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Ha JT, Freedman SB, Kelly DM, Neuen BL, Perkovic V, Jun M, Badve SV. Kidney Function, Albuminuria, and Risk of Incident Atrial Fibrillation: A Systematic Review and Meta-Analysis. Am J Kidney Dis 2024; 83:350-359.e1. [PMID: 37777059 DOI: 10.1053/j.ajkd.2023.07.023] [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: 03/22/2023] [Revised: 07/19/2023] [Accepted: 07/31/2023] [Indexed: 10/02/2023]
Abstract
RATIONALE & OBJECTIVE Atrial fibrillation (AF) and chronic kidney disease (CKD) often coexist. However, it is not known whether CKD is an independent risk factor for incident AF. Therefore, we evaluated the association between markers of CKD-estimated glomerular filtration rate (eGFR) and albuminuria-and incident AF. STUDY DESIGN Systematic review and meta-analysis of cohort studies and randomized controlled trials. SETTING & STUDY POPULATIONS Participants with measurement of eGFR and/or albuminuria who were not receiving dialysis. SELECTION CRITERIA FOR STUDIES Cohort studies and randomized controlled trials were included that reported incident AF risk in adults according to eGFR and/or albuminuria. ANALYTICAL APPROACH Age- or multivariate-adjusted risk ratios (RRs) for incident AF were extracted from cohort studies, and RRs for each trial were derived from event data. RRs for incident AF were pooled using random-effects models. RESULTS 38 studies involving 28,470,249 participants with 530,041 incident AF cases were included. Adjusted risk of incident AF was greater among participants with lower eGFR than those with higher eGFR (eGFR<60 vs≥60mL/min/1.73m2: RR, 1.43; 95% CI, 1.30-1.57; and eGFR<90 vs≥90mL/min/1.73m2: RR, 1.42; 95% CI, 1.26-1.60). Adjusted incident AF risk was greater among participants with albuminuria (any albuminuria vs no albuminuria: RR, 1.43; 95% CI, 1.25-1.63; and moderately to severely increased albuminuria vs normal to mildly increased albuminuria: RR, 1.64; 95% CI, 1.31-2.06). Subgroup analyses showed an exposure-dependent association between CKD and incident AF, with the risk increasing progressively at lower eGFR and higher albuminuria categories. LIMITATIONS Lack of patient-level data, interaction between eGFR and albuminuria could not be evaluated, possible ascertainment bias due to variation in the methods of AF detection. CONCLUSIONS Lower eGFR and greater albuminuria were independently associated with increased risk of incident AF. CKD should be regarded as an independent risk factor for incident AF. PLAIN-LANGUAGE SUMMARY Irregular heartbeat, or atrial fibrillation (AF), is the commonest abnormal heart rhythm. AF occurs commonly in people with chronic kidney disease (CKD), and CKD is also common in people with AF. However, CKD in not widely recognized as a risk factor for new-onset or incident AF. In this research, we combined data on more than 28 million participants in 38 studies to determine whether CKD itself increases the chances of incident AF. We found that both commonly used markers of kidney disease (estimated glomerular filtration rate and albuminuria, ie, protein in the urine) were independently associated with a greater risk of incident AF. This finding suggests that CKD should be recognized as an independent risk factor for incident AF.
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Affiliation(s)
- Jeffrey T Ha
- The George Institute for Global Health, Sydney, NSW, Australia; Faculty of Medicine and Health, University of New South Wales, Sydney, NSW, Australia; Department of Renal Medicine, St George Hospital, Sydney, NSW, Australia
| | - S Ben Freedman
- Heart Research Institute, Charles Perkins Centre, The University of Sydney, Sydney, NSW, Australia
| | - Dearbhla M Kelly
- J. Philip Kistler Stroke Research Center, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts; Global Brain Health Institute, Trinity College Dublin, Ireland
| | - Brendon L Neuen
- The George Institute for Global Health, Sydney, NSW, Australia; Faculty of Medicine and Health, University of New South Wales, Sydney, NSW, Australia
| | - Vlado Perkovic
- The George Institute for Global Health, Sydney, NSW, Australia; Faculty of Medicine and Health, University of New South Wales, Sydney, NSW, Australia
| | - Min Jun
- The George Institute for Global Health, Sydney, NSW, Australia; Faculty of Medicine and Health, University of New South Wales, Sydney, NSW, Australia
| | - Sunil V Badve
- The George Institute for Global Health, Sydney, NSW, Australia; Faculty of Medicine and Health, University of New South Wales, Sydney, NSW, Australia; Department of Renal Medicine, St George Hospital, Sydney, NSW, Australia.
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Sun W, Freedman SB, Martinez C, Wallenhorst C, Yan BP. ATRIAL FIBRILLATION DETECTED BY SINGLE TIMEPOINT HANDHELD ECG SCREENING AND THE RISK OF ISCHEMIC STROKE IN A YOUNGER CHINESE POPULATION AGED 55-64. J Am Coll Cardiol 2022. [DOI: 10.1016/s0735-1097(22)02472-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
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Chen Y, Huang QF, Sheng CS, Lei L, Xu SK, Zhang W, Shao S, Wang D, Cheng YB, Wang Y, Guo QH, Zhang DY, Li Y, Li Y, Freedman SB, Wang JG. Cross-sectional Association Between Blood Pressure Status and Atrial Fibrillation in an Elderly Chinese Population. Am J Hypertens 2019; 32:777-785. [PMID: 31004151 DOI: 10.1093/ajh/hpz060] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/02/2019] [Revised: 04/10/2019] [Accepted: 04/12/2019] [Indexed: 01/21/2023] Open
Abstract
OBJECTIVE Atrial fibrillation (AF) and hypertension are prevalent chronic disease conditions in the elderly population. In the present cross-sectional study, we investigated the association between blood pressure (BP) and AF in an elderly Chinese population. METHOD Our elderly (≥65 years) subjects were residents recruited from 6 communities in Shanghai from 2006 to 2017. Atrial fibrillation was systematically screened by rest 12-lead electrocardiogram (ECG) or by a handheld single-lead ECG. BP status was defined according to the European hypertension guidelines as optimal, normal, or high-normal BP, and stage 1, 2, or 3 hypertension. RESULT In the 6,966 participants (women 56.0%, mean age: 72.3 years), the prevalence of AF was 3.3%, and the prevalence of hypertension was 58.7% (83.7% treated). In all participants, the association with prevalent AF was negative for systolic BP (odds ratio [OR] per 10-mm Hg increase 0.79, 95% confidence interval [CI]: 0.71-0.88, P < 0.0001) but positive for diastolic BP (OR per 5-mm Hg increase 1.11, 95% CI: 1.02-1.22, P = 0.02). In untreated participants (n = 3,544), the association with prevalent AF was U-shaped for both systolic and diastolic BP, with the nadir at high-normal BP and a significantly higher risk of prevalent AF in optimal systolic BP (OR: 3.11, 95% CI: 1.65-5.85, P = 0.004) and stage 2 or 3 diastolic hypertension relative to the nadir (OR: 8.04, 95% CI: 2.28-28.3, P = 0.001). CONCLUSION In the elderly population, BP shows a complicated relationship with prevalent AF, with high-normal BP at the lowest risk and optimal systolic BP and stage 2 or 3 diastolic hypertension at increased risks.
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Affiliation(s)
- Yi Chen
- Department of Hypertension, Center for Epidemiological Studies and Clinical Trials, Shanghai Key Laboratory of Hypertension, The Shanghai Institute of Hypertension, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Qi-Fang Huang
- Department of Hypertension, Center for Epidemiological Studies and Clinical Trials, Shanghai Key Laboratory of Hypertension, The Shanghai Institute of Hypertension, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Chang-Sheng Sheng
- Department of Hypertension, Center for Epidemiological Studies and Clinical Trials, Shanghai Key Laboratory of Hypertension, The Shanghai Institute of Hypertension, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Lei Lei
- Department of Hypertension, Center for Epidemiological Studies and Clinical Trials, Shanghai Key Laboratory of Hypertension, The Shanghai Institute of Hypertension, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Shao-Kun Xu
- Department of Hypertension, Center for Epidemiological Studies and Clinical Trials, Shanghai Key Laboratory of Hypertension, The Shanghai Institute of Hypertension, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Wei Zhang
- Department of Hypertension, Center for Epidemiological Studies and Clinical Trials, Shanghai Key Laboratory of Hypertension, The Shanghai Institute of Hypertension, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Shuai Shao
- Department of Hypertension, Center for Epidemiological Studies and Clinical Trials, Shanghai Key Laboratory of Hypertension, The Shanghai Institute of Hypertension, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Dian Wang
- Department of Hypertension, Center for Epidemiological Studies and Clinical Trials, Shanghai Key Laboratory of Hypertension, The Shanghai Institute of Hypertension, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Yi-Bang Cheng
- Department of Hypertension, Center for Epidemiological Studies and Clinical Trials, Shanghai Key Laboratory of Hypertension, The Shanghai Institute of Hypertension, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Ying Wang
- Department of Hypertension, Center for Epidemiological Studies and Clinical Trials, Shanghai Key Laboratory of Hypertension, The Shanghai Institute of Hypertension, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Qian-Hui Guo
- Department of Hypertension, Center for Epidemiological Studies and Clinical Trials, Shanghai Key Laboratory of Hypertension, The Shanghai Institute of Hypertension, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Dong-Yan Zhang
- Department of Hypertension, Center for Epidemiological Studies and Clinical Trials, Shanghai Key Laboratory of Hypertension, The Shanghai Institute of Hypertension, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Yan Li
- Department of Hypertension, Center for Epidemiological Studies and Clinical Trials, Shanghai Key Laboratory of Hypertension, The Shanghai Institute of Hypertension, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Yong Li
- Department of Cardiology, Huashan Hospital, Fudan University, Shanghai, China
| | - S Ben Freedman
- Sydney Medical School, The University of Sydney, Sydney, Australia
- Department of Cardiology, Concord Hospital and Anzac Research Institute, Concord, Australia
| | - Ji-Guang Wang
- Department of Hypertension, Center for Epidemiological Studies and Clinical Trials, Shanghai Key Laboratory of Hypertension, The Shanghai Institute of Hypertension, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
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Xie J, Nettel-Aguirre A, Lee BE, Chui L, Pang XL, Zhuo R, Parsons B, Vanderkooi OG, Tarr PI, Ali S, Dickinson JA, Hagen E, Svenson LW, MacDonald SE, Drews SJ, Tellier R, Graham T, Lavoie M, MacDonald J, Freedman SB. Relationship between enteric pathogens and acute gastroenteritis disease severity: a prospective cohort study. Clin Microbiol Infect 2018; 25:454-461. [PMID: 29964235 DOI: 10.1016/j.cmi.2018.06.016] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2018] [Revised: 05/28/2018] [Accepted: 06/09/2018] [Indexed: 12/18/2022]
Abstract
OBJECTIVES To evaluate the relationship between individual bacterial and viral pathogens and disease severity. METHODS Children <18 years with three or more episodes of vomiting and/or diarrhoea were enrolled in two Canadian paediatric emergency departments between December 2014 and August 2016. Specimens were analysed employing molecular panels, and outcome data were collected 14 days after enrolment. The primary outcome was severe disease over the entire illness (symptom onset until 14-day follow-up), quantified employing the Modified Vesikari Scale (MVS) score. The score was additionally analysed in two other time periods: index (symptom onset until enrolment) and follow-up (enrolment until 14-day follow-up). RESULTS Median participant age was 20.7 (IQR: 11.3, 44.2) months; 47.4% (518/1093) and 73.4% (802/1093) of participants had index and total MVS scores ≥11, respectively. The most commonly identified pathogens were rotavirus (289/1093; 26.4%) and norovirus (258/1093; 23.6%). In multivariable analysis, severe disease over the entire illness was associated with rotavirus (OR = 9.60; 95%CI: 5.69, 16.19), Salmonella (OR = 6.61; 95%CI: 1.50, 29.17), adenovirus (OR = 2.53; 95%CI: 1.62, 3.97), and norovirus (OR = 1.43; 95%CI: 1.01, 2.01). Pathogens associated with severe disease at the index visit were: rotavirus only (OR = 6.13; 95%CI: 4.29, 8.75), Salmonella (OR = 4.59; 95%CI: 1.71, 12.29), adenovirus only (OR = 2.06; 95%CI: 1.41, 3.00), rotavirus plus adenovirus (OR = 3.15; 95%CI: 1.35, 7.37), and norovirus (OR = 0.68; 95%CI: 0.49, 0.94). During the follow-up period, rotavirus (OR = 2.21; 95%CI: 1.50, 3.25) and adenovirus (OR = 2.10; 95%CI: 1.39, 3.18) were associated with severe disease. CONCLUSIONS In children presenting for emergency department care with acute gastroenteritis, pathogens identified were predominantly viruses, and several of which were associated with severe disease. Salmonella was the sole bacterium independently associated with severe disease.
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Affiliation(s)
- J Xie
- Section of Pediatric Emergency Medicine, Alberta Children's Hospital, University of Calgary, Calgary, Alberta, Canada
| | - A Nettel-Aguirre
- Departments of Pediatrics and of Community Health Sciences, Cumming School of Medicine, Faculty of Kinesiology, Alberta Children's Hospital Research Institute, O'Brien Population Health Institute, University of Calgary, Calgary, Alberta, Canada
| | - B E Lee
- Department of Pediatrics, Faculty of Medicine and Dentistry, Women and Children's Health Research Institute, University of Alberta, Edmonton, Alberta, Canada
| | - L Chui
- Provincial Laboratory for Public Health, Alberta, Canada; Department of Laboratory Medicine and Pathology, University of Alberta, Edmonton, Alberta, Canada
| | - X L Pang
- Provincial Laboratory for Public Health, Alberta, Canada; Department of Laboratory Medicine and Pathology, University of Alberta, Edmonton, Alberta, Canada
| | - R Zhuo
- Department of Laboratory Medicine and Pathology, University of Alberta, Edmonton, Alberta, Canada
| | - B Parsons
- Department of Laboratory Medicine and Pathology, University of Alberta, Edmonton, Alberta, Canada
| | - O G Vanderkooi
- Departments of Pediatrics, Microbiology, Immunology and Infectious Diseases, Pathology and Laboratory Medicine and Community Health Sciences and the Alberta Children's Hospital Research Institute, University of Calgary, Calgary, Alberta, Canada
| | - P I Tarr
- Division of Gastroenterology, Hepatology, and Nutrition, Department of Pediatrics, Washington University School of Medicine, St Louis, MO, USA
| | - S Ali
- Department of Pediatrics, Faculty of Medicine and Dentistry, Women and Children's Health Research Institute, University of Alberta, Edmonton, Alberta, Canada
| | - J A Dickinson
- Department of Family Medicine, University of Calgary, Calgary, Alberta, Canada; Department of Community Health Sciences, University of Calgary, Calgary, Alberta, Canada
| | - E Hagen
- Section of Pediatric Emergency Medicine, Alberta Children's Hospital, University of Calgary, Calgary, Alberta, Canada
| | - L W Svenson
- Analytics and Performance Reporting, Alberta Health Division of Preventive Medicine, School of Public Health, University of Alberta, Edmonton, Alberta, Canada
| | - S E MacDonald
- Faculty of Nursing, University of Alberta, Edmonton, Canada; School of Public Health, University of Alberta, Edmonton, Canada; Department of Pediatrics, University of Calgary, Calgary, Alberta, Canada
| | - S J Drews
- Provincial Laboratory for Public Health, Alberta, Canada; Department of Laboratory Medicine and Pathology, University of Alberta, Edmonton, Alberta, Canada
| | - R Tellier
- Provincial Laboratory for Public Health, Alberta, Canada; Departments of Pathology and Laboratory Medicine and Microbiology, Immunology and Infectious Diseases, University of Calgary, Calgary, Alberta, Canada
| | - T Graham
- Alberta Health Services, Edmonton Zone, Alberta, Canada; Department of Emergency Medicine, Faculty of Medicine & Dentistry, University of Alberta, Edmonton, Alberta, Canada
| | - M Lavoie
- Population and Public Health, Fraser Health, Surrey, British Columbia, Canada
| | - J MacDonald
- Department of Community Health Sciences, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - S B Freedman
- Sections of Pediatric Emergency Medicine and Gastroenterology, Alberta Children's Hospital, Alberta Children's Hospital Research Institute, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada.
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Lowres N, Neubeck L, Redfern J, Freedman SB. Screening to identify unknown atrial fibrillation. Thromb Haemost 2017; 110:213-22. [DOI: 10.1160/th13-02-0165] [Citation(s) in RCA: 242] [Impact Index Per Article: 34.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/24/2013] [Accepted: 03/21/2013] [Indexed: 11/05/2022]
Abstract
SummaryAtrial fibrillation (AF) is associated with a significantly increased stroke risk which is highly preventable with appropriate oral anticoagulant therapy (OAC). However, AF may be asymptomatic and unrecognised prior to stroke. We aimed to determine if single time-point screening for AF could identify sufficient numbers with previously undiagnosed AF, to be effective for stroke prevention. This is a systematic review of clinical trials, by searching electronic medical databases, reference lists and grey literature. Studies were included if they evaluated a general ambulant adult population, using electrocardiography or pulse palpation to identify AF. We identified 30 individual studies (n=122,571, mean age 64 years, 54% male) in nine countries. Participants were recruited either from general practitioner and outpatient clinics (12 studies) or population screening/community advertisements (18 studies). Prevalence of AF across all studies was 2.3% (95% CI, 2.2–2.4%), increasing to 4.4% (CI, 4.1–4.6%) in those ≥65 years (16 studies, n= 27,884). Overall incidence of previously unknown AF (14 studies, n=67,772) was 1.0% (CI, 0.89–1.04%), increasing to 1.4% (CI, 1.2–1.6%) in those ≥65 years (8 studies, n= 18,189) in whom screening setting did not influence incidence identified. Of those with previously unknown AF, 67% were at high risk of stroke. Screening can identify 1.4% of the population ≥65 years with previously undiagnosed AF. Many of those identified would be eligible for, and benefit from OAC to prevent stroke. Given this incidence, community AF screening strategies in at risk older age groups could potentially reduce the overall health burden associated with AF.
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Lowres N, Neubeck L, Salkeld G, Krass I, McLachlan AJ, Redfern J, Bennett AA, Briffa T, Bauman A, Martinez C, Wallenhorst C, Lau JK, Brieger DB, Sy RW, Freedman SB. Feasibility and cost-effectiveness of stroke prevention through community screening for atrial fibrillation using iPhone ECG in pharmacies. Thromb Haemost 2017; 111:1167-76. [DOI: 10.1160/th14-03-0231] [Citation(s) in RCA: 355] [Impact Index Per Article: 50.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/13/2014] [Accepted: 03/18/2014] [Indexed: 11/05/2022]
Abstract
SummaryAtrial fibrillation (AF) causes a third of all strokes, but often goes undetected before stroke. Identification of unknown AF in the community and subsequent anti-thrombotic treatment could reduce stroke burden. We investigated community screening for unknown AF using an iPhone electrocardiogram (iECG) in pharmacies, and determined the cost-effectiveness of this strategy. Pharmacists performed pulse palpation and iECG recordings, with cardiologist iECG over-reading. General practitioner review/12-lead ECG was facilitated for suspected new AF. An automated AF algorithm was retrospectively applied to collected iECGs. Cost-effectiveness analysis incorporated costs of iECG screening, and treatment/outcome data from a United Kingdom cohort of 5,555 patients with incidentally detected asymptomatic AF. A total of 1,000 pharmacy customers aged ≥65 years (mean 76 ± 7 years; 44% male) were screened. Newly identified AF was found in 1.5% (95% CI, 0.8–2.5%); mean age 79 ± 6 years; all had CHA2DS2-VASc score ≥2. AF prevalence was 6.7% (67/1,000). The automated iECG algorithm showed 98.5% (CI, 92–100%) sensitivity for AF detection and 91.4% (CI, 89–93%) specificity. The incremental cost-effectiveness ratio of extending iECG screening into the community, based on 55% warfarin prescription adherence, would be $AUD5,988 (€3,142; $USD4,066) per Quality Adjusted Life Year gained and $AUD30,481 (€15,993; $USD20,695) for preventing one stroke. Sensitivity analysis indicated cost-effectiveness improved with increased treatment adherence. Screening with iECG in pharmacies with an automated algorithm is both feasible and cost-effective. The high and largely preventable stroke/thromboembolism risk of those with newly identified AF highlights the likely benefits of community AF screening. Guideline recommendation of community iECG AF screening should be considered.Previous Presentation: This study was presented in part as an oral presentation at the Cardiac Society of Australia and New Zealand Conference; 9 August 2013; Sydney, Australia, abstract published in Heart Lung Circulation 2013;22:S223.Trial registration: Australian New Zealand clinical trials registry: ACTRN12612000406808.
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Neubeck L, Orchard J, Lowres N, Freedman SB. To Screen or Not to Screen? Examining the Arguments Against Screening for Atrial Fibrillation. Heart Lung Circ 2017. [DOI: 10.1016/j.hlc.2017.05.118] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
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Simons LA, Ortiz M, Freedman SB, Waterhouse BJ, Colquhoun D, Thomas G. Improved persistence with non-vitamin-K oral anticoagulants compared with warfarin in patients with atrial fibrillation: recent Australian experience. Curr Med Res Opin 2016; 32:1857-1861. [PMID: 27463735 DOI: 10.1080/03007995.2016.1218325] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.6] [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] [Indexed: 02/07/2023]
Abstract
OBJECTIVE Long-term anticoagulant therapy in patients with non-valvular atrial fibrillation (AF) is essential to prevent thromboembolic complications, especially ischemic stroke, but treatment persistence with warfarin is poor. This study examines Australian nationwide persistence in AF patients using a non-vitamin-K oral anticoagulant (NOAC) drug. RESEARCH DESIGN AND METHODS We assessed national Pharmaceutical Benefit Scheme records November-December 2013 through March 2015 for prescription of NOAC drugs in a 10% random sample of long-term concession card holders. An historical comparison was made with patients prescribed warfarin in 2008. Key outcome measures were (i) the proportion not filling first repeat prescription and (ii) discontinuation within 12 months. RESULTS A total of 1471 patients with AF were new users of a NOAC drug (228 apixaban, 645 dabigatran, 598 rivaroxaban) and 1348 were new users of warfarin. Mean age on a NOAC was 76 years (58% male), on warfarin 74 years (54% male). Only 9% (95% CI 7-10) failed to collect the first repeat prescription on a NOAC, 30% (27-32) discontinued within 12 months; corresponding proportions on warfarin were 14% (12-16) and 62% (60-65). In a regression model adjusted for age, gender, heart failure, hypertension and diabetes, warfarin-treated patients were 2.5 times more likely to discontinue over 12 months than those who were NOAC treated (hazard ratio =2.47 [95% CI 2.19-2.79]). CONCLUSIONS Persistence with NOAC drugs in patients with AF appears to be superior to warfarin. If continued long-term, this alone will be of clinical importance in the prevention of stroke and death.
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Affiliation(s)
- Leon A Simons
- a UNSW Lipid Research Department , St Vincent's Hospital , Darlinghurst , NSW , Australia
| | - Michael Ortiz
- b UNSW St Vincent's Clinical School , Darlinghurst , NSW , Australia
- c Zitro Consulting Services , Sydney , Australia
| | - S Ben Freedman
- d Sydney Medical School, University of Sydney , Concord Repatriation General Hospital Cardiology Department , NSW , Australia
- e Anzac Institute , Concord , NSW , Australia
| | | | - David Colquhoun
- g University of Queensland, Wesley Medical Centre , Auchenflower , QLD , Australia
| | - Gareth Thomas
- h Pfizer Australia Pty Ltd , West Ryde , NSW , Australia
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Orchard J, Lowres N, Freedman SB, Ladak L, Lee W, Zwar N, Peiris D, Kamaladasa Y, Li J, Neubeck L. Screening for atrial fibrillation during influenza vaccinations by primary care nurses using a smartphone electrocardiograph (iECG): A feasibility study. Eur J Prev Cardiol 2016; 23:13-20. [DOI: 10.1177/2047487316670255] [Citation(s) in RCA: 72] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Affiliation(s)
- Jessica Orchard
- Sydney Nursing School, Charles Perkins Centre, University of Sydney, Australia
- Sydney Medical School, University of Sydney, Australia
| | - Nicole Lowres
- Sydney Nursing School, Charles Perkins Centre, University of Sydney, Australia
| | - S Ben Freedman
- Sydney Medical School, University of Sydney, Australia
- Cardiology Department, Concord Repatriation General Hospital, University of Sydney, Australia
- Anzac Research Institute, Sydney, Australia
- Heart Research Institute, Charles Perkins Centre, University of Sydney, Australia
| | - Laila Ladak
- Sydney Nursing School, Charles Perkins Centre, University of Sydney, Australia
| | - William Lee
- Victor Chang Cardiac Research Institute, Sydney, Australia
| | - Nicholas Zwar
- School of Public Health and Community Medicine, University of New South Wales, Australia
| | - David Peiris
- The George Institute for Global Health, Sydney, Australia
| | | | - Jialin Li
- Sydney Nursing School, Charles Perkins Centre, University of Sydney, Australia
| | - Lis Neubeck
- Sydney Nursing School, Charles Perkins Centre, University of Sydney, Australia
- School of Nursing, Midwifery and Social Care, Edinburgh Napier University, UK
- School of Nursing and Midwifery, Faculty of Medicine, Nursing and Health Sciences, Flinders University, Australia
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Orchard J, Lowres N, Freedman SB, Li J, Neubeck L. Feasibility of screening for atrial fibrillation in primary care: Just a heartbeat away? Eur J Prev Cardiol 2016; 23:1783-1784. [PMID: 27489238 DOI: 10.1177/2047487316663547] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Affiliation(s)
| | | | | | - Jialin Li
- University of Sydney, Sydney, Australia
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Piraino PS, Yednock TA, Freedman SB, Messersmith EK, Pleiss MA, Karlik SJ. Suppression of acute experimental allergic encephalomyelitis with a small molecule inhibitor of α4 integrin. Mult Scler 2016; 11:683-90. [PMID: 16320728 DOI: 10.1191/1352458505ms1223oa] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
Purpose: To determine the efficacy of a small molecule inhibitor of α4 integrin (CT301) at reversing the clinical, pathological and MR- detectable deficits associated with the acute phase of experimental allergic encephalomyelitis (EAE). Materials and methods: EAE was induced in 36 female Hartley guinea pigs, and the treatment period was from day 11 to day 17 post-immunization. Animals received either saline (n=12), anti-α4 integrin antibody (AN100226m; n=12) or CT301 (n=12). T2-weighted fast spin echo and T1-weighted pre- and post-contrast scans were performed at the beginning (day 11) and end (day 18) of the treatment period, and scored for cerebral inflammation and gadolinium enhancement. T1-weighted images were further analyzed to quantify this enhancement as a measure of blood-brain barrier integrity. Dissected CNS was evaluated for inflammation and demyelination. Results: CT301 successfully reversed two clinical indicators of disease over the course of the treatment period. These animals showed decreased T2-weighted abnormalities, as well as a reduction in gadolinium leakage on T1-weighted images. Meningeal and perivascular inflammation was decreased by anti-α4 integrin treatments. Conclusion: CT301 effectively reverses the clinical, pathological and MR-detectable deficits of acute EAE, and may therefore be a promising therapeutic agent in multiple sclerosis (MS).
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Affiliation(s)
- P S Piraino
- Department of Physiology and Pharmacology, University of Western Ontario, London, Canada
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Chan T, Dabin B, Hyun K, Ranasinghe I, Neubeck L, Aliprandi-Costa B, Lefkovits J, Devlin G, Juergens C, Chew DP, Brieger D, Freedman SB. Falling cholesterol trend at acute coronary syndrome presentation is strongly related to statin use for secondary prevention. Int J Cardiol 2016; 212:192-7. [DOI: 10.1016/j.ijcard.2016.03.038] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/10/2015] [Revised: 02/27/2016] [Accepted: 03/13/2016] [Indexed: 10/22/2022]
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Affiliation(s)
- S Ben Freedman
- Sydney Medical School, The University of Sydney, Sydney, Australia2Department of Cardiology, Concord Hospital, Sydney, Australia3Anzac Research Institute, Concord, Sydney, Australia
| | - Nicole Lowres
- Sydney Medical School, The University of Sydney, Sydney, Australia2Department of Cardiology, Concord Hospital, Sydney, Australia3Anzac Research Institute, Concord, Sydney, Australia
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Kirchhof P, Breithardt G, Bax J, Benninger G, Blomstrom-Lundqvist C, Boriani G, Brandes A, Brown H, Brueckmann M, Calkins H, Calvert M, Christoffels V, Crijns H, Dobrev D, Ellinor P, Fabritz L, Fetsch T, Freedman SB, Gerth A, Goette A, Guasch E, Hack G, Haegeli L, Hatem S, Haeusler KG, Heidbüchel H, Heinrich-Nols J, Hidden-Lucet F, Hindricks G, Juul-Möller S, Kääb S, Kappenberger L, Kespohl S, Kotecha D, Lane DA, Leute A, Lewalter T, Meyer R, Mont L, Münzel F, Nabauer M, Nielsen JC, Oeff M, Oldgren J, Oto A, Piccini JP, Pilmeyer A, Potpara T, Ravens U, Reinecke H, Rostock T, Rustige J, Savelieva I, Schnabel R, Schotten U, Schwichtenberg L, Sinner MF, Steinbeck G, Stoll M, Tavazzi L, Themistoclakis S, Tse HF, Van Gelder IC, Vardas PE, Varpula T, Vincent A, Werring D, Willems S, Ziegler A, Lip GY, Camm AJ. A roadmap to improve the quality of atrial fibrillation management: proceedings from the fifth Atrial Fibrillation Network/European Heart Rhythm Association consensus conference. Europace 2015; 18:37-50. [DOI: 10.1093/europace/euv304] [Citation(s) in RCA: 103] [Impact Index Per Article: 11.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/26/2015] [Accepted: 08/13/2015] [Indexed: 12/30/2022] Open
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Freedman SB, Martinez C, Lowres N, Neubeck L. "Off the pulse" about incidental atrial fibrillation. Lancet 2015; 386:1339-1340. [PMID: 26460775 DOI: 10.1016/s0140-6736(15)00333-5] [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] [Indexed: 11/28/2022]
Affiliation(s)
- S Ben Freedman
- Sydney Medical School, University of Sydney, Sydney, NSW, Australia; Department of Cardiology, Concord Hospital and Anzac Research Institute, Concord, NSW 2137, Australia.
| | - Carlos Martinez
- Institute for Epidemiology, Statistics and Informatics, Frankfurt, Germany
| | - Nicole Lowres
- Sydney Medical School, University of Sydney, Sydney, NSW, Australia; Department of Cardiology, Concord Hospital and Anzac Research Institute, Concord, NSW 2137, Australia
| | - Lis Neubeck
- Sydney Nursing School, Charles Perkins Centre, University of Sydney, Sydney, NSW, Australia
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Lowres N, Krass I, Neubeck L, Redfern J, McLachlan AJ, Bennett AA, Freedman SB. Atrial fibrillation screening in pharmacies using an iPhone ECG: a qualitative review of implementation. Int J Clin Pharm 2015. [DOI: 10.1007/s11096-015-0169-1] [Citation(s) in RCA: 42] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
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Sindone AP, Freedman SB. Is risk-benefit of warfarin for atrial fibrillation with heart failure determined by heart failure severity? Thromb Haemost 2015; 114:1-3. [PMID: 25947352 DOI: 10.1160/th15-04-0297] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/10/2015] [Accepted: 04/10/2015] [Indexed: 12/18/2022]
Affiliation(s)
- Andrew P Sindone
- Prof. Andrew Sindone, Department of Cardiology, Concord Hospital, Sydney, NSW 2139, Australia, E-mail:
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Freedman SB, Katholing A, Reitbrock S, Martinez C. RESIDUAL RISK OF STROKE AND DEATH IN ANTICOAGULANT TREATED INCIDENTAL ATRIAL FIBRILLATION. J Am Coll Cardiol 2015. [DOI: 10.1016/s0735-1097(15)60345-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
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Lowres N, Freedman SB, Gallagher R, Kirkness A, Marshman D, Orchard J, Neubeck L. Identifying postoperative atrial fibrillation in cardiac surgical patients posthospital discharge, using iPhone ECG: a study protocol. BMJ Open 2015; 5:e006849. [PMID: 25586373 PMCID: PMC4298095 DOI: 10.1136/bmjopen-2014-006849] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/05/2022] Open
Abstract
INTRODUCTION Postoperative atrial fibrillation (AF) occurs in 30-40% of patients after cardiac surgery. Identification of recurrent postoperative AF is required to initiate evidence-based management to reduce the risk of subsequent stroke. However, as AF is often asymptomatic, recurrences may not be detected after discharge. This study determines feasibility and impact of a self-surveillance programme to identify recurrence of postoperative AF in the month of posthospital discharge. METHODS AND ANALYSIS This is a feasibility study, using a cross-sectional study design, of self-screening for AF using a hand-held single-lead iPhone electrocardiograph device (iECG). Participants will be recruited from the cardiothoracic surgery wards of the Royal North Shore Hospital and North Shore Private Hospital, Sydney, Australia. Cardiac surgery patients admitted in sinus rhythm and experiencing a transient episode of postoperative AF will be eligible for recruitment. Participants will be taught to take daily ECG recordings for 1 month posthospital discharge using the iECG and will be provided education regarding AF, including symptoms and health risks. The primary outcome is the feasibility of patient self-monitoring for AF recurrence using an iECG. Secondary outcomes include proportion of patients identified with recurrent AF; estimation of stroke risk and patient knowledge. Process outcomes and qualitative data related to acceptability of patient's use of the iECG and sustainability of the screening programme beyond the trial setting will also be collected. ETHICS AND DISSEMINATION Primary ethics approval was received on 25 February 2014 from Northern Sydney Local Health District Human Resource Ethics Committee, and on 17 July 2014 from North Shore Private Hospital Ethics Committee. Results will be disseminated via forums including, but not limited to, peer-reviewed publications and presentation at national and international conferences. TRIAL REGISTRATION NUMBER ACTRN12614000383662.
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Affiliation(s)
- Nicole Lowres
- Cardiology Department, Concord Repatriation General Hospital, Sydney, New South Wales, Australia
- Department of Vascular Biology, Anzac Research Institute, Concord, New South Wales, Australia
- Sydney Medical School, University of Sydney, Sydney, New South Wales, Australia
| | - S Ben Freedman
- Cardiology Department, Concord Repatriation General Hospital, Sydney, New South Wales, Australia
- Department of Vascular Biology, Anzac Research Institute, Concord, New South Wales, Australia
- Sydney Medical School, University of Sydney, Sydney, New South Wales, Australia
| | - Robyn Gallagher
- Sydney Nursing School, University of Sydney, Sydney, New South Wales, Australia
| | - Ann Kirkness
- North Shore Cardiovascular Education Centre, Royal North Shore Hospital, Sydney, New South Wales, Australia
| | - David Marshman
- Department of Cardiothoracic Surgery, Royal North Shore Hospital, Sydney, New South Wales, Australia
| | - Jessica Orchard
- School of Public Health, University of Sydney, Sydney, New South Wales, Australia
| | - Lis Neubeck
- Sydney Nursing School, University of Sydney, Sydney, New South Wales, Australia
- The George Institute for Global Health, Sydney, New South Wales, Australia
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Ben Freedman S, Gersh BJ, Lip GYH. Misperceptions of aspirin efficacy and safety may perpetuate anticoagulant underutilization in atrial fibrillation. Eur Heart J 2014; 36:653-6. [PMID: 25548061 DOI: 10.1093/eurheartj/ehu494] [Citation(s) in RCA: 46] [Impact Index Per Article: 4.6] [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: 12/20/2022] Open
Affiliation(s)
- S Ben Freedman
- Sydney Medical School, Concord Clinical School, The University of Sydney, Concord, NSW 2139, Australia Department of Cardiology and Anzac Research Institute, Concord Hospital 3W, The University of Sydney, Hospital Rd, Concord, NSW 2139, Australia
| | - Bernard J Gersh
- Division of Cardiovascular Diseases, Mayo Clinic College of Medicine, Rochester, MN, USA
| | - Gregory Y H Lip
- University of Birmingham Centre for Cardiovascular Sciences, City Hospital, Birmingham, UK Aalborg University, Aalborg, Denmark
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Lowres N, Redfern J, Freedman SB, Orchard J, Bennett AA, Briffa T, Bauman A, Neubeck L. Choice of Health Options In prevention of Cardiovascular Events for people with Atrial Fibrillation (CHOICE-AF): A pilot study. Eur J Cardiovasc Nurs 2014; 15:39-46. [DOI: 10.1177/1474515114549687] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/31/2014] [Accepted: 08/11/2014] [Indexed: 11/16/2022]
Affiliation(s)
- Nicole Lowres
- Cardiology Department, Concord Repatriation General Hospital, Australia
- Sydney Medical School, University of Sydney, Australia
| | - Julie Redfern
- Sydney Medical School, University of Sydney, Australia
- The George Institute for Global Health, Australia
| | - S Ben Freedman
- Cardiology Department, Concord Repatriation General Hospital, Australia
- Sydney Medical School, University of Sydney, Australia
| | | | - Alexandra A Bennett
- Faculty of Pharmacy, University of Sydney, Australia
- Centre for Education and Research on Aging, Concord Repatriation General Hospital, Australia
| | - Tom Briffa
- School of Population Health, University of Western Australia, Australia
| | - Adrian Bauman
- School of Public Health, University of Sydney, Australia
| | - Lis Neubeck
- The George Institute for Global Health, Australia
- Sydney Nursing School, University of Sydney, Australia
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Martinez C, Katholing A, Freedman SB. Adverse prognosis of incidentally detected ambulatory atrial fibrillation. A cohort study. Thromb Haemost 2014; 112:276-86. [PMID: 24953051 DOI: 10.1160/th4-04-0383] [Citation(s) in RCA: 108] [Impact Index Per Article: 10.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/24/2014] [Accepted: 05/14/2014] [Indexed: 11/05/2022]
Abstract
It was the aim of this study to determine prognosis of incidentally detected ambulatory atrial fibrillation (IA-AF) and its response to antithrombotic therapy. We performed a cohort study of 5,555 patients with IA-AF (mean age 70.9 ± 10.1, 38.4% female) and 24,705 age- and gender-matched controls without AF followed three years using UK Clinical Practice Research Datalink. We measured incidence rates of stroke, all-cause mortality, myocardial infarction, major bleeding, and effect of antithrombotic therapy. Patients with IA-AF had mean CHA2DS2VASc score 2.5 ± 1.5, 73% with score ≥2. The stroke incidence rate (IR) was 19.4 (95% confidence interval 17.1 - 21.9)/1,000 person-years vs 8.4 (7.7 - 9.1) in controls (p<0.001), mortality 40.1 (36.8 - 43.6)/1,000 person-years vs 20.9 (19.8 - 22.0) in controls (p<0.001), and myocardial infarction 9.0 (7.5 - 10.8)/1,000 person-years vs 6.5 (5.9 - 7.2) in controls (p<0.001). IRs of all endpoints increased with age. Oral anticoagulant ± antiplatelet therapy received by 51.0% in year following IA-AF was associated with adjusted hazard ratio (HR) of 0.35 (0.17 - 0.71) for stroke, and 0.56 (0.36 - 0.85) for death compared to no therapy, while antiplatelet treatment was associated with a non-significant reduction of HR: 0.81 (0.51 - 1.29) for stroke, and 0.80 (0.55 - 1.15) for death, though both carried a similar small non-significant adjusted excess IR of major bleeding. In conclusion, asymptomatic AF detected incidentally is associated with a significant adverse effect on stroke and death, with reduction in both associated with oral anticoagulant but not antiplatelet treatment. This provides justification to assess cost-effectiveness of community screening to detect unknown AF.
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Affiliation(s)
| | | | - S B Freedman
- Prof. S. Ben Freedman, Department of Cardiology, Concord Hospital 3W, Hospital Rd, Concord, NSW 2139, Australia, Tel.: + 62 2 9767 7358, Fax: +61 2 9767 6780, E-mail:
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Cai X, Freedman SB, Witting PK. Serum amyloid A stimulates cultured endothelial cells to migrate and proliferate: inhibition by the multikinase inhibitor BIBF1120. Clin Exp Pharmacol Physiol 2014; 40:662-70. [PMID: 23819722 DOI: 10.1111/1440-1681.12148] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/24/2013] [Revised: 06/18/2013] [Accepted: 06/27/2013] [Indexed: 11/30/2022]
Abstract
In the present study, we tested whether serum amyloid A (SAA) protein, an established biomarker of inflammation, also plays a role in stimulating neovascularization. To evaluate this possibility, human carotid artery endothelial (HCtAE) cells were cultured and cellular migration and the proinflammatory and/or thrombotic activity of SAA (0, 1 or 10 μg/mL) on vascular endothelial cells was verified by determining gene regulation relative to control (in the absence of SAA). Exposure of HCtAE cells to SAA increased expression of the transcription factor nuclear factor-κB (NFKB), tumour necrosis factor (TNF) and pro-coagulative tissue factor (F3), and stimulated phosphorylation of the P65 subunit of the NFKB complex. Enhanced production of TNF and NFKB was paralleled by increased vascular endothelial growth factor (VEGF) mRNA and protein expression, as demonstrated by quantitative polymerase chain reaction, western blotting and ELISA. Administration of 10 μg/mL SAA enhanced endothelial cell migration (1.6-fold vs control), stimulated regrowth of HCtAE cells after mechanical injury (~1.2-fold vs control) and increased endothelial tube formation relative to control after 6 h. The SAA-mediated enhancement of endothelial cell migration, proliferation and tube formation were markedly inhibited by pretreatment of HCtAE cells with the multi-angiokinase receptor inhibitor BIBF1120 (100 nmol/L), although SAA-stimulated gene responses for F3 and NFKB were unaffected by 100 nmol/L BIBF1120 pretreatment. Overall, BIBF1120 inhibited the pro-angiogenic activity of SAA on vascular endothelial cells in this experimental model of inflammation.
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Affiliation(s)
- Xiaoping Cai
- Discipline of Pathology, University of Sydney, Sydney, New South Wales, Australia
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Hua S, Song C, Geczy CL, Freedman SB, Witting PK. A role for acute-phase serum amyloid A and high-density lipoprotein in oxidative stress, endothelial dysfunction and atherosclerosis. Redox Rep 2013; 14:187-96. [DOI: 10.1179/135100009x12525712409490] [Citation(s) in RCA: 47] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/31/2022] Open
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Lowres N, Neubeck L, Freedman SB, Briffa T, Bauman A, Redfern J. Lifestyle risk reduction interventions in atrial fibrillation: a systematic review. Eur J Prev Cardiol 2013; 19:1091-100. [PMID: 23126003 DOI: 10.1177/1741826711422505] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
BACKGROUND The burden of atrial fibrillation (AF) is escalating even though it is potentially modifiable. Affected persons, at high risk of stroke and death, are typically not targeted for risk reduction. We aimed to determine if risk-factor interventions can improve physical functioning, health-related quality of life (HRQoL) and cardiovascular risk in AF. METHODS We conducted a systematic review of clinical trials evaluating lifestyle and biomedical risk reduction interventions in AF patients. Trials were identified by searching electronic databases, reference lists and grey literature. Trials were included if conducted by a health professional, and reported changes in multiple risk factor levels or HRQoL. RESULTS Five trials, solely exercise based, were identified (166 participants): two randomised controlled trials, one quasi-experimental and two pre-post designs. Exercise capacity improved after 2-12 months in the intervention group in all trials. This was assessed by maximal oxygen uptake (two trials, 2.5-5.4 ml/kg/min (17-32%) improvement, p < 0.02); six-minute walking distance (one trial, 114 m (27%) improvement, p < 0.001); cumulated work (one trial, 564 W/min (37%) improvement, p < 0.001) and incremental exercise testing (one trial, 11 m/min (10%) improvement, p = 0.05). Three trials evaluated heart rate (HR), demonstrating HR reduction at rest (7-13 bpm, p < 0.05) and during exercise (9 bpm, p < 0.05). Two trials measured HRQoL, both reporting significant improvements in SF-36 physical summary scores. CONCLUSIONS Literature suggests risk reduction interventions for AF can improve exercise levels, HRQoL and reduce HR, but the evidence base is small, methodologically compromised and focused on physical functioning. High-quality research in this area is required in order to help the multitudes of people living with AF.
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Affiliation(s)
- Nicole Lowres
- ANZAC Research Institute, University of Sydney, Sydney, Australia.
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Neubeck L, Freedman SB, Clark AM, Briffa T, Bauman A, Redfern J. Participating in cardiac rehabilitation: a systematic review and meta-synthesis of qualitative data. Eur J Prev Cardiol 2012; 19:494-503. [PMID: 22779092 DOI: 10.1177/1741826711409326] [Citation(s) in RCA: 212] [Impact Index Per Article: 17.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Abstract
BACKGROUND Participation in cardiac rehabilitation (CR) benefits patients with coronary heart disease (CHD), yet worldwide only some 15–30% of those eligible attend. To improve understanding of the reasons for poor participation we undertook a systematic review and meta-synthesis of the qualitative literature. METHODS Qualitative studies identifying patient barriers and enablers to attendance at CR were identified by searching multiple electronic databases, reference lists, relevant conference lists, grey literature, and keyword searching of the Internet (1990–2010). Studies were selected if they included patients with CHD and reviewed experience or understanding about CR. Meta-synthesis was used to review the papers and to synthesize the data. RESULTS From 1165 papers, 34 unique studies were included after screening. These included 1213 patients from eight countries. Study methodology included interviews (n = 25), focus groups (n = 5), and mixed-methods (n = 4). Key reasons for not attending CR were physical barriers, such as lack of transport, or financial cost, and personal barriers, such as embarrassment about participation, or misunderstanding the reasons for onset of CHD or the purpose of CR. CONCLUSIONS There is a vast amount of qualitative research which investigates patients’ reasons for non-attendance at CR. Key issues include system-level and patient-level barriers, which are potentially modifiable. Future research would best be directed at investigating strategies to overcome these barriers.
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Affiliation(s)
- Lis Neubeck
- Faculty of Medicine, University of Sydney, Sydney, Australia.
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Briffa TG, Neubeck L, Clark AM, Freedman SB, Redfern J. Changing the lexicon of ‘Cardiac Rehabilitation’: a progressive step. Eur J Prev Cardiol 2012; 19:167-8. [DOI: 10.1177/1741826710395438] [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: 11/15/2022]
Affiliation(s)
| | - Lis Neubeck
- Concord Repatriation General Hospital, Concord, Australia
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Neubeck L, Redfern J, Freedman SB. Letter by neubeck et Al regarding article, "impact of cardiac rehabilitation on mortality and cardiovascular events after percutaneous coronary intervention in the community". Circulation 2011; 124:e572; author reply e573. [PMID: 22125195 DOI: 10.1161/circulationaha.111.046961] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
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Neubeck L, Briffa T, Freedman SB, Clark AM, Redfern J. Nurse-led telephone interventions for people with cardiac disease: the importance of the multi-disciplinary approach. Eur J Cardiovasc Nurs 2011; 10:70-1. [PMID: 20826113 DOI: 10.1016/j.ejcnurse.2010.08.003] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/09/2010] [Accepted: 08/10/2010] [Indexed: 10/19/2022]
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Ayer JG, Song C, Steinbeck K, Celermajer DS, Ben Freedman S. Increased tissue factor activity in monocytes from obese young adults. Clin Exp Pharmacol Physiol 2011; 37:1049-54. [PMID: 20659134 DOI: 10.1111/j.1440-1681.2010.05430.x] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/12/2023]
Abstract
1. The relationship between inflammation, obesity-related proteins and tissue factor (TF), the major initiator of the extrinsic clotting cascade, is not well understood. We examined if basal and stimulated peripheral blood mononuclear cell (PBMC) TF-procoagulant activity (PCA) was higher in obese subjects and examined the effects of leptin, resistin and serum amyloid A (SAA). 2. PBMC from 12 obese (six male, aged 29±4years, body mass index 46.0±8.7kg/m(2) ) and 12 age- and sex-matched lean controls were cultured either unstimulated or stimulated by lipopolysaccharide (LPS; 10ρg/mL and 100ng/mL, for 4-16h) or SAA (1 ng/mL, 25ng/mL, 250ng/mL, for 4h). Separately, PBMC from lean subjects were cultured unstimulated with leptin (100ρg/mL, 1ng/mL, 10ng/mL, 100ng/mL, 1 μg/mL), resistin (0.1ng/mL, 1ng/mL, 10ng/mL, 100ng/mL) or leptin (100ng/mL) plus LPS (100ρg/mL). TF-PCA was determined by a 1-stage plasma recalcification assay. 3. Four-hour unstimulated PBMC TF-PCA was greater in the obese (90.4±16.5 vs 39.9±4.7mu TF/10(6) PBMC, P=0.01). After 4h stimulation with SAA or LPS the TF-PCA was similar. Unstimulated TF-PCA correlated with log serum high sensitivity C- reactive protein (hs-CRP) (r=0.42, P=0.04) and insulin (r=0.44, P=0.048), but not with log serum SAA (r=0.192, P=0.55). Physiological concentrations of leptin or resistin and leptin plus LPS did not increase TF-PCA in PBMC from lean subjects. 4. Basal PBMC TF-PCA is higher in the obese and is associated with serum hs-CRP. The obesity-related proteins SAA, leptin and resistin are unlikely to play a major role in increasing PBMC TF-PCA.
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Affiliation(s)
- Julian G Ayer
- Department Of Cardiology, Royal Prince Alfred Hospital, Australia
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Song C, Hsu K, Yamen E, Yan W, Fock J, Witting PK, Geczy CL, Freedman SB. Serum amyloid A induction of cytokines in monocytes/macrophages and lymphocytes. Atherosclerosis 2009; 207:374-83. [DOI: 10.1016/j.atherosclerosis.2009.05.007] [Citation(s) in RCA: 95] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/10/2008] [Revised: 05/04/2009] [Accepted: 05/06/2009] [Indexed: 11/28/2022]
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Goyette J, Yan WX, Yamen E, Chung YM, Lim SY, Hsu K, Rahimi F, Di Girolamo N, Song C, Jessup W, Kockx M, Bobryshev YV, Freedman SB, Geczy CL. Pleiotropic roles of S100A12 in coronary atherosclerotic plaque formation and rupture. J Immunol 2009; 183:593-603. [PMID: 19542470 DOI: 10.4049/jimmunol.0900373] [Citation(s) in RCA: 61] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
Macrophages, cytokines, and matrix metalloproteinases (MMP) play important roles in atherogenesis. The Ca(2+)-binding protein S100A12 regulates monocyte migration and may contribute to atherosclerosis by inducing proinflammatory cytokines in macrophages. We found significantly higher S100A12 levels in sera from patients with coronary artery disease than controls and levels correlated positively with C-reactive protein. S100A12 was released into the coronary circulation from ruptured plaque in acute coronary syndrome, and after mechanical disruption by percutaneous coronary intervention in stable coronary artery disease. In contrast to earlier studies, S100A12 did not stimulate proinflammatory cytokine production by human monocytes or macrophages. Similarly, no induction of MMP genes was found in macrophages stimulated with S100A12. Because S100A12 binds Zn(2+), we studied some functional aspects that could modulate atherogenesis. S100A12 formed a hexamer in the presence of Zn(2+); a novel Ab was generated that specifically recognized this complex. By chelating Zn(2+), S100A12 significantly inhibited MMP-2, MMP-9, and MMP-3, and the Zn(2+)-induced S100A12 complex colocalized with these in foam cells in human atheroma. S100A12 may represent a new marker of this disease and may protect advanced atherosclerotic lesions from rupture by inhibiting excessive MMP-2 and MMP-9 activities by sequestering Zn(2+).
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Affiliation(s)
- Jesse Goyette
- Centre for Infection and Inflammation Research, University of New South Wales, Sydney, Australia
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Affiliation(s)
- David B Brieger
- Vascular Biology Group, ANZAC Research Institute, University of Sydney, Sydney, NSW, Australia
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Abstract
BACKGROUND AND HYPOTHESIS Many episodes of ischemia in daily life are silent occurring during sedentary activities and may be related to mental stress. In 35 patients with stable angina and positive exercise test awaiting bypass surgery, we investigated whether laboratory mental stress tests would trigger ischemia of a comparable severity to that occurring in daily life and attempted to elucidate some of the underlying mechanisms. METHODS All patients underwent exercise testing, personality assessment, 2-day Holter monitoring, and laboratory mental stress tests while on their usual medications. RESULTS Only four patients (12%) had positive mental stress test (ST depression > or = 0.1 mV). All episodes were silent and usually associated with fast heart rate (> 90 beats/min). In contrast, ambulatory ischemia was common (average duration of 51 min per 24 h), and at least one episode was recorded in 27 patients (77%) including the 4 with positive test. Patients with positive mental stress test had a higher heart rate during testing (124 +/- 24 vs. 86 +/- 16 beats/min, p < 0.01), and a shorter exercise time and time to 1 mm ST depression on cycle ergometry than those with negative mental stress test. None of the four patients were on beta blockers. There was no difference in personality inventory between the two groups. Comparisons between patients with and without positive mental stress test revealed no difference in the duration and frequency of ambulatory ischemia, or in the occurrence of silent ischemia. However, the heart rate at onset of ambulatory ischemia tended to be higher in the patients with positive mental stress test (96 +/- 9 vs. 62 +/- 43, p = 0.07). Further subgroup analysis in patients without beta blockers (4 mental stress test positive and 18 negative) showed similar results. CONCLUSIONS Laboratory mental stress test is a weak inducer of ischemia detected by electrocardiographic monitoring in patients with frequent ambulatory ischemia. Wall motion evaluation during mental stress test may improve sensitivity. While larger scale studies may determine its clinical role, the present study illustrated that patients with heightened heart rate response to mental stress were identified in whom beta blockers could be the drug of choice.
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Affiliation(s)
- C K Wong
- Hallstrom Institute of Cardiology, University of Sydney, Royal Prince Alfred Hospital, Australia
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Lowe HC, Freedman SB. The late open artery hypothesis: the case and the artery remain closed. Eur Heart J 2008; 30:129-30. [PMID: 19109348 DOI: 10.1093/eurheartj/ehn563] [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] [Indexed: 11/13/2022] Open
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Neubeck L, Redfern J, Briffa T, Bauman A, Hare D, Freedman SB. The CHOICE (Choice of Health Options In prevention of Cardiovascular Events) replication trial: study protocol. BMC Cardiovasc Disord 2008; 8:25. [PMID: 18838009 PMCID: PMC2572037 DOI: 10.1186/1471-2261-8-25] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/15/2008] [Accepted: 10/06/2008] [Indexed: 01/08/2023] Open
Abstract
Background Although morbidity and mortality from coronary heart disease (CHD) are high, only a minority of acute coronary syndrome (ACS) survivors accesses an effective secondary prevention program. We aim to determine whether the previously proven CHOICE program can be replicated at multiple sites and whether ongoing reinforcement further improves risk factor modification. Methods/design Participants eligible for but not accessing standard cardiac rehabilitation will be randomly allocated to either a previously tested 3-month CHOICE program or a 30-month CHOICE program (CHOICE-plus). Both groups will participate in individualised risk factor modules of differing duration that involve choice, goal setting and telephone follow-up for three months. CHOICE-plus will also receive additional face-to-face and telephone reinforcement between three and 30 months. At one site we will recruit a randomised control group, receiving conventional care. Primary outcomes are lipid levels, blood pressure, physical activity levels and smoking rates. Secondary outcomes include readmission rates, death, the number of risk factors, other modifiable risk factors, quality of life and process evaluation measures over three years. Discussion We present the rationale and design of a multi-centre, replication study testing a modular approach for the secondary prevention of CHD following an ACS. Trial Registration [Clinical Trial Registration Number, ACTRN12608000182392]
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Affiliation(s)
- Lis Neubeck
- Faculty of Medicine, University of Sydney, Sydney, Australia.
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Redfern J, Briffa T, Ellis E, Freedman SB. Choice of secondary prevention improves risk factors after acute coronary syndrome: 1-year follow-up of the CHOICE (Choice of Health Options In prevention of Cardiovascular Events) randomised controlled trial. Heart 2008; 95:468-75. [PMID: 18801781 DOI: 10.1136/hrt.2008.150870] [Citation(s) in RCA: 103] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
OBJECTIVE To determine the effect of a new CHOICE (Choice of Health Options In prevention of Cardiovascular Events) programme on cardiovascular risk factors in acute coronary syndrome (ACS) survivors. DESIGN Single-blind randomised controlled trial. SETTING Tertiary referral hospital in Sydney Australia. PATIENTS 144 ACS survivors who were not accessing standard cardiac rehabilitation. Data were also collected on a further 64 ACS survivors attending standard cardiac rehabilitation. INTERVENTION The CHOICE group (n = 72) participated in a brief, patient-centred, modular programme comprising a clinic visit plus telephone support, encompassing mandatory cholesterol lowering and tailored preferential risk modification. The control group (n = 72) participated in continuing conventional care but no centrally coordinated secondary prevention. MAIN OUTCOME MEASURES Values for total cholesterol, systolic blood pressure, smoking status and physical activity. RESULTS CHOICE and control groups were well matched at baseline. At 12 months, the CHOICE group (n = 67) had significantly better risk factor levels than controls (n = 69) for total cholesterol (TC) (mean (SEM) 4.0 (0.1) vs 4.7 (0.1) mmol/l, p<0.001), systolic blood pressure (131.6 (1.8) vs 143.9 (2.3) mm Hg, p<0.001), body mass index (28.9 (0.7) vs 31.2 (0.7) kg/m(2), p = 0.025) and physical activity (1369.1 (167.2) vs 715.1 (103.5) METS/kg/min, p = 0.001) as well as a better knowledge of risk factor targets. Also at 1 year, fewer CHOICE participants (21%) had three or more risk factors above widely recommended levels then controls (72%) (p<0.001). CONCLUSIONS Participation in a brief CHOICE programme significantly improved the modifiable risk profiles and risk factor knowledge of ACS survivors over 12 months. CHOICE is an effective alternative for dealing with the widespread underuse of existing secondary prevention programmes. TRIAL REGISTRATION NUMBER ISRCTN42984084.
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Affiliation(s)
- J Redfern
- Department of Cardiology, Concord Hospital, Hospital Road, Concord, Australia.
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Page SL, Birden HH, Hudson JN, Thistlethwaite JE, Roberts C, Wilson I, Bushnell J, Hogg J, Freedman SB, Yeomans N. Medical schools can cooperate: a new joint venture to provide medical education in the Northern Rivers region of New South Wales. Med J Aust 2008; 188:179-81. [DOI: 10.5694/j.1326-5377.2008.tb01568.x] [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] [Received: 06/18/2007] [Accepted: 09/11/2007] [Indexed: 11/17/2022]
Affiliation(s)
- Sue L Page
- North Coast Medical Education Collaboration, Lismore, NSW
| | | | - J Nicky Hudson
- Graduate School of Medicine, University of Wollongong, Wollongong, NSW
| | - Jill E Thistlethwaite
- Centre for Innovation in Professional Health Education and Research, University of Sydney, Sydney, NSW
| | - Chris Roberts
- Centre for Innovation in Professional Health Education and Research, University of Sydney, Sydney, NSW
| | - Ian Wilson
- School of Medicine, University of Western Sydney, Sydney, NSW
| | - John Bushnell
- Graduate School of Medicine, University of Wollongong, Wollongong, NSW
| | - John Hogg
- Graduate School of Medicine, University of Wollongong, Wollongong, NSW
| | | | - Neville Yeomans
- School of Medicine, University of Western Sydney, Sydney, NSW
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Redfern J, Ellis ER, Briffa T, Freedman SB. High risk-factor level and low risk-factor knowledge in patients not accessing cardiac rehabilitation after acute coronary syndrome. Med J Aust 2007; 186:21-5. [PMID: 17229029 DOI: 10.5694/j.1326-5377.2007.tb00783.x] [Citation(s) in RCA: 57] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/20/2006] [Accepted: 09/04/2006] [Indexed: 11/17/2022]
Abstract
OBJECTIVE To document the risk-factor profile and risk-factor knowledge of patients with an acute coronary syndrome (ACS) not attending standard cardiac rehabilitation. DESIGN AND SETTING Cross-sectional comparison in a tertiary hospital. PARTICIPANTS Patients admitted to hospital with an ACS, residing within 20 km of the hospital, and without severe comorbidity who did not access cardiac rehabilitation (NCR) were compared with a group about to commence standard cardiac rehabilitation (SCR). MAIN OUTCOME MEASURES Risk-factor profile, knowledge of risk factors via face-to-face assessment, quality of life. RESULTS Of the 446 patients eligible for cardiac rehabilitation, 208 attended for assessment (NCR: n = 144; SCR: n = 64). The NCR group had higher mean (+/- SEM) low-density lipoprotein (LDL) cholesterol levels (2.6 +/- 0.1 v 2.3 +/- 0.1; P = 0.02), and were more likely than the SCR group to have a total cholesterol level of > 4.0 mmol/L (78% v 53%; P < 0.001) and an LDL cholesterol level > 2.5 mmol/L (47% v 25%; P = 0.01). They were more likely than the SCR group to be physically inactive (77% v 22%; P < 0.001); obese (46% v 33%; P = 0.04); depressed (21% v 5%; P < 0.001); or current smokers (21% v 1%; P < 0.001). Compared with the SCR group, the NCR group also had higher risk scores (LIPID risk score) (4.5 v 2.1; P < 0.001); lower quality of life (Medical Outcome Short Form [SF-36] Health Survey); and significantly poorer knowledge of risk factors. Among patients with at least two modifiable cardiac risk factors, the NCR group were less likely than the SCR group to be able to state at least one risk factor (24% v 38%; P < 0.001). CONCLUSIONS Patients not participating in cardiac rehabilitation after an ACS have more adverse risk profiles and poorer knowledge of risk factors compared with those about to commence cardiac rehabilitation. Alternate models for secondary prevention are required to improve health outcomes in patients not attending cardiac rehabilitation.
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Abstract
C-reactive protein (CRP) and serum amyloid A (SAA) increase in the blood of patients with inflammatory conditions and CRP-induced monocyte tissue factor (TF) may contribute to inflammation-associated thrombosis. This study demonstrates that SAA is a potent and rapid inducer of human monocyte TF. SAA induced TF mRNA in PBMC within 30 min and optimal procoagulant activity within 4 h, whereas CRP (25 mug/ml)-induced activity was minimal at this time. Unlike CRP, SAA did not synergize with LPS. Procoagulant activity was inhibited by anti-TF and was dependent on factors VII and X, and TF Ag levels were elevated on CD14(+) monocytes. Responses were optimal with lymphocytes, although these were not obligatory. Inhibitor studies indicate activation of NF-kappaB through the ERK1/2 and p38 MAPK pathways; the cyclo-oxygenase pathway was not involved. SAA-induced TF was partially inhibited by high-density lipoprotein, but not by low-density lipoprotein or by apolipoprotein A-I. SAA is a ligand for the receptor for advanced glycation end products (RAGE), and TF generation was suppressed by approximately 50% by a RAGE competitor, soluble RAGE, and by approximately 85% by anti-RAGE IgG. However, another RAGE ligand, high mobility group box-1 protein, capable of inducing monocyte chemotactic protein-1 mRNA in 2 h, did not induce TF within 24 h. Cross-linking studies confirmed SAA binding to soluble RAGE. Elevated SAA is a marker of disease activity in patients with rheumatoid arthritis, and PBMC from patients with rheumatoid arthritis were more sensitive to SAA than normals, suggesting a new link between inflammation and thrombosis.
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Affiliation(s)
- Hong Cai
- Inflammatory Diseases Research Unit, School of Medical Sciences, University of New South Wales, Sydney, Australia
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Redfern J, Ellis E, Briffa T, Freedman SB. Modular prevention of heart disease following acute coronary syndrome (ACS) [ISRCTN42984084]. BMC Cardiovasc Disord 2006; 6:26. [PMID: 16762079 PMCID: PMC1524985 DOI: 10.1186/1471-2261-6-26] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2006] [Accepted: 06/09/2006] [Indexed: 11/10/2022] Open
Abstract
Background Coronary heart disease (CHD) is a major cause of morbidity and mortality in Australia and it is recommended that all persons with unstable angina (UA) or myocardial infarction (MI) participate in secondary prevention as offered in cardiac rehabilitation (CR) programs. However, the majority of patients do not access standard CR and have higher baseline coronary risk and poorer knowledge of CHD than those persons due to commence CR. The objective of this study is to investigate whether a modular guided self-choice approach to secondary prevention improves coronary risk profile and knowledge in patients who do not access standard CR. Methods/Design This randomised controlled trial with one year follow-up will be conducted at a tertiary referral hospital. Participants eligible for but not accessing standard CR will be randomly allocated to either a modular or conventional care group. Modular care will involve participation in individualised modules that involve choice, goal-setting and coaching. Conventional care will involve ongoing heart disease management as directed by the participant's doctors. Both modular and conventional groups will be compared with a contemporary reference group of patients attending CR. Outcomes include measured modifiable risk factors, relative heart disease risk and knowledge of risk factors. Discussion We present the rationale and design of a randomised controlled trial testing a modular approachfor the secondary prevention of coronary heart disease following acute coronary syndrome.
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Affiliation(s)
- Julie Redfern
- School of Physiotherapy, University of Sydney, Sydney, Australia
| | - Elizabeth Ellis
- School of Physiotherapy, University of Sydney, Sydney, Australia
| | - Tom Briffa
- School of Physiotherapy, Curtin University of Technology, Perth, Australia
| | - SB Freedman
- Department of Cardiology, Concord Repatriation General Hospital, Sydney, Australia
- Faculty of Medicine, University of Sydney, Sydney, Australia
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Lau GT, Ridley LJ, Bannon PG, Freedman SB, Brieger DB, Sullivan D, Wong LA, Kritharides L. Hypertriglyceridaemia is associated with early non-patency of coronary bypass grafts. Heart 2006; 92:536-8. [PMID: 16537772 PMCID: PMC1860861 DOI: 10.1136/hrt.2005.068593] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
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Song CJ, Nakagomi A, Chandar S, Cai H, Lim IGS, McNeil HP, Freedman SB, Geczy CL. C-reactive protein contributes to the hypercoagulable state in coronary artery disease. J Thromb Haemost 2006; 4:98-106. [PMID: 16409458 DOI: 10.1111/j.1538-7836.2005.01705.x] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
OBJECTIVES Elevated plasma C-reactive protein (CRP) levels predict coronary events, but it is unclear whether CRP plays a role in thrombosis associated with these events. We investigated tissue factor (TF) induction by CRP on peripheral blood mononuclear cells (PBMC) from patients with coronary disease. PATIENTS AND METHODS PBMC from 35 patients with stable angina (SA) in study 1, 10 male patients with SA, 10 with unstable angina (UA) and 10 matched controls in study 2, and 25 patients with inflammatory disorders (ID) and 24 normal controls in study 3 were stimulated with CRP, interferon-gamma (IFN) or lipopolysaccharide (LPS), or their combination. PBMC from additional normal donors were also stimulated with CRP in adherent and non-adherent conditions, and TF activity, antigen and mRNA expression detected. RESULTS CRP (5-25 microg mL(-1)) dose dependently induced more TF on PBMC from SA patients than 42 contemporary controls (P = 0.001, study 1). Compared with controls, patients with SA or UA had higher basal, and much higher CRP- or CRP/LPS-induced monocyte TF activity although serum CRP levels were similar (study 2). IFN induced monocyte TF activity in patients with angina, but not in controls. Basal or CRP-induced TF levels did not differ between controls and ID, even though ID patients had much higher serum CRP levels (study 3). CRP-induced monocyte TF activity correlated with serum CRP levels in controls (P = 0.005) and ID (P = 0.007) in study 3, but not in patients with angina (P =0.84) in study 2. CRP induced more TF activity, protein and mRNA under adherent than non-adherent conditions implying that it may mainly target macrophages in lymphocyte-rich lesions. CONCLUSIONS Our results indicate that monocytes from patients with angina are preactivated and express TF but CRP is unlikely to be a major priming factor in vivo. IFN and CRP further increase TF levels that may contribute to the hypercoagulable state in coronary disease.
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Affiliation(s)
- C J Song
- School of Medical Sciences, The University of New South Wales, Sydney, Australia
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Piraino PS, Yednock TA, Messersmith EK, Pleiss MA, Freedman SB, Hammond RR, Karlik SJ. Spontaneous remyelination following prolonged inhibition of alpha4 integrin in chronic EAE. J Neuroimmunol 2005; 167:53-63. [PMID: 16095724 DOI: 10.1016/j.jneuroim.2005.06.018] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2004] [Revised: 06/09/2005] [Accepted: 06/10/2005] [Indexed: 10/25/2022]
Abstract
Inhibition of alpha(4)beta(1) integrin blocks immune cell influx into the CNS providing benefit to patients with multiple sclerosis and in animal model systems. We have used this mechanism to examine whether the presence of inflammatory cells suppresses spontaneous myelin repair in experimental autoimmune encephalomyelitis. We observed (1) 87% of plaques showed remyelination after 40 days of treatment; (2) myelin repair occurred in half of the total lesion area; (3) half of the animals regained motor function. There was no significant repair or gain of motor function in vehicle-treated animals. Therefore, prolonged inhibition of CNS inflammation, in the absence of targeted myelin repair, facilitates mechanisms of spontaneous remyelination.
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Affiliation(s)
- P S Piraino
- Department of Physiology and Pharmacology, University of Western Ontario, Medical Sciences Building, Room 223, London, ON, Canada
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Emmett L, Magee M, Freedman SB, Van der Wall H, Bush V, Trieu J, Van Gaal W, Allman KC, Kritharides L. The role of left ventricular hypertrophy and diabetes in the presence of transient ischemic dilation of the left ventricle on myocardial perfusion SPECT images. J Nucl Med 2005; 46:1596-601. [PMID: 16204708] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/04/2023] Open
Abstract
UNLABELLED Transient ischemic dilation of the left ventricle found on SPECT myocardial perfusion imaging (MPI) is an accepted marker of severe and extensive coronary artery disease (CAD) and poor prognosis. The influence of other clinical variables on the incidence of transient ischemic dilation is less certain. The aim of this study was to investigate clinical factors that may influence the incidence of transient ischemic dilation. In particular, we looked at factors that may independently affect subendocardial perfusion, such as left ventricular hypertrophy (LVH) and diabetes. METHODS MPI studies of 103 consecutive patients who had undergone recent coronary angiography (< or =6 mo) and transthoracic echocardiography within a year of stress electrocardiography-gated MPI were retrospectively analyzed. Transient ischemic dilation was assessed quantitatively using a software program. A ratio cutoff of > or =1.22 was considered to represent transient ischemic dilation. Summed stress score and summed difference score (ischemia score) were determined using the standard 17-segment 5-point scoring system to quantify myocardial ischemia. LVH was defined as a left ventricular wall thickness of >11 mm on M-mode echocardiography. Severe CAD was defined as severe stenosis (> or =90%) of either the left anterior descending artery or both the right coronary and lateral circumflex arteries. RESULTS Nineteen (18%) of the 103 patients had transient ischemic dilation, 19 (18%) had LVH, and 23 (22%) were diabetic. A high percentage had severe CAD (46/103 [45%]), whereas 57 of 103 (55%) had less severe CAD (30/103 [29%]) or nonsignificant CAD (26/103 [25%]). Severe CAD (P < 0.001), diabetes (P < 0.0001), LVH (P < 0.003), and the ischemia score (P < 0.023) were independent predictors of transient ischemic dilation by multivariate logistic regression. In patients with severe CAD, the effect of LVH on the incidence of transient ischemic dilation was additive, increasing the incidence from 21% (8/38) without LVH to 75% (6/8) with LVH (P < 0.006). Likewise, with severe CAD, the incidence of transient ischemic dilation rose from 21% (7/33) in patients without diabetes to 54% (7/13) in those with diabetes (P < 0.04). CONCLUSION The presence of transient ischemic dilation on myocardial perfusion SPECT is associated with the presence of severe CAD, but this association is modified by the presence of LVH and diabetes.
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Affiliation(s)
- Louise Emmett
- Department of Nuclear Medicine, Concord Hospital, University of Sydney, Sydney, Australia.
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Zeng B, Prasan A, Fung KC, Solanki V, Bruce D, Freedman SB, Brieger D. Elevated circulating levels of matrix metalloproteinase-9 and -2 in patients with symptomatic coronary artery disease. Intern Med J 2005; 35:331-5. [PMID: 15892761 DOI: 10.1111/j.1445-5994.2005.00822.x] [Citation(s) in RCA: 63] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
BACKGROUND Matrix metalloproteinases (MMP-9 and MMP-2) have been implicated in development of atherosclerosis and plaque rupture in acute coronary syndromes (ACS). AIM To determine the relationship between circulating MMPs and symptomatic coronary artery disease. METHODS Plasma levels of MMP-9 and MMP-2 were measured in patients with ACS, stable angina (SA) and in controls, using a quantitative gelatin zymography. These measurements were correlated with markers of systemic inflammation (hs-CRP) in all subjects and myocardial injury (troponin T) in patients with ACS. RESULTS Plasma MMP-9 in ACS was greater than in SA, and was greater in SA than in controls (P < 0.01 ACS vs SA and controls, P < 0.01 SA vs control). Plasma MMP-2 was significantly greater in ACS than SA or controls (P < 0.01 vs SA and controls). There was strong overall relationship between hs-CRP and MMP-9 (r = 0.65, P < 0.0001) driven by a significant relationship in ACS patients (r = 0.58, P = 0.02), as there was no significant association in SA or controls. A weaker overall correlation was found between hs-CRP and MMP-2 (r = 0.39, P = 0.02), but no significant relationship was present for either of the two patient subgroups or controls. There was no correlation between levels of troponin T and MMP-9, MMP-2 or hs-CRP in ACS patients. CONCLUSION Quantitative gelatin zymography identifies increased circulating levels of MMP-9 and MMP-2 in patients with symptomatic coronary disease. MMP-9 and MMP-2 are higher in ACS than SA patients and might have use as markers of plaque rupture or instability. The strong relationship between MMP-9 and hs-CRP in ACS patients suggests MMP-9 might be an additional marker and/or consequence of the inflammatory component in ACS.
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Affiliation(s)
- B Zeng
- Department of Cardiology, Concord Hospital, Vascular Biology Laboratory, ANZAC Research Institute, University of Sydney, Australia
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Pepine CJ, Rouleau JL, Annis K, Ducharme A, Ma P, Lenis J, Davies R, Thadani U, Chaitman B, Haber HE, Freedman SB, Pressler ML, Pitt B. Effects of angiotensin-converting enzyme inhibition on transient ischemia: the Quinapril Anti-Ischemia and Symptoms of Angina Reduction (QUASAR) trial. J Am Coll Cardiol 2004; 42:2049-59. [PMID: 14680725 DOI: 10.1016/j.jacc.2003.07.027] [Citation(s) in RCA: 32] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
OBJECTIVES We sought to determine whether angiotensin-converting enzyme inhibition (ACE-I) (i.e., quinapril) prevents transient ischemia (exertional and spontaneous) in patients with coronary artery disease (CAD). BACKGROUND It is known that ACE-I reduces the risk of death, myocardial infarction (MI), and other CAD-related outcomes in high-risk patients. Numerous studies have confirmed that ACE-I improves coronary flow and endothelial function. Whether ACE-I also decreases transient ischemia is unclear, because no studies have been adequately designed or sufficiently powered to evaluate this issue. METHODS Using a randomized, double-blinded, placebo-controlled, multicenter design, we enrolled 336 CAD patients with stable angina. None had uncontrolled hypertension, left ventricular (LV) dysfunction, or recent MI, and all developed electrocardiographic (ECG) evidence of ischemia during exercise. They were randomly assigned to one of two groups: 40 mg/day quinapril (n = 177) or placebo (n = 159) for 8 weeks. Patients then entered an additional eight-week treatment phase to examine the full dose range. Those assigned to 40 mg quinapril continued that dose and those assigned to placebo were titrated to 80 mg/day. Treadmill testing, the Seattle Angina Questionnaire, and ambulatory ECG monitoring were used to assess responses at baseline and at 8 and 16 weeks. RESULTS The groups did not differ significantly at entry or in terms of indexes assessing myocardial ischemia at 8 or 16 weeks of treatment. In this low-risk population, ACE-I was not associated with serious adverse events. CONCLUSIONS Our findings suggest short-term ACE-I in CAD patients without hypertension, LV dysfunction, or acute MI is not associated with significant effects on transient ischemia.
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Affiliation(s)
- Carl J Pepine
- University of Florida College of Medicine, Division of Cardiovascular Medicine, Gainesville, Florida 32610-0277, USA.
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Allman KC, Freedman SB. Emergency department assessment of patients with acute chest pain: myocardial perfusion imaging, blood tests, or both? J Nucl Cardiol 2004; 11:87-9. [PMID: 14752476 DOI: 10.1016/j.nuclcard.2003.10.008] [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] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
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Piraino PS, Yednock TA, Freedman SB, Messersmith EK, Pleiss MA, Vandevert C, Thorsett ED, Karlik SJ. Prolonged reversal of chronic experimental allergic encephalomyelitis using a small molecule inhibitor of alpha4 integrin. J Neuroimmunol 2002; 131:147-59. [PMID: 12458046 DOI: 10.1016/s0165-5728(02)00273-4] [Citation(s) in RCA: 37] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
CNS leukocytic invasion in experimental allergic encephalomyelitis (EAE) depends on alpha4beta1 integrin/vascular cell adhesion molecule-1 (VCAM-1) interactions. A small molecule inhibitor of alpha4beta1 integrin (CT301) was administered to guinea pigs in the chronic phase (>d40) of EAE for 10, 20, 30 or 40 days. CT301 elicited a rapid, significant improvement in the clinical and pathological scores that was maintained throughout the treatment period. A progressive loss of cells in the spinal cord of treated animals confirmed the resolution of inflammation associated with clinical recovery. Therefore, prolonged inhibition of alpha4beta1 integrin caused a sustained reversal of disease pathology in chronic EAE and may be similarly useful in MS.
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Affiliation(s)
- P S Piraino
- Department of Physiology, London Health Sciences Center, University of Western Ontario, London, ON, Canada
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