiology, University of Texas Southwestern Medical Center and Parkland Health and Hospital System, Dallas, TX 75235-8830, USA.
| | - Neha J Pagidipati
- Division of Cardiology, Duke University Medical Center and Duke Clinical Research Institute, Durham, NC, USA
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Pagidipati NJ, Deedwania P. A Comprehensive Cardiovascular-Renal-Metabolic Risk Reduction Approach to Patients with Type 2 Diabetes Mellitus. Am J Med 2021; 134:1076-1084. [PMID: 34029524 DOI: 10.1016/j.amjmed.2021.04.024] [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] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/15/2021] [Revised: 04/27/2021] [Accepted: 04/27/2021] [Indexed: 01/10/2023]
Abstract
Despite decades of research into risk-reduction strategies, cardiovascular disease and renal disease remain leading causes of morbidity and mortality among patients with type 2 diabetes mellitus. Given the tight clustering of cardiovascular and renal disease with the metabolic abnormalities of type 2 diabetes mellitus, we can think of these conditions together as cardiovascular-renal-metabolic disease states. A holistic view of cardiovascular-renal-metabolic disease states is critical to provide integrated patient-centered care to individuals with these disease states. Here, we explore the cardiovascular and renal risks associated with type 2 diabetes mellitus and highlight the importance of reducing cardiovascular-renal-metabolic disease risk in a comprehensive manner. We advocate a cross-disciplinary, team-based model to manage cardiovascular-renal-metabolic disease risk among patients with type 2 diabetes mellitus.
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Affiliation(s)
| | - Prakash Deedwania
- School of Medicine, University of California, San Francisco, Fresno.
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Nelson AJ, Pagidipati NJ, Aroda VR, Cavender MA, Green JB, Lopes RD, Al-Khalidi H, Gaynor T, Kaltenbach LA, Kirk JK, Lingvay I, Magwire ML, O'Brien EC, Pak J, Pop-Busui R, Richardson CR, Reed M, Senyucel C, Webb L, McGuire DK, Granger CB. Incorporating SGLT2i and GLP-1RA for Cardiovascular and Kidney Disease Risk Reduction: Call for Action to the Cardiology Community. Circulation 2021; 144:74-84. [PMID: 34228476 DOI: 10.1161/circulationaha.121.053766] [Citation(s) in RCA: 26] [Impact Index Per Article: 8.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/10/2023]
Abstract
Multiple sodium glucose cotransporter-2 inhibitors (SGLT-2i) and glucagon-like peptide-1 receptor agonists (GLP-1RA) have been shown to impart significant cardiovascular and kidney benefits, but are underused in clinical practice. Both SGLT-2i and GLP-1RA were first studied as glucose-lowering drugs, which may have impeded uptake by cardiologists in the wake of proven cardiovascular efficacy. Their significant effect on cardiovascular and kidney outcomes, which are largely independent of glucose-lowering effects, must drive a broader use of these drugs. Cardiologists are 3 times more likely than endocrinologists to see patients with both type 2 diabetes and cardiovascular disease, thus they are ideally positioned to share responsibility for SGLT-2i and GLP-1RA treatment with primary care providers. In order to increase adoption, SGLT-2i and GLP-1RA must be reframed as primarily cardiovascular and kidney disease risk-reducing agents with a side effect of glucose-lowering. Coordinated and multifaceted interventions engaging clinicians, patients, payers, professional societies, and health systems must be implemented to incentivize the adoption of these medications as part of routine cardiovascular and kidney care. Greater use of SGLT-2i and GLP-1RA will improve outcomes for patients with type 2 diabetes at high risk for cardiovascular and kidney disease.
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Affiliation(s)
- Adam J Nelson
- Duke Clinical Research Institute, Durham, NC (A.J.N., N.J.P., J.B.G., R.D.L., H.A., L.A.K., E.C.O., M.R., L.W., C.B.G.)
| | - Neha J Pagidipati
- Duke Clinical Research Institute, Durham, NC (A.J.N., N.J.P., J.B.G., R.D.L., H.A., L.A.K., E.C.O., M.R., L.W., C.B.G.)
| | | | | | - Jennifer B Green
- Duke Clinical Research Institute, Durham, NC (A.J.N., N.J.P., J.B.G., R.D.L., H.A., L.A.K., E.C.O., M.R., L.W., C.B.G.)
| | - Renato D Lopes
- Duke Clinical Research Institute, Durham, NC (A.J.N., N.J.P., J.B.G., R.D.L., H.A., L.A.K., E.C.O., M.R., L.W., C.B.G.)
| | - Hussein Al-Khalidi
- Duke Clinical Research Institute, Durham, NC (A.J.N., N.J.P., J.B.G., R.D.L., H.A., L.A.K., E.C.O., M.R., L.W., C.B.G.)
| | - Tanya Gaynor
- Boehringer Ingelheim Pharmaceuticals Inc, Ridgefield, CT (T.G., J.P.)
| | - Lisa A Kaltenbach
- Duke Clinical Research Institute, Durham, NC (A.J.N., N.J.P., J.B.G., R.D.L., H.A., L.A.K., E.C.O., M.R., L.W., C.B.G.)
| | | | - Ildiko Lingvay
- University of Texas Southwestern Medical Center, Dallas (I.L., D.K.)
| | | | - Emily C O'Brien
- Duke Clinical Research Institute, Durham, NC (A.J.N., N.J.P., J.B.G., R.D.L., H.A., L.A.K., E.C.O., M.R., L.W., C.B.G.)
| | - Jonathan Pak
- Boehringer Ingelheim Pharmaceuticals Inc, Ridgefield, CT (T.G., J.P.)
| | | | | | - Monica Reed
- Duke Clinical Research Institute, Durham, NC (A.J.N., N.J.P., J.B.G., R.D.L., H.A., L.A.K., E.C.O., M.R., L.W., C.B.G.)
| | | | - Laura Webb
- Duke Clinical Research Institute, Durham, NC (A.J.N., N.J.P., J.B.G., R.D.L., H.A., L.A.K., E.C.O., M.R., L.W., C.B.G.)
| | | | - Christopher B Granger
- Duke Clinical Research Institute, Durham, NC (A.J.N., N.J.P., J.B.G., R.D.L., H.A., L.A.K., E.C.O., M.R., L.W., C.B.G.)
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Pagidipati NJ, Svetkey LP. Time for a Renewed Focus on the DASH-Low Sodium Diet. J Am Coll Cardiol 2021; 77:2635-2637. [PMID: 34045019 DOI: 10.1016/j.jacc.2021.03.323] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/29/2021] [Accepted: 03/30/2021] [Indexed: 11/24/2022]
Affiliation(s)
- Neha J Pagidipati
- Duke University School of Medicine, Durham, North Carolina, USA; Duke Clinical Research Institute, Durham, North Carolina, USA.
| | - Laura P Svetkey
- Duke University School of Medicine, Durham, North Carolina, USA
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40
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Bihlmeyer NA, Kwee LC, Clish CB, Deik AA, Gerszten RE, Pagidipati NJ, Laferrère B, Svetkey LP, Newgard CB, Kraus WE, Shah SH. Metabolomic profiling identifies complex lipid species and amino acid analogues associated with response to weight loss interventions. PLoS One 2021; 16:e0240764. [PMID: 34043632 PMCID: PMC8158886 DOI: 10.1371/journal.pone.0240764] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/25/2020] [Accepted: 03/16/2021] [Indexed: 02/07/2023] Open
Abstract
Obesity is an epidemic internationally. While weight loss interventions are efficacious, they are compounded by heterogeneity with regards to clinically relevant metabolic responses. Thus, we sought to identify metabolic biomarkers that are associated with beneficial metabolic changes to weight loss and which distinguish individuals with obesity who would most benefit from a given type of intervention. Liquid chromatography mass spectrometry-based profiling was used to measure 765 metabolites in baseline plasma from three different weight loss studies: WLM (behavioral intervention, N = 443), STRRIDE-PD (exercise intervention, N = 163), and CBD (surgical cohort, N = 125). The primary outcome was percent change in insulin resistance (as measured by the Homeostatic Model Assessment of Insulin Resistance [%ΔHOMA-IR]) over the intervention. Overall, 92 individual metabolites were associated with %ΔHOMA-IR after adjustment for multiple comparisons. Concordantly, the most significant metabolites were triacylglycerols (TAGs; p = 2.3e-5) and diacylglycerols (DAGs; p = 1.6e-4), with higher baseline TAG and DAG levels associated with a greater improvement in insulin resistance with weight loss. In tests of heterogeneity, 50 metabolites changed differently between weight loss interventions; we found amino acids, peptides, and their analogues to be most significant (4.7e-3) in this category. Our results highlight novel metabolic pathways associated with heterogeneity in response to weight loss interventions, and related biomarkers which could be used in future studies of personalized approaches to weight loss interventions.
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Affiliation(s)
- Nathan A. Bihlmeyer
- Duke Molecular Physiology Institute, Duke University, Durham, North Carolina, United States of America
| | - Lydia Coulter Kwee
- Duke Molecular Physiology Institute, Duke University, Durham, North Carolina, United States of America
| | - Clary B. Clish
- Metabolomics Platform, Broad Institute of MIT and Harvard, Cambridge, Massachusetts, United States of America
| | - Amy Anderson Deik
- Metabolomics Platform, Broad Institute of MIT and Harvard, Cambridge, Massachusetts, United States of America
| | - Robert E. Gerszten
- Division of Cardiovascular Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts, United States of America
| | - Neha J. Pagidipati
- Duke Clinical Research Institute, Duke University, Durham, North Carolina, United States of America
- Department of Medicine, Duke University School of Medicine, Durham, North Carolina, United States of America
| | - Blandine Laferrère
- Columbia University Irving Medical Center, New York, New York, United States of America
| | - Laura P. Svetkey
- Department of Medicine, Duke University School of Medicine, Durham, North Carolina, United States of America
| | - Christopher B. Newgard
- Duke Molecular Physiology Institute, Duke University, Durham, North Carolina, United States of America
| | - William E. Kraus
- Duke Molecular Physiology Institute, Duke University, Durham, North Carolina, United States of America
| | - Svati H. Shah
- Duke Molecular Physiology Institute, Duke University, Durham, North Carolina, United States of America
- Duke Clinical Research Institute, Duke University, Durham, North Carolina, United States of America
- Department of Medicine, Duke University School of Medicine, Durham, North Carolina, United States of America
- * E-mail:
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41
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Kammerlander AA, Mayrhofer T, Ferencik M, Pagidipati NJ, Karady J, Ginsburg GS, Lu MT, Bittner DO, Puchner SB, Bihlmeyer NA, Meyersohn NM, Emami H, Shah SH, Douglas PS, Hoffmann U. Association of Metabolic Phenotypes With Coronary Artery Disease and Cardiovascular Events in Patients With Stable Chest Pain. Diabetes Care 2021; 44:1038-1045. [PMID: 33558267 PMCID: PMC7985425 DOI: 10.2337/dc20-1760] [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] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/14/2020] [Accepted: 01/11/2021] [Indexed: 02/03/2023]
Abstract
OBJECTIVE Obesity and metabolic syndrome are associated with major adverse cardiovascular events (MACE). However, whether distinct metabolic phenotypes differ in risk for coronary artery disease (CAD) and MACE is unknown. We sought to determine the association of distinct metabolic phenotypes with CAD and MACE. RESEARCH DESIGN AND METHODS We included patients from the Prospective Multicenter Imaging Study for Evaluation of Chest Pain (PROMISE) who underwent coronary computed tomography (CT) angiography. Obesity was defined as a BMI ≥30 kg/m2 and metabolically healthy as less than or equal to one metabolic syndrome component except diabetes, distinguishing four metabolic phenotypes: metabolically healthy/unhealthy and nonobese/obese (MHN, MHO, MUN, and MUO). Differences in severe calcification (coronary artery calcification [CAC] ≥400), severe CAD (≥70% stenosis), high-risk plaque (HRP), and MACE were assessed using adjusted logistic and Cox regression models. RESULTS Of 4,381 patients (48.4% male, 60.5 ± 8.1 years of age), 49.4% were metabolically healthy (30.7% MHN and 18.7% MHO) and 50.6% unhealthy (22.3% MUN and 28.4% MUO). MHO had similar coronary CT findings as compared with MHN (severe CAC/CAD and HRP; P > 0.36 for all). Among metabolically unhealthy patients, those with obesity had similar CT findings as compared with nonobese (P > 0.10 for all). However, both MUN and MUO had unfavorable CAD characteristics as compared with MHN (P ≤ 0.017 for all). A total of 130 events occurred during follow-up (median 26 months). Compared with MHN, MUN (hazard ratio [HR] 1.61 [95% CI 1.02-2.53]) but not MHO (HR 1.06 [0.62-1.82]) or MUO (HR 1.06 [0.66-1.72]) had higher risk for MACE. CONCLUSIONS In patients with stable chest pain, four metabolic phenotypes exhibit distinctly different CAD characteristics and risk for MACE. Individuals who are metabolically unhealthy despite not being obese were at highest risk in our cohort.
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Affiliation(s)
- Andreas A Kammerlander
- Cardiovascular Imaging Research Center, Massachusetts General Hospital, Harvard Medical School, Boston, MA .,Division of Cardiology, Medical University of Vienna, Vienna, Austria
| | - Thomas Mayrhofer
- Cardiovascular Imaging Research Center, Massachusetts General Hospital, Harvard Medical School, Boston, MA.,School of Business Studies, Stralsund University of Applied Sciences, Stralsund, Germany
| | - Maros Ferencik
- Cardiovascular Imaging Research Center, Massachusetts General Hospital, Harvard Medical School, Boston, MA.,Knight Cardiovascular Institute, Oregon Health & Science University, Portland, OR
| | - Neha J Pagidipati
- Duke Clinical Research Institute, Duke University School of Medicine, Durham, NC
| | - Julia Karady
- Cardiovascular Imaging Research Center, Massachusetts General Hospital, Harvard Medical School, Boston, MA
| | - Geoffrey S Ginsburg
- Duke Center for Applied Genomics & Precision Medicine, Duke University School of Medicine, Durham, NC
| | - Michael T Lu
- Cardiovascular Imaging Research Center, Massachusetts General Hospital, Harvard Medical School, Boston, MA
| | - Daniel O Bittner
- Cardiovascular Imaging Research Center, Massachusetts General Hospital, Harvard Medical School, Boston, MA.,Department of Cardiology, Friedrich-Alexander University Erlangen-Nürnberg, Erlangen, Germany
| | - Stefan B Puchner
- Cardiovascular Imaging Research Center, Massachusetts General Hospital, Harvard Medical School, Boston, MA.,Department of Biomedical Imaging and Image-Guided Therapy, Medical University of Vienna, Vienna, Austria
| | | | - Nandini M Meyersohn
- Cardiovascular Imaging Research Center, Massachusetts General Hospital, Harvard Medical School, Boston, MA
| | - Hamed Emami
- Cardiovascular Imaging Research Center, Massachusetts General Hospital, Harvard Medical School, Boston, MA
| | - Svati H Shah
- Duke Clinical Research Institute, Duke University School of Medicine, Durham, NC.,Duke Molecular Physiology Institute, Durham, NC
| | - Pamela S Douglas
- Duke Clinical Research Institute, Duke University School of Medicine, Durham, NC
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Nelson AJ, Pagidipati NJ, Granger CB. The SAMSON trial: using a placebo to improve medication tolerability. Eur Heart J Cardiovasc Pharmacother 2021; 7:e13. [PMID: 33638980 DOI: 10.1093/ehjcvp/pvab017] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Affiliation(s)
- Adam J Nelson
- Duke Clinical Research Institute and the Division of Cardiology, Duke University Medical Center, Durham, NC, USA
| | - Neha J Pagidipati
- Duke Clinical Research Institute and the Division of Cardiology, Duke University Medical Center, Durham, NC, USA
| | - Christopher B Granger
- Duke Clinical Research Institute and the Division of Cardiology, Duke University Medical Center, Durham, NC, USA
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43
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Goldstein BA, Phelan M, Pagidipati NJ, Peskoe SB. How and when informative visit processes can bias inference when using electronic health records data for clinical research. J Am Med Inform Assoc 2021; 26:1609-1617. [PMID: 31553474 DOI: 10.1093/jamia/ocz148] [Citation(s) in RCA: 16] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/13/2019] [Revised: 07/16/2019] [Accepted: 07/23/2019] [Indexed: 01/05/2023] Open
Abstract
OBJECTIVE Electronic health records (EHR) data have become a central data source for clinical research. One concern for using EHR data is that the process through which individuals engage with the health system, and find themselves within EHR data, can be informative. We have termed this process informed presence. In this study we use simulation and real data to assess how the informed presence can impact inference. MATERIALS AND METHODS We first simulated a visit process where a series of biomarkers were observed informatively and uninformatively over time. We further compared inference derived from a randomized control trial (ie, uninformative visits) and EHR data (ie, potentially informative visits). RESULTS We find that only when there is both a strong association between the biomarker and the outcome as well as the biomarker and the visit process is there bias. Moreover, once there are some uninformative visits this bias is mitigated. In the data example we find, that when the "true" associations are null, there is no observed bias. DISCUSSION These results suggest that an informative visit process can exaggerate an association but cannot induce one. Furthermore, careful study design can, mitigate the potential bias when some noninformative visits are included. CONCLUSIONS While there are legitimate concerns regarding biases that "messy" EHR data may induce, the conditions for such biases are extreme and can be accounted for.
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Affiliation(s)
- Benjamin A Goldstein
- Department of Biostatistics and Bioinformatics, Duke University, Durham, North Carolina, USA.,Center for Predictive Medicine, Duke Clinical Research Institute, Durham, North Carolina, USA
| | - Matthew Phelan
- Center for Predictive Medicine, Duke Clinical Research Institute, Durham, North Carolina, USA
| | - Neha J Pagidipati
- Center for Predictive Medicine, Duke Clinical Research Institute, Durham, North Carolina, USA.,Department of Medicine, Duke University, Durham, North Carolina, USA
| | - Sarah B Peskoe
- Department of Biostatistics and Bioinformatics, Duke University, Durham, North Carolina, USA
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Nelson AJ, Ardissino M, Haynes K, Shambhu S, Eapen ZJ, McGuire DK, Carnicelli A, Lopes RD, Green JB, O'Brien EC, Pagidipati NJ, Granger CB. Gaps in Evidence-Based Therapy Use in Insured Patients in the United States With Type 2 Diabetes Mellitus and Atherosclerotic Cardiovascular Disease. J Am Heart Assoc 2021; 10:e016835. [PMID: 33432843 PMCID: PMC7955303 DOI: 10.1161/jaha.120.016835] [Citation(s) in RCA: 29] [Impact Index Per Article: 9.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/13/2023]
Abstract
Background Evidence‐based therapies are generally underused for cardiovascular risk reduction; however, less is known about contemporary patients with type 2 diabetes mellitus and atherosclerotic cardiovascular disease. Methods and Results Pharmacy and medical claims data from within Anthem were queried for patients with established atherosclerotic cardiovascular disease and type 2 diabetes mellitus. Using an index date of April 18, 2018, we evaluated the proportion of patients with a prescription claim for any of the 3 evidence‐based therapies on, or covering, the index date ±30 days: high‐intensity statin, angiotensin‐converting enzyme inhibitor or angiotensin receptor blocker, and sodium glucose cotransporter‐2 inhibitor or glucagon‐like peptide‐1 receptor agonist. The potential benefit of achieving 100% adoption of all 3 evidence‐based therapies was simulated using pooled treatment estimates from clinical trials. Of the 155 958 patients in the sample, 24.7% were using a high‐intensity statin, 53.1% were using an angiotensin‐converting enzyme inhibitor or angiotensin receptor blocker, and 9.9% were using either an sodium glucose cotransporter‐2 inhibitor or glucagon‐like peptide‐1 receptor agonists. Overall, only 2.7% of the population were covered by prescriptions for all 3 evidence‐based therapies, and 37.4% were on none of them. Over a 12‐month period, 70.6% of patients saw a cardiologist, while only 18% saw an endocrinologist. Increasing the use of evidence‐based therapies to 100% over 3 years of treatment could be expected to reduce 4546 major atherosclerotic cardiovascular events (myocardial infarction, stroke, or cardiovascular death) in eligible but untreated patients. Conclusions Alarming gaps exist in the contemporary use of evidence‐based therapies in this large population of insured patients with type 2 diabetes mellitus and atherosclerotic cardiovascular disease. These data provide a call to action for patients, providers, industry, regulators, professional societies, and payers to close these gaps in care.
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Affiliation(s)
- Adam J Nelson
- Duke Clinical Research Institute Duke University School of Medicine Durham NC
| | - Maddalena Ardissino
- Duke Clinical Research Institute Duke University School of Medicine Durham NC.,Imperial College London London United Kingdom
| | | | | | | | | | - Anthony Carnicelli
- Duke Clinical Research Institute Duke University School of Medicine Durham NC
| | - Renato D Lopes
- Duke Clinical Research Institute Duke University School of Medicine Durham NC
| | - Jennifer B Green
- Duke Clinical Research Institute Duke University School of Medicine Durham NC
| | - Emily C O'Brien
- Duke Clinical Research Institute Duke University School of Medicine Durham NC
| | - Neha J Pagidipati
- Duke Clinical Research Institute Duke University School of Medicine Durham NC
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Blumer V, Pagidipati NJ. Hypertensive Disorders of Pregnancy and Long-Term Heart Failure Risk: A Missed Opportunity for Prevention. Hypertension 2020; 76:1420-1422. [PMID: 33026911 DOI: 10.1161/hypertensionaha.120.15924] [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: 11/16/2022]
Affiliation(s)
- Vanessa Blumer
- From the Division of Cardiology, Duke University Medical Center, Durham, NC (V.B., N.J.P.)
| | - Neha J Pagidipati
- From the Division of Cardiology, Duke University Medical Center, Durham, NC (V.B., N.J.P.).,Duke Clinical Research Institute, Durham, NC (N.J.P.)
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Nelson AJ, Navar AM, Mulder H, Wojdyla D, Philip S, Granowitz C, Peterson ED, Pagidipati NJ. Association Between Triglycerides and Residual Cardiovascular Risk in Patients With Type 2 Diabetes Mellitus and Established Cardiovascular Disease (From the Bypass Angioplasty Revascularization Investigation 2 Diabetes [BARI 2D] Trial). Am J Cardiol 2020; 132:36-43. [PMID: 32773223 DOI: 10.1016/j.amjcard.2020.07.005] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [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: 04/26/2020] [Revised: 07/01/2020] [Accepted: 07/03/2020] [Indexed: 01/15/2023]
Abstract
Triglyceride (TG) levels encompass several lipoproteins that have been implicated in atherogenic pathways. Whether TG levels independently associate with cardiovascular disease both overall and, in particular among patients with established coronary artery disease (CAD) and type 2 diabetes (T2DM), remains controversial. Data from the Bypass Angioplasty Revascularization Investigation 2 Diabetes (BARI 2D) trial was used to evaluate patients with T2DM and CAD. Cox proportional hazards models were used to determine the association between TG levels and outcomes. Stepwise adjustment was performed for demographics, clinical factors, lipid profile and statin treatment. The primary composite outcome was time to CV death, myocardial infarction (MI), or stroke and secondary outcome was CV death. Among 2,307 patients with T2DM and CAD, the mean (±SD) TG levels were 181 (±136) with a median (Q1-Q3) 148mg/dL (104-219). Overall, 51% of patients had TG <150 mg/dL, 18% 150-199 mg/dL, 28% 200-499 mg/dL and 3% ≥500 mg/dL. Participants with elevated TG levels (≥150 mg/dL) were younger (61 vs 63 years, p <0.001), had higher BMI (32 vs 30 kg/m2, p <0.001), more likely to have had prior MI (34.2 vs 30.1%, p = 0.033) and revascularization (25.8 vs 21.4%, p = 0.013), had lower HDL-C (34 vs 39 mg/dL, p <0.001) and higher HbA1c (8 vs 7%, p <0.001). In unadjusted analyses, baseline TG levels were linearly associated with both the primary composite and secondary outcomes. In fully adjusted analyses, every 50 mg/dL increase in TG level was associated with a 3.8% (HR 1.038, 95%CI 1.004-1.072, p <0.001) increase in the primary composite outcome and a 6.4% (HR 1.064 95%CI 1.018-1.113, p <0.001) increase in the secondary outcome. There was no interaction between TG and outcomes within key subgroups including female sex, additional non-coronary atherosclerotic disease, CKD or low LDL (<100 mg/dL). In conclusion, among patients with T2DM and CAD, elevated TG were independently associated with adverse cardiovascular outcomes, even after adjustment for clinical and simple biochemical covariates.
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Affiliation(s)
- Adam J Nelson
- Duke Clinical Research Institute, Duke University, Durham, North Carolina
| | - Ann Marie Navar
- Duke Clinical Research Institute, Duke University, Durham, North Carolina
| | - Hillary Mulder
- Duke Clinical Research Institute, Duke University, Durham, North Carolina
| | - Daniel Wojdyla
- Duke Clinical Research Institute, Duke University, Durham, North Carolina
| | | | | | - Eric D Peterson
- Duke Clinical Research Institute, Duke University, Durham, North Carolina
| | - Neha J Pagidipati
- Duke Clinical Research Institute, Duke University, Durham, North Carolina.
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Lumsden RH, Pagidipati NJ, Phelan MP, Chiswell K, Peterson ED. Prevalence and Management of Adult Obesity in a Large U.S. Academic Health System. Am J Prev Med 2020; 58:817-824. [PMID: 32444000 DOI: 10.1016/j.amepre.2020.01.018] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [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: 09/19/2019] [Revised: 01/19/2020] [Accepted: 01/20/2020] [Indexed: 10/24/2022]
Abstract
INTRODUCTION Both medication and surgical interventions can be used to treat obesity, yet their use and effectiveness in routine clinical practice are not clear. This study sought to characterize the prevalence and management of patients with obesity within a large U.S. academic medical center. METHODS All patients aged ≥18 years who were seen in a primary care clinic within the Duke Health System between 2013 and 2016 were included. Patients were categorized according to baseline BMI as underweight or normal weight (<25 kg/m2), overweight (25-29.9 kg/m2), Class I obesity (30-34.9 kg/m2), Class II obesity (35-39.9 kg/m2), and Class III obesity (≥40 kg/m2). Baseline characteristics and use of weight loss medication were assessed by BMI category. Predicted change in BMI was modeled over 3 years. All data were analyzed between 2017 and 2018. RESULTS Of the 173,462 included patients, most were overweight (32%) or obese (40%). Overall, <1% (n=295) of obese patients were prescribed medication for weight loss or underwent bariatric surgery within the 3-year study period. Most patients had no change in BMI class (70%) at 3 years. CONCLUSIONS Despite a high prevalence of obesity within primary care clinics of a large, U.S. academic health center, the use of pharmacologic and surgical therapies was low, and most patients had no weight change over 3 years. This highlights the significant need for improvement in obesity care at a health system level.
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Affiliation(s)
- Rebecca H Lumsden
- Department of Medicine, Duke University Medical Center, Durham, North Carolina
| | - Neha J Pagidipati
- Department of Medicine, Duke University Medical Center, Durham, North Carolina; Duke Clinical Research Institute, Duke University School of Medicine, Durham, North Carolina.
| | - Matthew P Phelan
- Duke Clinical Research Institute, Duke University School of Medicine, Durham, North Carolina
| | - Karen Chiswell
- Duke Clinical Research Institute, Duke University School of Medicine, Durham, North Carolina
| | - Eric D Peterson
- Department of Medicine, Duke University Medical Center, Durham, North Carolina; Duke Clinical Research Institute, Duke University School of Medicine, Durham, North Carolina
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Aberra T, Peterson ED, Pagidipati NJ, Mulder H, Wojdyla DM, Philip S, Granowitz C, Navar AM. The association between triglycerides and incident cardiovascular disease: What is "optimal"? J Clin Lipidol 2020; 14:438-447.e3. [PMID: 32571728 DOI: 10.1016/j.jacl.2020.04.009] [Citation(s) in RCA: 32] [Impact Index Per Article: 8.0] [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: 10/07/2019] [Revised: 04/24/2020] [Accepted: 04/27/2020] [Indexed: 02/08/2023]
Abstract
BACKGROUND Elevated triglycerides (TGs) are associated with increased risk of cardiovascular disease (CVD), but the best way to both measure TGs and assess TG-related risk remains unknown. OBJECTIVE The objective of the study was to evaluate the association between TGs and CVD and determine whether the average of a series of TG measurements is more predictive of CVD risk than a single TG measurement. METHODS We examined 15,792 study participants, aged 40-65 years, free of CVD from the Atherosclerosis Risk in Communities and Framingham Offspring studies, using fasting TG measurements across multiple examinations over time. With up to 10 years of follow-up, we assessed time-to-first CVD event, as well as a composite of myocardial infarction, stroke, or cardiovascular death. RESULTS Compared with a single TG measurement, average TGs over time had greater discrimination for CVD risk (C-statistic, 0.60 vs 0.57). Risk for CVD increased as average TGs rose until an inflection point of ~100 mg/dL in men and ~200 mg/dL in women, above which this risk association plateaued. The relationship between average TGs and CVD remained statistically significant in multivariable modeling adjusting for low-density lipoprotein cholesterol, and interactions were found by sex and high-density lipoprotein cholesterol level. CONCLUSIONS The average of several TG readings provides incremental improvements for the prediction of CVD relative to a single TG measurement. Regardless of the method of measurement, higher TGs were associated with increased CVD risk, even at levels previously considered "optimal" (<150 mg/dL).
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Affiliation(s)
- Tsion Aberra
- Duke Clinical Research Institute, Durham, NC, USA
| | | | | | | | | | - Sephy Philip
- Department of Medical Affairs, Amarin Pharma, Inc., Bedminster, NJ, USA
| | - Craig Granowitz
- Department of Medical Affairs, Amarin Pharma, Inc., Bedminster, NJ, USA
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Taron J, Foldyna B, Mayrhofer T, Osborne MT, Ferencik M, Pagidipati NJ, Douglas P, Hoffmann U. DIFFERENT SPECTRUM OF ADVERSE EVENTS IN PATIENTS WITH NONOBSTRUCTIVE VERSUS OBSTRUCTIVECORONARY ARTERY DISEASE: INSIGHTS FROM THE PROSPECTIVE MULTICENTER IMAGING STUDY FOR EVALUATION OF CHEST PAIN (PROMISE) TRIAL. J Am Coll Cardiol 2020. [DOI: 10.1016/s0735-1097(20)30647-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
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Reed SD, Li Y, Dakin HA, Becker F, Leal J, Gustavson SM, Kartman B, Wittbrodt E, Mentz RJ, Pagidipati NJ, Bethel MA, Gray AM, Holman RR, Hernandez AF. Within-Trial Evaluation of Medical Resources, Costs, and Quality of Life Among Patients With Type 2 Diabetes Participating in the Exenatide Study of Cardiovascular Event Lowering (EXSCEL). Diabetes Care 2020; 43:374-381. [PMID: 31806653 PMCID: PMC7210004 DOI: 10.2337/dc19-0950] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [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: 05/10/2019] [Accepted: 11/05/2019] [Indexed: 02/03/2023]
Abstract
OBJECTIVE To compare medical resource use, costs, and health utilities for 14,752 patients with type 2 diabetes who were randomized to once-weekly exenatide (EQW) or placebo in addition to usual diabetes care in the Exenatide Study of Cardiovascular Event Lowering (EXSCEL). RESEARCH DESIGN AND METHODS Medical resource use data and responses to the EuroQol 5-Dimension (EQ-5D) instrument were collected at baseline and throughout the trial. Medical resources and medications were assigned values by using U.S. Medicare payments and wholesale acquisition costs, respectively. Secondary analyses used English costs. RESULTS Patients were followed for an average of 3.3 years, during which time those randomized to EQW experienced 0.41 fewer inpatient days (7.05 vs. 7.46 days; relative rate ratio 0.91; P = 0.05). Rates of outpatient medical visits were similar, as were total inpatient and outpatient costs. Mean costs for nonstudy diabetes medications over the study period were ∼$1,600 lower with EQW than with placebo (P = 0.01). Total within-study costs, excluding study medication, were lower in the EQW arm than in the placebo arm ($28,907 vs. $30,914; P ≤ 0.01). When including the estimated cost of EQW, total mean costs were significantly higher in the EQW group than in the placebo group ($42,697 vs. $30,914; P < 0.01). With English costs applied, mean total costs, including exenatide costs, were £1,670 higher in the EQW group than the placebo group (£10,874 vs. £9,204; P < 0.01). There were no significant differences in EQ-5D health utilities between arms over time. CONCLUSIONS Medical costs were lower in the EQW arm than the placebo arm, but total costs were significantly higher once the cost of branded exenatide was incorporated.
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Affiliation(s)
- Shelby D Reed
- Duke Clinical Research Institute, Duke University School of Medicine, Durham, NC
| | - Yanhong Li
- Duke Clinical Research Institute, Duke University School of Medicine, Durham, NC
| | - Helen A Dakin
- Oxford Health Economic Research Centre, University of Oxford, Oxford, U.K
| | - Frauke Becker
- Oxford Health Economic Research Centre, University of Oxford, Oxford, U.K
| | - Jose Leal
- Oxford Health Economic Research Centre, University of Oxford, Oxford, U.K
| | | | | | | | - Robert J Mentz
- Duke Clinical Research Institute, Duke University School of Medicine, Durham, NC
| | - Neha J Pagidipati
- Duke Clinical Research Institute, Duke University School of Medicine, Durham, NC
| | | | - Alastair M Gray
- Oxford Health Economic Research Centre, University of Oxford, Oxford, U.K
| | - Rury R Holman
- Diabetes Trials Unit, University of Oxford, Oxford, U.K
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