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Jyotsna F, Ikram J, Nageeta F, Komal F, Anjlee F, Patel H, Nassri T, Kumari M, Kumar R, Shah SU, Kashif M, Varrassi G, Kumar S, Patel T. Unlocking the Potential of Immunotherapy in Cardiovascular Disease: A Comprehensive Review of Applications and Future Directions. Cureus 2023; 15:e42790. [PMID: 37664375 PMCID: PMC10469982 DOI: 10.7759/cureus.42790] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/22/2023] [Accepted: 08/01/2023] [Indexed: 09/05/2023] Open
Abstract
Immunotherapy has emerged as a pioneering therapeutic approach that harnesses the immune system's abilities to combat diseases, particularly in the field of oncology where it has led to significant advancements. However, despite its significant impact in the field of oncology, the potential of immunotherapy in the context of cardiovascular disease (CVD) has not been thoroughly investigated. The purpose of this narrative review is to address the existing knowledge and potential uses of immunotherapy in the field of cardiovascular disease (CVD), with the intention of filling the existing gap in understanding. Furthermore, the review thoroughly examines the future prospects of this swiftly advancing field, providing insights into the aspects that necessitate further investigation and addressing the forthcoming challenges. The review is organized into four distinct sections to enhance comprehension. The first section introduces immunotherapy, presenting the fundamental concepts and principles. The second section explores the immunomodulatory mechanisms in cardiovascular disease (CVD), with a specific focus on the intricate interplay between the immune system and the development of cardiovascular pathogenesis. The utilization of immunotherapy in specific cardiovascular conditions will be examined, investigating the application of immunotherapy in the context of different cardiovascular diseases. The future prospects and challenges in immunotherapy for cardiovascular diseases will be discussed, highlighting the potential areas for future research and addressing the barriers that must be overcome to effectively implement immunotherapeutic interventions in the management of cardiovascular diseases.
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Affiliation(s)
- Fnu Jyotsna
- Medicine, Dr. B.R. Ambedkar Medical College & Hospital, Mohali, IND
| | - Jibran Ikram
- Orthopaedics and Trauma, Rehman Medical Institute, Peshawar, PAK
| | - Fnu Nageeta
- Medicine, Ghulam Muhammad Mahar Medical College, Sukkur, PAK
| | - Fnu Komal
- Medicine, Chandka Medical College, Larkana, PAK
| | - Fnu Anjlee
- Medicine, Ghulam Muhammad Mahar Medical College, Sukkur, PAK
| | - Harshkumar Patel
- Internal Medicine, PDU (Pandit Dindayal Upadhyay) Medical College, Rajkot, IND
| | - Taleb Nassri
- Medicine, Heart and Vascular Institute, Dearborn, USA
| | - Meena Kumari
- Internal Medicine, Dow University of Health Sciences, Karachi, PAK
| | - Rajesh Kumar
- Business Intelligence and Data Analytics, Westcliff University, Irvine, USA
| | | | - Maham Kashif
- Medicine, Khawaja Muhammad Safdar Medical College, Wazirabad, PAK
| | | | - Satesh Kumar
- Medicine and Surgery, Shaheed Mohtarma Benazir Bhutto Medical College, Karachi, PAK
| | - Tirath Patel
- Medicine, American University of Antigua, St. John, ATG
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Talpur AS, Fattah A, Hewadmal H, Hafizyar F, Farooq J, Shaik TA, Qadar LT, Zaidi SMH, Pirzada S, Bahar AR. Asymptomatic Hyperuricemia as an Independent Risk Factor for Myocardial Infarction in Adult Population: A Four-Year Follow-Up Study. Cureus 2023; 15:e34614. [PMID: 36891011 PMCID: PMC9986685 DOI: 10.7759/cureus.34614] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/03/2023] [Indexed: 02/07/2023] Open
Abstract
Introduction A condition in which uric acid levels are elevated but there are no accompanying symptoms is known as asymptomatic hyperuricemia. As a result of the disparity in opinions and findings between the studies, the guidelines regarding whether or not asymptomatic hyperuricemia should be treated are unclear. Material and methods Between the months of January 2017 and June 2022, this research was carried out in the community in collaboration with the internal medicine unit and the public health unit of Liaquat University of Medical and Health Sciences. After obtaining informed consent from each participant, the researchers enrolled 1,500 patients in the study who had uric acid levels that were greater than 7.0 mg/dL. These patients ranged in age from 40 to 70 years old and were of either gender. As a control group, 1,500 patients were recruited who did not have abnormally high levels of uric acid. Patients were monitored for a total of 48 months or until the occurrence of a major cardiovascular event (MACCE) or death from all causes, whichever occurred first. Death, cardiovascular mortality, non-fatal myocardial infarction, and non-fatal stroke were the four categories that made up the primary outcome, also known as MACCEs. Results In the hyperuricemic group, the incidence of myocardial infarction that did not result in death was significantly higher than in the non-hyperuricemic group (1.6% vs. 0.7%; p-value, 0.04). However, the result was not significant for deaths from all causes, deaths from cardiovascular disease, or strokes that did not result in death. Conclusion Asymptomatic hyperuricemia is a potential threat to one's health that can lead to cardiovascular diseases and may go undiagnosed in some cases. It is important to remember that hyperuricemia can lead to delirious complications, so efforts should be made to perform routine monitoring and management of the condition.
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Affiliation(s)
| | - Abdul Fattah
- Internal Medicine, Indus Medical College, Tando Muhammad Khan, PAK
| | - Hewad Hewadmal
- Cardiology, Sheikh Zayed Medical College/Hospital, Rahim Yar Khan, PAK
| | | | - Jawad Farooq
- Medicine, Liaquat University of Medical and Health Sciences, Jamshoro, PAK
| | - Tanveer Ahamad Shaik
- Cardiovascular Medicine, University of Louisville School of Medicine, Louisville, USA.,Cardiovascular Medicine, Liaquatian Research Council, Hyderabad, PAK
| | - Laila Tul Qadar
- Internal Medicine, Dow University of Health Sciences, Civil Hospital Karachi, Karachi, PAK
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Muacevic A, Adler JR, Savlania A, Ravi A, Kaman L, Behera A. Demographics and Prevalence of Risk Factors in Patients With Peripheral Arterial Disease Presenting to a Tertiary Care Center in Northern India. Cureus 2022; 14:e32397. [PMID: 36636535 PMCID: PMC9830964 DOI: 10.7759/cureus.32397] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/11/2022] [Indexed: 12/14/2022] Open
Abstract
Introduction Globally around 236.62 million people over 25 had the peripheral arterial occlusive disease (PAOD) in 2015, out of which 72.91 were in lower and middle-income countries. It will be a significant health problem in our country as the Indian population is aging. Our study aims to determine the demographics and prevalence risk factors in patients presenting with PAOD. Methods This prospective observational study was conducted from January 2020 to April 2021 at a tertiary care center in Northern India. A total of 275 patients with PAOD were enrolled in the study. The demographics and the prevalence of the risk factors were studied. Results Males (85.8%) were predominantly affected compared to females (14.2%). About 80.4% were smokers, of which 84.16% predominantly smoked Bidi. Around 39.3% had diabetes mellitus, 43.3% were hypertensive, and dyslipidemia was present in 17.1%. History of coronary artery disease and cerebrovascular accident was present in 22.3% and 12%, respectively. Farming was the occupation for 29.1% and 32.4% had not received formal schooling. The mean annual income was Rupees 1,56,025 (rupees 13,000 per month). Overall, the socioeconomic status was low. Conclusion The demographics and the prevalence of risk factors in patients with PAOD in Northern India differ from those in South India and the Western populations. Most of the patients were elderly males belonging to low socioeconomic status. There is a need for a central registry for vascular diseases in India to monitor the trends of the annual incidence of PAOD and to look for the prevalence of risk factors.
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Adhikary D, Barman S, Ranjan R, Stone H. A Systematic Review of Major Cardiovascular Risk Factors: A Growing Global Health Concern. Cureus 2022; 14:e30119. [PMID: 36381818 PMCID: PMC9644238 DOI: 10.7759/cureus.30119] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/09/2022] [Indexed: 04/08/2023] Open
Abstract
Cardiovascular disease has become a growing global and public health concern among non-communicable diseases (NCDs). The purpose of the study was to focus on the increasing prevalence of the risk factors of cardiovascular diseases (CVD), irrespective of age and gender, and its effect on public health worldwide. A literature search was done in the electronic database: Medline, PubMed, Web of Science, Google Scholar, and the World Health Organization (WHO) website, based on recent research and the prevalence of the risk factors of cardiovascular diseases. Moreover, a manual search for published work has also been done. The coronary heart disease studies were not restricted during the search by sample size because of the limited number of studies in selected countries. The study reviews the potential risk factors responsible for coronary heart disease globally. Smoking was highly prevalent among the United States and Pakistani populations, but hypertension and diabetes were more common in Tanzania and the United Kingdom. However, dyslipidaemia and obesity were common in almost all the selected countries. CVD risk factors are highly prevalent in some countries, varying socioeconomic, gender, and educational levels. Furthermore, there has always been a need for awareness in the public and educational programs for a healthy lifestyle, intake of nutritional food, and increased physical activity to improve health conditions and reduce the risk of cardiovascular diseases.
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Affiliation(s)
- Dipannita Adhikary
- Faculty of Life Sciences and Medicine, King's College London, London, GBR
- Cardiovascular Science, Impulse Hospital, Dhaka, BGD
| | - Shanto Barman
- College of Medicine, Mugda Medical College and Hospital, Dhaka, BGD
| | - Redoy Ranjan
- Cardiac Surgery, Bangabandhu Sheikh Mujib Medical University, Dhaka, BGD
- Institute of Cardiovascular Research, Royal Holloway University of London, London, GBR
- Surgical Science Programme, The University of Edinburgh, Edinburgh, GBR
| | - Hana Stone
- Faculty of Life Sciences and Medicine, King's College London, London, GBR
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Tsaban G, Yaskolka Meir A, Rinott E, Zelicha H, Kaplan A, Shalev A, Katz A, Rudich A, Tirosh A, Shelef I, Youngster I, Lebovitz S, Israeli N, Shabat M, Brikner D, Pupkin E, Stumvoll M, Thiery J, Ceglarek U, Heiker JT, Körner A, Landgraf K, von Bergen M, Blüher M, Stampfer MJ, Shai I. The effect of green Mediterranean diet on cardiometabolic risk; a randomised controlled trial. Heart 2021; 107:1054-1061. [PMID: 33234670 DOI: 10.1136/heartjnl-2020-317802] [Citation(s) in RCA: 27] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/13/2020] [Revised: 09/29/2020] [Accepted: 10/07/2020] [Indexed: 12/13/2022] Open
Abstract
BACKGROUND A Mediterranean diet is favourable for cardiometabolic risk. OBJECTIVE To examine the residual effect of a green Mediterranean diet, further enriched with green plant-based foods and lower meat intake, on cardiometabolic risk. METHODS For the DIRECT-PLUS parallel, randomised clinical trial we assigned individuals with abdominal obesity/dyslipidaemia 1:1:1 into three diet groups: healthy dietary guidance (HDG), Mediterranean and green Mediterranean diet, all combined with physical activity. The Mediterranean diets were equally energy restricted and included 28 g/day walnuts. The green Mediterranean diet further included green tea (3-4 cups/day) and a Wolffia globosa (Mankai strain; 100 g/day frozen cubes) plant-based protein shake, which partially substituted animal protein. We examined the effect of the 6-month dietary induction weight loss phase on cardiometabolic state. RESULTS Participants (n=294; age 51 years; body mass index 31.3 kg/m2; waist circumference 109.7 cm; 88% men; 10 year Framingham risk score 4.7%) had a 6-month retention rate of 98.3%. Both Mediterranean diets achieved similar weight loss ((green Mediterranean -6.2 kg; Mediterranean -5.4 kg) vs the HDG group -1.5 kg; p<0.001), but the green Mediterranean group had a greater reduction in waist circumference (-8.6 cm) than the Mediterranean (-6.8 cm; p=0.033) and HDG (-4.3 cm; p<0.001) groups. Stratification by gender showed that these differences were significant only among men. Within 6 months the green Mediterranean group achieved greater decrease in low-density lipoprotein cholesterol (LDL-C; green Mediterranean -6.1 mg/dL (-3.7%), -2.3 (-0.8%), HDG -0.2 mg/dL (+1.8%); p=0.012 between extreme groups), diastolic blood pressure (green Mediterranean -7.2 mm Hg, Mediterranean -5.2 mm Hg, HDG -3.4 mm Hg; p=0.005 between extreme groups), and homeostatic model assessment for insulin resistance (green Mediterranean -0.77, Mediterranean -0.46, HDG -0.27; p=0.020 between extreme groups). The LDL-C/high-density lipoprotein cholesterol (HDL-C) ratio decline was greater in the green Mediterranean group (-0.38) than in the Mediterranean (-0.21; p=0.021) and HDG (-0.14; p<0.001) groups. High-sensitivity C-reactive protein reduction was greater in the green Mediterranean group (-0.52 mg/L) than in the Mediterranean (-0.24 mg/L; p=0.023) and HDG (-0.15 mg/L; p=0.044) groups. The green Mediterranean group achieved a better improvement (-3.7% absolute risk reduction) in the 10-year Framingham Risk Score (Mediterranean-2.3%; p=0.073, HDG-1.4%; p<0.001). CONCLUSIONS The green MED diet, supplemented with walnuts, green tea and Mankai and lower in meat/poultry, may amplify the beneficial cardiometabolic effects of Mediterranean diet. TRIAL REGISTRATION NUMBER This study is registered under ClinicalTrials.gov Identifier no NCT03020186.
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Affiliation(s)
- Gal Tsaban
- Faculty of Health Sciences, Ben-Gurion University of the Negev, Beer Sheva, Israel
- Department of Medicine, Soroka University Medical Center, Beer Sheva, Israel
| | - Anat Yaskolka Meir
- Faculty of Health Sciences, Ben-Gurion University of the Negev, Beer Sheva, Israel
| | - Ehud Rinott
- Faculty of Health Sciences, Ben-Gurion University of the Negev, Beer Sheva, Israel
| | - Hila Zelicha
- Faculty of Health Sciences, Ben-Gurion University of the Negev, Beer Sheva, Israel
| | - Alon Kaplan
- Faculty of Health Sciences, Ben-Gurion University of the Negev, Beer Sheva, Israel
| | - Aryeh Shalev
- Department of Cardiology, Soroka University Medical Center, Beer Sheva, Israel
| | - Amos Katz
- Faculty of Health Sciences, Ben-Gurion University of the Negev, Beer Sheva, Israel
| | - Assaf Rudich
- Faculty of Health Sciences, Ben-Gurion University of the Negev, Beer Sheva, Israel
| | - Amir Tirosh
- Division of Endocrinology, Diabetes and Metabolism, Sheba Medical Center at Tel Hashomer, Tel Hashomer, Israel
- Harvard University T H Chan School of Public Health, Boston, Massachusetts, USA
| | - Ilan Shelef
- Division of Diagnostic and Interventional Imaging, Soroka University Medical Center, Beer Sheva, Israel
| | - Ilan Youngster
- Center for Microbiome Research, Yitzhak Shamir Medical Center Assaf Harofeh, Zerifin, Israel
- Tel Aviv University Sackler Faculty of Medicine, Tel Aviv, Israel
| | - Sharon Lebovitz
- Faculty of Health Sciences, Ben-Gurion University of the Negev, Beer Sheva, Israel
| | - Noa Israeli
- Faculty of Health Sciences, Ben-Gurion University of the Negev, Beer Sheva, Israel
| | - May Shabat
- Faculty of Health Sciences, Ben-Gurion University of the Negev, Beer Sheva, Israel
| | - Dov Brikner
- Department of Medicine, Nuclear Research Centre Negev, Beer-Sheva, Israel
| | - Efrat Pupkin
- Department of Medicine, Nuclear Research Centre Negev, Beer-Sheva, Israel
| | | | | | - Uta Ceglarek
- Department of Medicine, Leipzig University, Leipzig, Germany
| | - John T Heiker
- Department of Medicine, Leipzig University, Leipzig, Germany
| | - Antje Körner
- Department of Medicine, Leipzig University, Leipzig, Germany
| | | | - Martin von Bergen
- Faculty of Life Sciences, Leipzig University, Leipzig, Germany
- Department of Molecular Systems Biology, Helmholtz-Centre for Environmental Research - UFZ, Leipzig, Germany
| | - Matthias Blüher
- Department of Medicine, Leipzig University, Leipzig, Germany
| | - Meir J Stampfer
- Harvard University T H Chan School of Public Health, Boston, Massachusetts, USA
- Brigham and Women's Hospital Channing Division of Network Medicine, Boston, Massachusetts, USA
| | - Iris Shai
- Faculty of Health Sciences, Ben-Gurion University of the Negev, Beer Sheva, Israel
- Harvard University T H Chan School of Public Health, Boston, Massachusetts, USA
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Affiliation(s)
- Jes Sanddal Lindholt
- Department of Cardiothoracic and Vascular Surgery, Odense University Hospital, Elitary Research Centre for Individualized Medicine in Arterial Disease (CIMA), University of Southern Denmark, Odense, Denmark
| | - Rikke Søgaard
- Department of Cardiothoracic and Vascular Surgery, Odense University Hospital, Elitary Research Centre for Individualized Medicine in Arterial Disease (CIMA), University of Southern Denmark, Odense, Denmark
- Advisory Board Regarding the National Screening Programmes, Danish National Board of Health, Copenhagen, Denmark
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Vyas MV, Chaturvedi N, Hughes AD, Marmot M, Tillin T. Cardiovascular disease recurrence and long-term mortality in a tri-ethnic British cohort. Heart 2021; 107:996-1002. [PMID: 33067326 PMCID: PMC8165149 DOI: 10.1136/heartjnl-2020-317641] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/24/2020] [Revised: 09/16/2020] [Accepted: 09/21/2020] [Indexed: 11/09/2022] Open
Abstract
OBJECTIVE Ethnic differences in cardiovascular disease incidence, but not cardiovascular disease recurrence, are reported. We characterised long-term risk of major adverse cardiovascular event (MACE) and mortality following a non-fatal cardiovascular event in a British cohort of South Asians, African Caribbeans and Europeans. METHODS We identified index and recurrent cardiovascular events and mortality between 1988 and 2017 using hospital records and death registry. Using multivariable hazards models, we separately calculated the adjusted HR of MACE and death following index event, adjusting for demographics, vascular and lifestyle risk factors. Using interaction terms, we evaluated if decade of index event modified the association between ethnicity and outcomes. RESULTS South Asians were younger at the index event (median age 66 years, n=396) than Europeans (69 years, n=335) and African Caribbeans (70 years, n=70). During 4228 person-years, of the 801 patients, 537 developed MACE and 338 died, with the highest crude rate of MACE in South Asians. On adjustment of baseline factors, compared with the Europeans, the higher risk of MACE (HR 0.97, 95% CI 0.77 to 1.21) and the lower risk of mortality (HR 0.95, 95% CI 0.72 to 1.26) in South Asians was eliminated. African Caribbeans had similar outcomes to Europeans (HR MACE 1.04, 95% CI 0.74 to 1.47; and HR death 1.07, 95% CI 0.70 to 1.64). Long-term survival following an index event improved in South Asians (ptrend 0.02) and African Caribbeans (ptrend 0.07) compared with Europeans. CONCLUSIONS Baseline vascular risk factors explained the observed ethnic variation in cardiovascular disease recurrence and long-term mortality, with a relative improvement in survival of minority ethnic groups over time.
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Affiliation(s)
- Manav V Vyas
- Division of Neurology, University of Toronto, Toronto, Ontario, Canada
| | - Nish Chaturvedi
- MRC Unit for Lifelong Health and Ageing at UCL, University College London, London, UK
| | - Alun D Hughes
- MRC Unit for Lifelong Health and Ageing at UCL, University College London, London, UK
| | - Michael Marmot
- Epidemiology and Public Health, University College London, London, UK
| | - Therese Tillin
- MRC Unit for Lifelong Health and Ageing at UCL, University College London, London, UK
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Affiliation(s)
- Rabia Agca
- Rheumatology, Amsterdam UMC and Reade, Amsterdam, Noord-Holland, The Netherlands
| | - Yvo Smulders
- Internal Medicine, Amsterdam UMC, Amsterdam, Noord-Holland, The Netherlands
| | - Michael Nurmohamed
- Rheumatology, Amsterdam UMC and Reade, Amsterdam, Noord-Holland, The Netherlands
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Bae S, Kim SR, Kim MN, Shim WJ, Park SM. Impact of cardiovascular disease and risk factors on fatal outcomes in patients with COVID-19 according to age: a systematic review and meta-analysis. Heart 2021; 107:373-380. [PMID: 33334865 PMCID: PMC7747496 DOI: 10.1136/heartjnl-2020-317901] [Citation(s) in RCA: 155] [Impact Index Per Article: 51.7] [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] [Received: 07/28/2020] [Revised: 11/22/2020] [Accepted: 12/01/2020] [Indexed: 12/21/2022] Open
Abstract
OBJECTIVE Previous studies that evaluated cardiovascular risk factors considered age as a potential confounder. We aimed to investigate the impact of cardiovascular disease (CVD) and its risk factors on fatal outcomes according to age in patients with COVID-19. METHODS A systematic literature review and meta-analysis was performed on data collected from PubMed and Embase databases up to 11 June 2020. All observational studies (case series or cohort studies) that assessed in-hospital patients were included, except those involving the paediatric population. Prevalence rates of comorbid diseases and clinical outcomes were stratified by mean patient age in each study (ranges: <50 years, 50-60 years and ≥60 years). The primary outcome measure was a composite fatal outcome of severe COVID-19 or death. RESULTS We included 51 studies with a total of 48 317 patients with confirmed COVID-19 infection. Overall, the relative risk of developing severe COVID-19 or death was significantly higher in patients with risk factors for CVD (hypertension: OR 2.50, 95% CI 2.15 to 2.90; diabetes: 2.25, 95% CI 1.89 to 2.69) and CVD (3.11, 95% 2.55 to 3.79). Younger patients had a lower prevalence of hypertension, diabetes and CVD compared with older patients; however, the relative risk of fatal outcomes was higher among the former. CONCLUSIONS The results of the meta-analysis suggest that CVD and its risk factors (hypertension and diabetes) were closely related to fatal outcomes in COVID-19 for patients across all ages. Although young patients had lower prevalence rates of cardiovascular comorbidities than elderly patients, relative risk of fatal outcome in young patients with hypertension, diabetes and CVD was higher than in elderly patients. PROSPERO REGISTRATION NUMBER CRD42020198152.
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Affiliation(s)
- SungA Bae
- Division of Cardiology, Korea University Anam Hospital, Seoul, Korea (the Republic of)
| | - So Ree Kim
- Division of Cardiology, Korea University Anam Hospital, Seoul, Korea (the Republic of)
| | - Mi-Na Kim
- Division of Cardiology, Korea University Anam Hospital, Seoul, Korea (the Republic of)
| | - Wan Joo Shim
- Division of Cardiology, Korea University Anam Hospital, Seoul, Korea (the Republic of)
| | - Seong-Mi Park
- Division of Cardiology, Korea University Anam Hospital, Seoul, Korea (the Republic of)
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Gersh FL, O'Keefe JH, Lavie CJ. Postmenopausal hormone therapy for cardiovascular health: the evolving data. Heart 2021; 107:1115-1122. [PMID: 33619206 DOI: 10.1136/heartjnl-2019-316323] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/30/2020] [Revised: 10/28/2020] [Accepted: 11/02/2020] [Indexed: 01/26/2023] Open
Abstract
Postmenopausal (PM) hormone therapy (HT) was extremely popular for years as a treatment for many conditions, including cardiovascular (CV) disease (CVD) prevention. The adverse results from the Women's Health Initiative (WHI) ended the widespread prescriptive use of HT for nearly 20 years. The WHI findings have been broadly and unfairly applied to all hormone formulations, including modern treatments using human-identical hormones. Although CV health is indisputably linked to oestrogen status, HT involving any combination of hormones currently is not recommended for primary or secondary prevention of CVD. In the wake of more positive results from recent studies and re-evaluation of the WHI, HT has re-emerged as an issue for specialists in CVD to discuss with their patients. Rigorous scientific analysis is needed to explain the paradox of cardioprotection conferred by endogenous ovarian hormones with apparent cardiotoxicity inflicted by HT. This review will cover the origins of HT, hormone terminology and function, and key studies that contribute to our current understanding. Based on evolving evidence, if HT is to be used, we propose it be initiated immediately after cessation of ovarian hormone production and dosed as transdermal oestradiol combined with cyclic dosing of human-identical progesterone (P4).
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Affiliation(s)
- Felice L Gersh
- Internal Medicine, Fellowship in Integrative Medicine, University of Arizona College of Medicine, Irvine, California, USA
| | - James H O'Keefe
- University of Missouri-Kansas City, Department of Cardiology, Saint Luke's Mid America Heart Institute, Kansas City, Missouri, USA
| | - Carl J Lavie
- Cardiology, John Ochsner Heart and Vascular Institute, New Orleans, Louisiana, USA
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Mahtta D, Ramsey D, Krittanawong C, Al Rifai M, Khurram N, Samad Z, Jneid H, Ballantyne C, Petersen LA, Virani SS. Recreational substance use among patients with premature atherosclerotic cardiovascular disease. Heart 2021; 107:650-656. [PMID: 33589427 DOI: 10.1136/heartjnl-2020-318119] [Citation(s) in RCA: 28] [Impact Index Per Article: 9.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/27/2020] [Revised: 12/14/2020] [Accepted: 12/15/2020] [Indexed: 12/12/2022] Open
Abstract
OBJECTIVE Despite an upsurge in the incidence of atherosclerotic cardiovascular diseases (ASCVD) among young adults, the attributable risk of recreational substance use among young patients has been incompletely evaluated. We evaluated the association of all recreational substances with premature and extremely premature ASCVD. METHODS In a cross-sectional analysis using the 2014-2015 nationwide Veterans Affairs Healthcare database and the Veterans wIth premaTure AtheroscLerosis (VITAL) registry, patients were categorised as having premature, extremely premature or non-premature ASCVD. Premature ASCVD was defined as having first ASCVD event at age <55 years for men and <65 years for women. Extremely premature was defined as having first ASCVD event at age <40 years while non-premature ASCVD was defined as having first ASCVD event at age ≥55 years for men and ≥65 years for women. Patients with premature ASCVD (n=135 703) and those with extremely premature ASCVD (n=7716) were compared against patients with non-premature ASCVD (n=1 112 455). Multivariable logistic regression models were used to study the independent association of all recreational substances with premature and extremely premature ASCVD. RESULTS Compared with patients with non-premature ASCVD, patients with premature ASCVD had a higher use of tobacco (62.9% vs 40.6%), alcohol (31.8% vs 14.8%), cocaine (12.9% vs 2.5%), amphetamine (2.9% vs 0.5%) and cannabis (12.5% vs 2.7%) (p<0.01 for all comparisons). In adjusted models, the use of tobacco (OR 1.97, 95% CI 1.94 to 2.00), alcohol (OR 1.50, 95% CI 1.47 to 1.52), cocaine (OR 2.44, 95% CI 2.38 to 2.50), amphetamine (OR 2.74, 95% CI 2.62 to 2.87), cannabis (OR 2.65, 95% CI 2.59 to 2.71) and other drugs (OR 2.53, 95% CI 2.47 to 2.59) was independently associated with premature ASCVD. Patients with polysubstance use had a graded response with the highest risk (~9-fold) of premature ASCVD among patients with use of ≥4 recreational substances. Similar trends were observed among patients with extremely premature ASCVD. Gender interactions with substance use were significant (p-interaction <0.05), with recreational substance use and premature ASCVD showing stronger associations among women than in men with premature ASCVD. CONCLUSIONS All subgroups of recreational substances were independently associated with a higher likelihood of premature and extremely premature ASCVD. Recreational substance use confers a greater magnitude of risk for premature ASCVD among women. A graded response relationship exists between increasing number of recreational substances used and higher likelihood of early-onset ASCVD.
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Affiliation(s)
- Dhruv Mahtta
- Health Policy, Quality & Informatics Program, Michael E. DeBakey VA Medical Center Health Services Research & Development Center for Innovations in Quality, Effectiveness, and Safety, Houston, Texas, USA.,Section of Cardiology, Department of Medicine, -Baylor College of Medicine, Houston, Texas, USA.,Section of Health Services Research, Department of Medicine, Baylor College of Medicine, Houston, Texas, USA
| | - David Ramsey
- Health Policy, Quality & Informatics Program, Michael E. DeBakey VA Medical Center Health Services Research & Development Center for Innovations in Quality, Effectiveness, and Safety, Houston, Texas, USA
| | - Chayakrit Krittanawong
- Section of Cardiology, Department of Medicine, -Baylor College of Medicine, Houston, Texas, USA
| | - Mahmoud Al Rifai
- Section of Cardiology, Department of Medicine, -Baylor College of Medicine, Houston, Texas, USA
| | - Nasir Khurram
- Division of Cardiovascular Medicine, Methodist DeBakey Heart & Vascular Center, Houston Methodist Hospital, Houston, Texas, USA
| | - Zainab Samad
- Department of Medicine, The Aga Khan University, Karachi, Sindh, Pakistan
| | - Hani Jneid
- Section of Cardiology, Department of Medicine, -Baylor College of Medicine, Houston, Texas, USA.,Section of Cardiovascular Research, Department of Medicine, Baylor College of Medicine, Houston, Texas, USA
| | - Christie Ballantyne
- Section of Cardiovascular Research, Department of Medicine, Baylor College of Medicine, Houston, Texas, USA
| | - Laura A Petersen
- Health Policy, Quality & Informatics Program, Michael E. DeBakey VA Medical Center Health Services Research & Development Center for Innovations in Quality, Effectiveness, and Safety, Houston, Texas, USA.,Section of Health Services Research, Department of Medicine, Baylor College of Medicine, Houston, Texas, USA
| | - Salim S Virani
- Health Policy, Quality & Informatics Program, Michael E. DeBakey VA Medical Center Health Services Research & Development Center for Innovations in Quality, Effectiveness, and Safety, Houston, Texas, USA .,Section of Cardiology, Department of Medicine, -Baylor College of Medicine, Houston, Texas, USA.,Section of Health Services Research, Department of Medicine, Baylor College of Medicine, Houston, Texas, USA.,Section of Cardiovascular Research, Department of Medicine, Baylor College of Medicine, Houston, Texas, USA
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12
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Betts J, Dewar EM, Stub D, Gao CX, Brown DW, Ikin JF, Zeleke BM, Biswas S, Abramson MJ, Liew D. Markers of Cardiovascular Disease among Adults Exposed to Smoke from the Hazelwood Coal Mine Fire. Int J Environ Res Public Health 2021; 18:1587. [PMID: 33567509 PMCID: PMC7914645 DOI: 10.3390/ijerph18041587] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 11/25/2020] [Revised: 01/27/2021] [Accepted: 02/01/2021] [Indexed: 11/17/2022]
Abstract
Little research has examined the effects of high concentration, medium-duration smoke exposure on cardiovascular health. We investigated whether six weeks of exposure to smoke from the 2014 Hazelwood coal mine fire in Victoria (Australia), was associated with long-term clinical or subclinical cardiovascular disease approximately four years later, in adult residents of the towns of Morwell (exposed, n = 336) and Sale (unexposed, n = 162). The primary outcome was serum high sensitivity (hs) C-reactive protein (CRP). Blood pressure, electrocardiogram, flow mediated dilatation and serum levels of hs-troponin, N-terminal pro B-type natriuretic peptide and lipids were secondary outcomes. There was no significant difference in weighted median hsCRP levels between exposed and unexposed participants (1.9 mg/L vs. 1.6 mg/L, p = 0.273). Other outcomes were comparable between the groups. hsCRP was associated in a predictable manner with current smoking, obesity and use of lipid-lowering therapy. Four years after a 6-week coal mine fire, this study found no association between smoke exposure and markers of clinical or subclinical cardiovascular disease in exposed adults.
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Affiliation(s)
- Juliana Betts
- School of Public Health and Preventive Medicine, Monash University, Melbourne, VIC 3004, Australia; (J.B.); (D.S.); (C.X.G.); (D.W.B.); (J.F.I.); (B.M.Z.); (S.B.); (D.L.)
| | - Elizabeth M. Dewar
- Department of Cardiology, Alfred Health, Melbourne, VIC 3004, Australia;
- Baker Heart and Diabetes Institute, Melbourne, VIC 3004, Australia
| | - Dion Stub
- School of Public Health and Preventive Medicine, Monash University, Melbourne, VIC 3004, Australia; (J.B.); (D.S.); (C.X.G.); (D.W.B.); (J.F.I.); (B.M.Z.); (S.B.); (D.L.)
- Department of Cardiology, Alfred Health, Melbourne, VIC 3004, Australia;
| | - Caroline X. Gao
- School of Public Health and Preventive Medicine, Monash University, Melbourne, VIC 3004, Australia; (J.B.); (D.S.); (C.X.G.); (D.W.B.); (J.F.I.); (B.M.Z.); (S.B.); (D.L.)
| | - David W. Brown
- School of Public Health and Preventive Medicine, Monash University, Melbourne, VIC 3004, Australia; (J.B.); (D.S.); (C.X.G.); (D.W.B.); (J.F.I.); (B.M.Z.); (S.B.); (D.L.)
| | - Jillian F. Ikin
- School of Public Health and Preventive Medicine, Monash University, Melbourne, VIC 3004, Australia; (J.B.); (D.S.); (C.X.G.); (D.W.B.); (J.F.I.); (B.M.Z.); (S.B.); (D.L.)
| | - Berihun M. Zeleke
- School of Public Health and Preventive Medicine, Monash University, Melbourne, VIC 3004, Australia; (J.B.); (D.S.); (C.X.G.); (D.W.B.); (J.F.I.); (B.M.Z.); (S.B.); (D.L.)
| | - Sinjini Biswas
- School of Public Health and Preventive Medicine, Monash University, Melbourne, VIC 3004, Australia; (J.B.); (D.S.); (C.X.G.); (D.W.B.); (J.F.I.); (B.M.Z.); (S.B.); (D.L.)
| | - Michael J. Abramson
- School of Public Health and Preventive Medicine, Monash University, Melbourne, VIC 3004, Australia; (J.B.); (D.S.); (C.X.G.); (D.W.B.); (J.F.I.); (B.M.Z.); (S.B.); (D.L.)
| | - Danny Liew
- School of Public Health and Preventive Medicine, Monash University, Melbourne, VIC 3004, Australia; (J.B.); (D.S.); (C.X.G.); (D.W.B.); (J.F.I.); (B.M.Z.); (S.B.); (D.L.)
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13
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Mallinson PAC, Luhar S, Williamson E, Barreto ML, Kinra S. Socioeconomic position and cardiovascular mortality in 63 million adults from Brazil. Heart 2021; 107:822-827. [PMID: 33483354 DOI: 10.1136/heartjnl-2020-318153] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/03/2020] [Revised: 12/20/2020] [Accepted: 12/29/2020] [Indexed: 12/19/2022] Open
Abstract
BACKGROUND It has been suggested that cardiovascular disease exhibits a 'social cross-over', from greater risk in higher socioeconomic groups to lower socioeconomic groups, on economic development, but robust evidence is lacking. We used standardised data to compare the social inequalities in cardiovascular mortality across states at varying levels of economic development in Brazil. METHODS We used national census and mortality data from 2010. We used age-adjusted multilevel Poisson regression to estimate the association between educational status and cardiovascular mortality by state-level economic development (assessed by quintiles of Human Development Index). RESULTS In 2010, there were 185 383 cardiovascular deaths among 62.5 million adults whose data were analysed. The age-adjusted cardiovascular mortality rate ratio for women with <8 years of education (compared with 8+ years) was 3.75 (95% CI 3.29 to 4.28) in the least developed one-fifth of states and 2.84 (95% CI 2.75 to 2.92) in the most developed one-fifth of states (p value for linear trend=0.002). Among men, corresponding rate ratios were 2.53 (95% CI 2.32 to 2.77) and 2.26 (95% CI 2.20 to 2.31), respectively (p value=0.258). Associations were similar across subtypes of cardiovascular disease (ischaemic heart disease and stroke) and robust to the size of geographical unit used for analysis. CONCLUSIONS Our results do not support a 'social crossover' in cardiovascular mortality on economic development. Our analyses, based on a large standardised dataset from a country that is currently experiencing economic transition, provide strong evidence that low socioeconomic groups experience the highest risk of cardiovascular disease, irrespective of the stage of national economic development.
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Affiliation(s)
| | - Shammi Luhar
- Faculty of Epidemiology and Population Health, London School of Hygiene & Tropical Medicine, London, UK.,Department of Public Health and Primary Care, University of Cambridge, Cambridge, Cambridgeshire, UK
| | - Elizabeth Williamson
- Faculty of Epidemiology and Population Health, London School of Hygiene & Tropical Medicine, London, UK
| | - Mauricio L Barreto
- Centre for Data and Knowledge Integration for Health (CIDACS), Fiocruz Bahia, Salvador, Bahia, Brazil.,Institute of Collective Health, Federal University of Bahia, Salvador, Bahia, Brazil
| | - Sanjay Kinra
- Faculty of Epidemiology and Population Health, London School of Hygiene & Tropical Medicine, London, UK
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14
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Marcuschamer I, Zusman O, Iakobishvili Z, Assali AR, Vaknin-Assa H, Goldenberg I, Cohen T, Shlomo N, Kornowski R, Eisen A. Outcome of patients with prior coronary bypass surgery admitted with an acute coronary syndrome. Heart 2021; 107:1820-1825. [PMID: 33462121 DOI: 10.1136/heartjnl-2020-318047] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/13/2020] [Revised: 12/29/2020] [Accepted: 12/30/2020] [Indexed: 11/04/2022] Open
Abstract
BACKGROUND Patients with prior coronary artery bypass graft surgery (CABG) are at increased risk for recurrent cardiovascular ischaemic events. Advances in management have improved prognosis of patients with acute coronary syndrome (ACS), yet it is not known whether similar trends exist in patients with prior CABG. AIM Examine temporal trends in the prevalence, treatment and clinical outcomes of patients with prior CABG admitted with ACS. METHODS Time-dependent analysis of patients with or without prior CABG admitted with an ACS who enrolled in the ACS Israeli Surveys between 2000 and 2016. Surveys were divided into early (2000-2008) and late (2010-2016) time periods. Outcomes included 30 days major adverse cardiac events (30d MACE) (death, myocardial infarction, stroke, unstable angina, stent thrombosis, urgent revascularisation) and 1-year mortality. RESULTS Among 15 152 patients with ACS, 1506 (9.9%) had a prior CABG. Patients with prior CABG were older (69 vs 63 years), had more comorbidities and presented more with non-ST elevation-ACS (82% vs 51%). Between time periods, utilisation of antiplatelets, statins and percutaneous interventions significantly increased in both groups (p<0.001 for each). The rate of 30d MACE decreased in patients with (19.1%-12.4%, p=0.001) and without (17.4%-9.5%, p<0.001) prior CABG. However, 1-year mortality decreased only in patients without prior CABG (10.5% vs 7.4%, p<0.001) and remained unchanged in patients with prior CABG. Results were consistent after propensity matching. CONCLUSIONS Despite an improvement in the management and prognosis of patients with ACS in the last decade, the rate of 1-year mortality of patients with prior CABG admitted with an ACS remained unchanged.
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Affiliation(s)
- Ilan Marcuschamer
- Cardiology Department, Rabin Medical Center, Petah Tikva, Israel.,Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Oren Zusman
- Cardiology Department, Rabin Medical Center, Petah Tikva, Israel.,Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Z Iakobishvili
- Cardiology Department, Rabin Medical Center, Petah Tikva, Israel.,Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Abid R Assali
- Cardiology Department, Rabin Medical Center, Petah Tikva, Israel.,Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Hanah Vaknin-Assa
- Cardiology Department, Rabin Medical Center, Petah Tikva, Israel.,Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Ilan Goldenberg
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel.,Israeli Association for Cardiovascular Trials, Sheba Medical Center, Ramat Gan, Israel.,The Leviev Heart Center, Sheba Medical Center, Tel Hashome, Israel
| | - Tal Cohen
- Israeli Association for Cardiovascular Trials, Sheba Medical Center, Ramat Gan, Israel.,The Leviev Heart Center, Sheba Medical Center, Tel Hashome, Israel
| | - Nir Shlomo
- Israeli Association for Cardiovascular Trials, Sheba Medical Center, Ramat Gan, Israel.,The Leviev Heart Center, Sheba Medical Center, Tel Hashome, Israel
| | - Ran Kornowski
- Cardiology Department, Rabin Medical Center, Petah Tikva, Israel.,Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Alon Eisen
- Cardiology Department, Rabin Medical Center, Petah Tikva, Israel .,Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
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15
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Barcella CA, Mohr G, Kragholm K, Christensen D, Gerds TA, Polcwiartek C, Wissenberg M, Bang C, Folke F, Torp-Pedersen C, Kessing LV, Gislason GH, Bach Søndergaard K. Risk of out-of-hospital cardiac arrest in patients with bipolar disorder or schizophrenia. Heart 2021; 107:1544-1551. [PMID: 33452118 DOI: 10.1136/heartjnl-2020-318078] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/21/2020] [Revised: 12/10/2020] [Accepted: 12/17/2020] [Indexed: 11/04/2022] Open
Abstract
OBJECTIVE Patients with bipolar disorder and schizophrenia are at high cardiovascular risk; yet, the risk of out-of-hospital cardiac arrest (OHCA) compared with the general population remains scarcely investigated. METHODS We conducted a nested case-control study using Cox regression to assess the association of bipolar disorder and schizophrenia with the HRs of OHCA of presumed cardiac cause (2001-2015). Reported are the HRs with 95% CIs overall and in subgroups defined by established cardiac disease, cardiovascular risk factors and psychotropic drugs. RESULTS We included 35 017 OHCA cases and 175 085 age-matched and sex-matched controls (median age 72 years and 66.9% male). Patients with bipolar disorder or schizophrenia had overall higher rates of OHCA compared with the general population: HR 2.74 (95% CI 2.41 to 3.13) and 4.49 (95% CI 4.00 to 5.10), respectively. The association persisted in patients with both cardiac disease and cardiovascular risk factors at baseline (bipolar disorder HR 2.14 (95% CI 1.72 to 2.66), schizophrenia 2.84 (95% CI 2.20 to 3.67)) and among patients without known risk factors (bipolar disorder HR 2.14 (95% CI 1.09 to 4.21), schizophrenia HR 5.16 (95% CI 3.17 to 8.39)). The results were confirmed in subanalyses only including OHCAs presenting with shockable rhythm or receiving an autopsy. Antipsychotics-but not antidepressants, lithium or antiepileptics (the last two only tested in bipolar disorder)-increased OHCA hazard compared with no use in both disorders. CONCLUSIONS Patients with bipolar disorder or schizophrenia have a higher rate of OHCA compared with the general population. Cardiac disease, cardiovascular risk factors and antipsychotics represent important underlying mechanisms.
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Affiliation(s)
- Carlo Alberto Barcella
- Department of Cardiology, Copenhagen University Hospital Gentofte, Hellerup, Copenhagen, Denmark
| | - Grimur Mohr
- Department of Cardiology, Copenhagen University Hospital Gentofte, Hellerup, Copenhagen, Denmark
| | - Kristian Kragholm
- Department of Cardiology, Aalborg University Hospital, Aalborg, Denmark
| | - Daniel Christensen
- Department of Cardiology, Copenhagen University Hospital Gentofte, Hellerup, Copenhagen, Denmark.,The Danish Heart Foundation, Copenhagen, Denmark
| | - Thomas A Gerds
- The Danish Heart Foundation, Copenhagen, Denmark.,Department of Biostatistics, University of Copenhagen, Copenhagen, Denmark
| | - Christoffer Polcwiartek
- Department of Cardiology, Aalborg University Hospital, Aalborg, Denmark.,Cardiology and Clinical Medicine, Aalborg University Hospital, Aalborg, Nordjylland, Denmark
| | - Mads Wissenberg
- Department of Cardiology, Copenhagen University Hospital Gentofte, Hellerup, Copenhagen, Denmark
| | - Casper Bang
- Department of Clinical Investigation and Cardiology, Nordsjællands Hospital, Hillerod, Denmark.,Department of Cardiology, Bispebjerg University Hospital, Copenhagen, Denmark
| | - Fredrik Folke
- Department of Cardiology, Copenhagen University Hospital Gentofte, Hellerup, Copenhagen, Denmark
| | - Christian Torp-Pedersen
- Department of Clinical Investigation and Cardiology, Nordsjællands Hospital, Hillerod, Denmark
| | - Lars Vedel Kessing
- Psychiatric Center Copenhagen, Copenhagen University Hospital, Copenhagen, Denmark
| | - Gunnar Hilmar Gislason
- Department of Cardiology, Copenhagen University Hospital Gentofte, Hellerup, Copenhagen, Denmark
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16
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Wu G, Liu J, Wang S, Yu S, Zhang C, Wang D, Zhang M, Yang Y, Kang L, Zhao S, Hui R, Zou Y, Wang J, Song L. N-terminal pro-brain natriuretic peptide and sudden cardiac death in hypertrophic cardiomyopathy. Heart 2020; 107:1576-1583. [PMID: 33361398 DOI: 10.1136/heartjnl-2020-317701] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/01/2020] [Revised: 11/20/2020] [Accepted: 11/24/2020] [Indexed: 11/04/2022] Open
Abstract
OBJECTIVE Elevated levels of N-terminal pro-brain natriuretic peptide (NT-proBNP) are associated with heart failure-related death in hypertrophic cardiomyopathy (HCM), but the relationship between NT-proBNP level and sudden cardiac death (SCD) in HCM remains undefined. METHODS The study prospectively enrolled 977 unrelated patients with HCM with available NT-proBNP results who were prospectively enrolled and followed for 3.0±2.1 years. The Harrell's C-statistic under the receiver operating characteristic curve was calculated to evaluate discrimination performance. A combination model was constructed by adding NT-proBNP tertiles to the HCM Risk-SCD model. The correlation between log NT-proBNP level and cardiac fibrosis as measured by late gadolinium enhancement (LGE) or Masson's staining was analysed. RESULTS During follow-up, 29 patients had SCD. Increased log NT-proBNP levels were associated with an increased risk of SCD events (adjusted HR 22.27, 95% CI 10.93 to 65.63, p<0.001). The C-statistic of NT-proBNP in predicting SCD events was 0.80 (p<0.001). The combined model significantly improved the predictive efficiency of the HCM Risk-SCD model from 0.72 to 0.81 (p<0.05), with a relative integrated discrimination improvement of 0.002 (p<0.001) and net reclassification improvement of 0.67 (p<0.001). Furthermore, log NT-proBNP levels were significantly correlated with cardiac fibrosis as detected either by LGE (r=0.257, p<0.001) or by Masson's trichrome staining in the myocardium (r=0.198, p<0.05). CONCLUSION NT-proBNP is an independent predictor of SCD in patients with HCM and may help with risk stratification of this disease.
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Affiliation(s)
- Guixin Wu
- State Key Laboratory of Cardiovascular Disease, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China.,Cardiomyopathy Ward, Fuwai Hospital, National Center for Cardiovascular Disease, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Jie Liu
- State Key Laboratory of Cardiovascular Disease, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China.,Cardiomyopathy Ward, Fuwai Hospital, National Center for Cardiovascular Disease, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Shuiyun Wang
- Department of Cardiac Surgery, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Shiqin Yu
- Department of Radiology, Fuwai Hospital, National Center for Cardiovascular Disease, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Ce Zhang
- Department of Cardiovascular Internal Medicine, Fuwai Hospital, National Center for Cardiovascular Disease, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Dong Wang
- Cardiomyopathy Ward, Fuwai Hospital, National Center for Cardiovascular Disease, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Mo Zhang
- Cardiomyopathy Ward, Fuwai Hospital, National Center for Cardiovascular Disease, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Yaoyao Yang
- Department of Cardiovascular Internal Medicine, Fuwai Hospital, National Center for Cardiovascular Disease, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Lianming Kang
- Cardiomyopathy Ward, Fuwai Hospital, National Center for Cardiovascular Disease, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Shihua Zhao
- Department of Radiology, Fuwai Hospital, National Center for Cardiovascular Disease, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Rutai Hui
- State Key Laboratory of Cardiovascular Disease, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Yubao Zou
- Department of Cardiovascular Internal Medicine, Fuwai Hospital, National Center for Cardiovascular Disease, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Jizheng Wang
- State Key Laboratory of Cardiovascular Disease, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Lei Song
- State Key Laboratory of Cardiovascular Disease, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China .,National Clinical Research Center of Cardiovascular Diseases, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
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17
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Pinto-Filho MM, Brant LC, Dos Reis RP, Giatti L, Duncan BB, Lotufo PA, da Fonseca MDJM, Mill JG, de Almeida MDCC, MacFarlane P, Barreto SM, Ribeiro ALP. Prognostic value of electrocardiographic abnormalities in adults from the Brazilian longitudinal study of adults' health. Heart 2020; 107:1560-1566. [PMID: 33361354 DOI: 10.1136/heartjnl-2020-318097] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/24/2020] [Revised: 11/18/2020] [Accepted: 11/22/2020] [Indexed: 11/04/2022] Open
Abstract
OBJECTIVE Cardiovascular diseases (CVDs) are highly preventable non-communicable diseases. ECG is a potential tool for risk stratification with respect to CVD. Our aim was to evaluate ECG's role in all-cause and cardiovascular mortality prediction. METHODS Participants from the Brazilian Longitudinal Study of Adult Health, free of known CVD at baseline were included. A 12-lead ECG was obtained at baseline (2008-2010). Participants were followed up to 2018 by annual interviews. Deaths were independently reviewed. Cox as well as Fine and Grey multivariable regression models were applied to evaluate if the presence of any major electrocardiographic abnormality (MEA), defined according to the Minnesota Code system, would predict total and cardiovascular deaths. We also evaluated the Net Reclassification Index of adding MEA to the Systematic Coronary Risk Evaluation (SCORE). RESULTS The 13 428 participants (median age 51 years, 45% men) were followed up for 8±1 years. All-cause and cardiovascular mortality occurred in 2.8% and 1.2% of the population, respectively. Prevalent MEA was an independent predictor of overall (HR=2.3, 95% CI 1.7 to 2.9) and cardiovascular mortality (HR=4.6, 95% CI 3.0 to 7.0) after adjustments for age, race, education and traditional cardiovascular risk factors. Adding MEA to the SCORE resulted in 9% mis-reclassification in the non-event subgroup and 33% correct reclassification in those with a fatal cardiovascular event. CONCLUSION Presence of MEA was an independent predictor of overall and cardiovascular mortality. ECG may have a role in risk prediction of cardiovascular mortality in primary care.
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Affiliation(s)
| | - Luisa Caldeira Brant
- Internal Medicine, Universidade Federal de Minas Gerais, Belo Horizonte, Minas Gerais, Brazil
| | | | - Luana Giatti
- Medicina Preventiva e Social, Universidade Federal de Minas Gerais, Belo Horizonte, Minas Gerais, Brazil
| | | | - Paulo A Lotufo
- Center for Clinical and Epidemiologic Research, Faculdade de Medicina, Universidade de Sao Paulo, Sao Paulo, Brazil
| | | | - Jose Geraldo Mill
- Physiological Sciences, Federal University of Espírito Santo, VITÓRIA, ESPÍRITO SANTO, Brazil
| | | | | | - Sandhi Maria Barreto
- Social and Preventive Medicine, Universidade Federal de Minas Gerais, Belo Horizonte, Minas Gerais, Brazil
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18
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Affiliation(s)
- Mary Yannakoulia
- School of Health Science and Education, Harokopio University, Attica, Greece
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19
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Matthews AA, Peacock Hinton S, Stanway S, Lyon AR, Smeeth L, Lund JL, Bhaskaran K. Endocrine therapy use and cardiovascular risk in postmenopausal breast cancer survivors. Heart 2020; 107:1327-1335. [PMID: 33177117 PMCID: PMC8327412 DOI: 10.1136/heartjnl-2020-317510] [Citation(s) in RCA: 23] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/05/2020] [Revised: 10/12/2020] [Accepted: 10/16/2020] [Indexed: 12/03/2022] Open
Abstract
Objective Examine the effect of tamoxifen and aromatase inhibitors (AIs) on the risk of 12 clinically relevant cardiovascular outcomes in postmenopausal female breast cancer survivors. Methods We carried out two prospective cohort studies among postmenopausal women with breast cancer in UK primary care and hospital data (2002–2016) and US Surveillance, Epidemiology and End Results-Medicare data (2008–2013). Using Cox adjusted proportional hazards models, we compared cardiovascular risks between AI and tamoxifen users; and in the USA, between users of both drug classes and women receiving no endocrine therapy. Results 10 005 (UK) and 22 027 (USA) women with postmenopausal breast cancer were included. In both countries, there were higher coronary artery disease risks in AI compared with tamoxifen users (UK age-standardised incidence rate: 10.17 vs 7.51 per 1000 person-years, HR: 1.29, 95% CI 0.94 to 1.76; US age-standardised incidence rate: 36.82 vs 26.02 per 1000 person-years, HR: 1.29, 95% C I1.06 to 1.55). However, comparisons with those receiving no endocrine therapy (US data) showed no higher risk for either drug class and a lower risk in tamoxifen users (age-standardised incidence rate tamoxifen vs unexposed: 26.02 vs 35.19 per 1000 person-years, HR: 0.74, 95% 0.60 to 0.92; age-standardised incidence rate AI vs unexposed: 36.82 vs 35.19, HR: 0.96, 95% CI 0.83 to 1.10). Similar patterns were seen for other cardiovascular outcomes (arrhythmia, heart failure and valvular heart disease). As expected, there was more venous thromboembolism in tamoxifen compared with both AI users and those unexposed. Conclusions Higher risks of several cardiovascular outcomes among AI compared with tamoxifen users appeared to be driven by protective effects of tamoxifen, rather than cardiotoxic effects of AIs.
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Affiliation(s)
- Anthony A Matthews
- Institute of Environmental Medicine, Karolinska Institute, Stockholm, Sweden .,Department of Epidemiology, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA.,Department of Epidemiology and Population Health, London School of Hygiene & Tropical Medicine, London, UK
| | - Sharon Peacock Hinton
- Department of Epidemiology, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
| | - Susannah Stanway
- Departmnet of Medicine, The Royal Marsden NHS Foundation Trust, London, UK
| | - Alexander Richard Lyon
- National Heart and Lung Institute, Imperial College, London, UK.,Royal Brompton and Harefield NHS Trust, London, UK
| | - Liam Smeeth
- Department of Epidemiology and Population Health, London School of Hygiene & Tropical Medicine, London, UK
| | - Jennifer L Lund
- Department of Epidemiology, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA.,Lineberger Comprehensive Cancer Center, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
| | - Krishnan Bhaskaran
- Department of Epidemiology and Population Health, London School of Hygiene & Tropical Medicine, London, UK
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Hurdus B, Munyombwe T, Dondo TB, Aktaa S, Oliver G, Hall M, Doherty P, Hall AS, Gale CP. Association of cardiac rehabilitation and health-related quality of life following acute myocardial infarction. Heart 2020; 106:1726-1731. [PMID: 32826289 PMCID: PMC7656151 DOI: 10.1136/heartjnl-2020-316920] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/20/2020] [Revised: 06/30/2020] [Accepted: 07/14/2020] [Indexed: 11/24/2022] Open
Abstract
OBJECTIVE To study the association of cardiac rehabilitation and physical activity with temporal changes in health-related quality of life (HRQoL) following acute myocardial infarction (AMI). METHODS Evaluation of the Methods and Management of Acute Coronary Events-3 is a nationwide longitudinal prospective cohort study of 4570 patients admitted with an AMI between 1 November 2011 and 17 September 2013. HRQoL was estimated using EuroQol 5-Dimension-3 Level Questionnaire at hospitalisation, 30 days, and 6 and 12 months following hospital discharge. The association of cardiac rehabilitation and self-reported physical activity on temporal changes in HRQoL was quantified using inverse probability of treatment weighting propensity score and multilevel regression analyses. RESULTS Cardiac rehabilitation attendees had higher HRQoL scores than non-attendees at 30 days (mean EuroQol 5-Visual Analogue Scale (EQ-VAS) scores: 71.0 (SD 16.8) vs 68.6 (SD 19.8)), 6 months (76.0 (SD 16.4) vs 70.2 (SD 19.0)) and 12 months (76.9 (SD 16.8) vs 70.4 (SD 20.4)). Attendees who were physically active ≥150 min/week had higher HRQoL scores compared with those who only attended cardiac rehabilitation at 30 days (mean EQ-VAS scores: 79.3 (SD 14.6) vs 70.2 (SD 17.0)), 6 months (82.2 (SD 13.9) vs 74.9 (SD 16.7)) and 12 months (84.1 (SD 12.1) vs 75.6 (SD 17.0)). Cardiac rehabilitation and self-reported physical activity of ≥150 min/week were each positively associated with temporal improvements in HRQoL (coefficient: 2.12 (95% CI 0.68 to 3.55) and 4.75 (95% CI 3.16 to 6.34), respectively). CONCLUSIONS Cardiac rehabilitation was independently associated with temporal improvements in HRQoL at up to 12 months following hospitalisation, with such changes further improved in patients who were physically active.
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Affiliation(s)
- Ben Hurdus
- Leeds Institute for Data Analytics, Leeds Institute of Cardiovascular and Metabolic Medicine, Leeds, UK
- Department of Cardiology, Leeds Teaching Hospitals NHS Trust, Leeds, UK
| | - Theresa Munyombwe
- Leeds Institute for Data Analytics, Leeds Institute of Cardiovascular and Metabolic Medicine, Leeds, UK
| | | | - Suleman Aktaa
- Leeds Institute for Data Analytics, Leeds Institute of Cardiovascular and Metabolic Medicine, Leeds, UK
- Department of Cardiology, Leeds Teaching Hospitals NHS Trust, Leeds, UK
| | | | - Marlous Hall
- Leeds Institute for Data Analytics, Leeds Institute of Cardiovascular and Metabolic Medicine, Leeds, UK
| | - Patrick Doherty
- Health Sciences, University of York, York, North Yorkshire, UK
| | - Alistair S Hall
- Leeds Institute for Data Analytics, Leeds Institute of Cardiovascular and Metabolic Medicine, Leeds, UK
- Department of Cardiology, Leeds Teaching Hospitals NHS Trust, Leeds, UK
| | - Chris P Gale
- Leeds Institute for Data Analytics, Leeds Institute of Cardiovascular and Metabolic Medicine, Leeds, UK
- Department of Cardiology, Leeds Teaching Hospitals NHS Trust, Leeds, UK
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21
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Affiliation(s)
- Tamar I de Vries
- Department of Vascular Medicine, University Medical Centre Utrecht, Utrecht University, Utrecht, The Netherlands
| | - Frank L J Visseren
- Department of Vascular Medicine, University Medical Centre Utrecht, Utrecht University, Utrecht, The Netherlands
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22
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De Bacquer D, van de Luitgaarden IAT, De Smedt D, Vynckier P, Bruthans J, Fras Z, Jankowski P, Dolzhenko M, Kotseva K, Wood D, De Backer G. Socioeconomic characteristics of patients with coronary heart disease in relation to their cardiovascular risk profile. Heart 2020; 107:799-806. [PMID: 33067329 DOI: 10.1136/heartjnl-2020-317549] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/18/2020] [Revised: 09/04/2020] [Accepted: 09/10/2020] [Indexed: 01/22/2023] Open
Abstract
OBJECTIVE People's socioeconomic status (SES) has a major impact on the risk of atherosclerotic cardiovascular disease (ASCVD) in primary prevention. In patients with existing ASCVD these associations are less documented. Here, we evaluate to what extent SES is still associated with patients' risk profile in secondary prevention. METHODS Based on results from a large sample of patients with coronary heart disease from the European Action on Secondary and Primary Prevention through Intervention to Reduce Events study, the relationship between SES and cardiovascular risk was examined. A SES summary score was empirically constructed from the patients' educational level, self-perceived income, living situation and perception of loneliness. RESULTS Analyses are based on observations in 8261 patients with coronary heart disease from 27 countries. Multivariate logistic regression analyses demonstrate that a low SES is associated (OR, 95% CI) with lifestyles such as smoking in men (1.63, 1.37 to 1.95), physical activity in men (1.51, 1.28 to 1.78) and women (1.77, 1.32 to 2.37) and obesity in men 1.28 (1.11 to 1.49) and women 1.65 (1.30 to 2.10). Patients with a low SES have more raised blood pressure in men (1.24, 1.07 to 1.43) and women (1.31, 1.03 to 1.67), used less statins and were less adherent to them. Cardiac rehabilitation programmes were less advised and attended by patients with a low SES. Access to statins in middle-income countries was suboptimal leaving about 80% of patients not reaching the low-density lipoprotein cholesterol target of <1.8 mmol/L. Patients' socioeconomic level was also strongly associated with markers of well-being. CONCLUSION These results illustrate the complexity of the associations between SES, well-being and secondary prevention in patients with ASCVD. They emphasise the need for integrating innovative policies in programmes of cardiac rehabilitation and secondary prevention.
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Affiliation(s)
- Dirk De Bacquer
- Department of Public Health and Primary Care, Ghent University, Ghent, Belgium
| | - Inge A T van de Luitgaarden
- Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht University, Utrecht, The Netherlands
| | - Delphine De Smedt
- Department of Public Health and Primary Care, Ghent University, Ghent, Belgium
| | - Pieter Vynckier
- Department of Public Health and Primary Care, Ghent University, Ghent, Belgium
| | - Jan Bruthans
- Centre for Cardiovascular Prevention, First Faculty of Medicine and Thomayer Hospital, Charles University, Prague, Czech Republic
| | - Zlatko Fras
- Preventive Cardiology Unit, Department of Vascular Medicine, Division of Internal Medicine, University Medical Centre Ljubljana, Ljubljana, Slovenia
| | - Piotr Jankowski
- Department of Cardiology, Interventional Electrocardiology and Hypertension, Jagiellonian University Medical College, Kraków, Poland
| | - Marina Dolzhenko
- Shupik's Medical Academy of Postgraduate Education, Kiev, Ukraine
| | - Kornelia Kotseva
- National Institute for Prevention and Cardiovascular Health, National University of Ireland Galway, Galway, Ireland
| | - David Wood
- National Institute for Prevention and Cardiovascular Health, National University of Ireland Galway, Galway, Ireland
| | - Guy De Backer
- Department of Public Health and Primary Care, Ghent University, Ghent, Belgium
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23
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Flacco ME, Acuti Martellucci C, Bravi F, Parruti G, Cappadona R, Mascitelli A, Manfredini R, Mantovani LG, Manzoli L. Treatment with ACE inhibitors or ARBs and risk of severe/lethal COVID-19: a meta-analysis. Heart 2020; 106:1519-1524. [PMID: 32611676 PMCID: PMC7371482 DOI: 10.1136/heartjnl-2020-317336] [Citation(s) in RCA: 69] [Impact Index Per Article: 17.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/13/2020] [Revised: 06/09/2020] [Accepted: 06/17/2020] [Indexed: 02/06/2023] Open
Abstract
OBJECTIVE It has been hypothesised that the use of ACE inhibitors and angiotensin receptor blockers (ARBs) might either increase or reduce the risk of severe or lethal COVID-19. The findings from the available observational studies varied, and summary estimates are urgently needed to elucidate whether these drugs should be suspended during the pandemic, or patients and physicians should be definitely reassured. This meta-analysis of adjusted observational data aimed to summarise the existing evidence on the association between these medications and severe/lethal COVID-19. METHODS We searched MedLine, Scopus and preprint repositories up to 8 June 2020 to retrieve cohort or case-control studies comparing the risk of severe/fatal COVID-19 (either mechanical ventilation, intensive care unit admission or death), among hypertensive subjects treated with: (1) ACE inhibitors, (2) ARBs and (3) both, versus untreated subjects. Data were combined using a random-effect generic inverse variance approach. RESULTS Ten studies, enrolling 9890 hypertensive subjects were included in the analyses. Compared with untreated subjects, those using either ACE inhibitors or ARBs showed a similar risk of severe or lethal COVID-19 (summary OR: 0.90; 95% CI 0.65 to 1.26 for ACE inhibitors; 0.92; 95% CI 0.75 to 1.12 for ARBs). The results did not change when both drugs were considered together, when death was the outcome and excluding the studies with significant, divergent results. CONCLUSION The present meta-analysis strongly supports the recommendation of several scientific societies to continue ARBs or ACE inhibitors for all patients, unless otherwise advised by their physicians who should thus be reassured.
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Affiliation(s)
- Maria Elena Flacco
- Department of Medical Sciences, University of Ferrara, Ferrara, Emilia-Romagna, Italy
| | | | - Francesca Bravi
- University Hospital of Ferrara Arcispedale Sant'Anna Medical Department, Cona, Emilia-Romagna, Italy
| | - Giustino Parruti
- Infectious Diseases Unit, Local Health Unit of Pescara, Pescara, Italy
| | - Rosaria Cappadona
- Department of Medical Sciences, University of Ferrara, Ferrara, Emilia-Romagna, Italy
| | | | - Roberto Manfredini
- Dipartimento di Scienze Mediche, Universita degli Studi di Ferrara, Ferrara, Italy
| | - Lorenzo G Mantovani
- Center for Public Health Research, University of Milan-Bicocca, Milano, Lombardia, Italy
- IRCCS MultiMedica, Sesto San Giovanni, Lombardia, Italy
| | - Lamberto Manzoli
- Department of Medical Sciences, University of Ferrara, Ferrara, Emilia-Romagna, Italy
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24
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Hippisley-Cox J, Young D, Coupland C, Channon KM, Tan PS, Harrison DA, Rowan K, Aveyard P, Pavord ID, Watkinson PJ. Risk of severe COVID-19 disease with ACE inhibitors and angiotensin receptor blockers: cohort study including 8.3 million people. Heart 2020; 106:1503-1511. [PMID: 32737124 PMCID: PMC7509391 DOI: 10.1136/heartjnl-2020-317393] [Citation(s) in RCA: 248] [Impact Index Per Article: 62.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/20/2020] [Revised: 07/08/2020] [Accepted: 07/13/2020] [Indexed: 01/08/2023] Open
Abstract
BACKGROUND There is uncertainty about the associations of angiotensive enzyme (ACE) inhibitor and angiotensin receptor blocker (ARB) drugs with COVID-19 disease. We studied whether patients prescribed these drugs had altered risks of contracting severe COVID-19 disease and receiving associated intensive care unit (ICU) admission. METHODS This was a prospective cohort study using routinely collected data from 1205 general practices in England with 8.28 million participants aged 20-99 years. We used Cox proportional hazards models to derive adjusted HRs for exposure to ACE inhibitor and ARB drugs adjusted for sociodemographic factors, concurrent medications and geographical region. The primary outcomes were: (a) COVID-19 RT-PCR diagnosed disease and (b) COVID-19 disease resulting in ICU care. FINDINGS Of 19 486 patients who had COVID-19 disease, 1286 received ICU care. ACE inhibitors were associated with a significantly reduced risk of COVID-19 disease (adjusted HR 0.71, 95% CI 0.67 to 0.74) but no increased risk of ICU care (adjusted HR 0.89, 95% CI 0.75 to 1.06) after adjusting for a wide range of confounders. Adjusted HRs for ARBs were 0.63 (95% CI 0.59 to 0.67) for COVID-19 disease and 1.02 (95% CI 0.83 to 1.25) for ICU care.There were significant interactions between ethnicity and ACE inhibitors and ARBs for COVID-19 disease. The risk of COVID-19 disease associated with ACE inhibitors was higher in Caribbean (adjusted HR 1.05, 95% CI 0.87 to 1.28) and Black African (adjusted HR 1.31, 95% CI 1.08 to 1.59) groups than the white group (adjusted HR 0.66, 95% CI 0.63 to 0.70). A higher risk of COVID-19 with ARBs was seen for Black African (adjusted HR 1.24, 95% CI 0.99 to 1.58) than the white (adjusted HR 0.56, 95% CI 0.52 to 0.62) group. INTERPRETATION ACE inhibitors and ARBs are associated with reduced risks of COVID-19 disease after adjusting for a wide range of variables. Neither ACE inhibitors nor ARBs are associated with significantly increased risks of receiving ICU care. Variations between different ethnic groups raise the possibility of ethnic-specific effects of ACE inhibitors/ARBs on COVID-19 disease susceptibility and severity which deserves further study.
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Affiliation(s)
| | - Duncan Young
- Adult Intensive Care Unit, John Radcliffe Hospital, Oxford, UK
- Kadoorie Centre, University of Oxford, Oxford, UK
| | - Carol Coupland
- Division of Primary Care, School of Medicine, University of Nottingham, Nottingham, UK
| | - Keith M Channon
- Division of Cardiovascular Medicine, British Heart Foundation Centre of Research Excellence, John Radcliffe Hospital, University of Oxford, Oxford, UK
| | - Pui San Tan
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
| | | | - Kathryn Rowan
- Intensive Care National Audit and Research Centre ICNARC, London, UK
| | - Paul Aveyard
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
| | - Ian D Pavord
- Respiratory Medicine Unit and Oxford Respiratory NIHR BRC Nuffield Department of MedicineNDM Research BuildingOld Road CampusUniversity of Oxford, Oxford, UK
| | - Peter J Watkinson
- Division of Cardiovascular Medicine, British Heart Foundation Centre of Research Excellence, John Radcliffe Hospital, University of Oxford, Oxford, UK
- Nuffield Department of Clinical Neurosciences, Oxford NIHR BRC, University of Oxford, Oxford, UK
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25
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Pinho-Gomes AC, Peters SAE, Thomson B, Woodward M. Sex differences in prevalence, treatment and control of cardiovascular risk factors in England. Heart 2020; 107:heartjnl-2020-317446. [PMID: 32887737 DOI: 10.1136/heartjnl-2020-317446] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/27/2020] [Revised: 08/06/2020] [Accepted: 08/07/2020] [Indexed: 11/04/2022] Open
Abstract
OBJECTIVE To investigate sex differences in prevalence, treatment and control of major cardiovascular risk factors in England. METHODS Data from the Health Survey for England 2012-2017 on non-institutionalised English adults (aged ≥16 years) were used to investigate sex differences in prevalence, treatment and control of major cardiovascular risk factors: body mass index, smoking, systolic blood pressure and hypertension, diabetes, and cholesterol and dyslipidaemia. Physical activity and diet were not assessed in this study. RESULTS Overall, 49 415 adults (51% women) were included. Sex differences persisted in prevalence of cardiovascular risk factors, with smoking, hypertension, overweight and dyslipidaemia remaining more common in men than in women in 2017. The proportion of individuals with neither hypertension, dyslipidaemia, diabetes nor smoking increased from 32% to 36% in women and from 28% to 29% in men between 2012 and 2017. Treatment and control of hypertension and diabetes improved over time and were comparable in both sexes in 2017 (66% and 51% for treatment and control of hypertension and 73% and 20% for treatment and control of diabetes). However, women were less likely than men to have treated and controlled dyslipidaemia (21% vs 28% for treatment and 15% vs 24% for control, for women versus men in 2017). CONCLUSIONS Important sex differences persist in cardiovascular risk factors in England, with an overall higher number of risk factors in men than in women. A combination of public health policy and individually tailored interventions is required to further reduce the burden of cardiovascular disease in England.
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Affiliation(s)
| | - Sanne A E Peters
- The George Institute for Global Health, University of Oxford, Oxford, UK
- Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht, The Netherlands
- The George Institute, University of Sydney, Camperdown, New South Wales, Australia
| | - Blake Thomson
- The George Institute for Global Health, University of Oxford, Oxford, UK
| | - Mark Woodward
- The George Institute for Global Health, University of Oxford, Oxford, UK
- The George Institute, University of Sydney, Camperdown, New South Wales, Australia
- Department of Epidemiology, Johns Hopkins University, Baltimore, MD, USA
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26
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Soares ALG, Hammerton G, Howe LD, Rich-Edwards J, Halligan S, Fraser A. Sex differences in the association between childhood maltreatment and cardiovascular disease in the UK Biobank. Heart 2020; 106:1310-1316. [PMID: 32665362 PMCID: PMC7476280 DOI: 10.1136/heartjnl-2019-316320] [Citation(s) in RCA: 19] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/10/2019] [Revised: 03/21/2020] [Accepted: 03/27/2020] [Indexed: 01/12/2023] Open
Abstract
OBJECTIVES To assess and compare associations between childhood maltreatment and cardiovascular disease (CVD) in men and women in the UK. In secondary analyses, we also explored possible age differences and associations with early onset CVD (<50 years). METHODS We included 157 311 participants from the UK Biobank who had information on physical, sexual or emotional abuse, emotional or physical neglect. CVD outcomes were defined as any CVD, hypertensive disease, ischaemic heart disease (IHD) and cerebrovascular disease. These were extracted from self-report, blood pressure measurements, hospital register and death register. The associations between maltreatment and CVD were assessed using Poisson regression with robust variance to estimate risk ratios, stratified by sex and adjusted for socioeconomic and demographic factors. RESULTS All types of maltreatment were associated with increased risk of CVD and IHD in both sexes. Additionally, in women all types of maltreatment were associated with higher risk of hypertensive disease, and all, except emotional neglect, were associated with cerebrovascular disease. In men, all but sexual abuse, were associated with higher risk of hypertensive disease, and all, except physical and sexual abuse, were associated with cerebrovascular disease. Associations were generally stronger in women, and individuals who were younger at baseline had stronger associations of childhood maltreatment with any CVD and IHD, but age differences were less evident when only early onset CVD was considered. CONCLUSIONS Childhood maltreatment was consistently associated with CVD and stronger associations were generally observed in women and seemed to be stronger for early onset CVD.
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Affiliation(s)
- Ana Luiza Gonçalves Soares
- Population Health Sciences, Bristol Medical School, University of Bristol, Bristol, UK
- MRC Integrative Epidemiology Unit, University of Bristol, Bristol, UK
| | - Gemma Hammerton
- Population Health Sciences, Bristol Medical School, University of Bristol, Bristol, UK
- MRC Integrative Epidemiology Unit, University of Bristol, Bristol, UK
| | - Laura D Howe
- Population Health Sciences, Bristol Medical School, University of Bristol, Bristol, UK
- MRC Integrative Epidemiology Unit, University of Bristol, Bristol, UK
| | - Janet Rich-Edwards
- Department of Medicine, Harvard Medical School, Boston, Massachusetts, USA
- Brigham and Women's Hospital and Department of Epidemiology, Harvard University T H Chan School of Public Health, Boston, Massachusetts, USA
| | - Sarah Halligan
- Department of Psychology, University of Bath, Bath, UK
- Department of Psychiatry and Mental Health, University of Cape Town, Cape Town, South Africa
| | - Abigail Fraser
- Population Health Sciences, Bristol Medical School, University of Bristol, Bristol, UK
- MRC Integrative Epidemiology Unit, University of Bristol, Bristol, UK
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Abstract
OBJECTIVE This study aimed to examine the association between loneliness, social isolation and cardiovascular disease (CVD), looking at both self-reported CVD diagnosis and CVD-related hospital admissions. METHODS Data were derived from the English Longitudinal Study of Ageing linked with administrative hospital records and mortality registry data. The analytical sample size was 5850 for the analysis of self-reported CVD and 4587 of CVD derived from hospital records, with a follow-up up to 9.6 years. Data were analysed using survival analysis, accounting for competing risks events. RESULTS The mean age was 64 years (SD 8.3). About 44%-45% were men. Within the follow-up, 17% participants reported having newly diagnosed CVD and 16% had a CVD-related hospital admission. We found that loneliness was associated with an increased risk of CVD events independent of potential confounders and risk factors. The hazard of people with the highest level of loneliness was about 30% higher for onset CVD diagnosis (HR: 1.05, 95% CI: 1.01 to 1.09) and 48% higher for CVD-related hospital admissions (HR: 1.08, 95% CI: 1.03 to 1.14), compared with the least lonely. There was little evidence that social isolation was independently associated with the risk of either CVD diagnosis or admission. CONCLUSIONS Our findings provided strong evidence for the relationship between loneliness and cardiovascular events. Loneliness should be considered as a psychosocial risk factor for CVD in both research and interventions for cardiovascular prevention.
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Affiliation(s)
- Feifei Bu
- Behavioural Science and Health, University College London, London, UK
| | - Paola Zaninotto
- Epidemiology and Public Health, University College London, London, UK
| | - Daisy Fancourt
- Behavioural Science and Health, University College London, London, UK
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28
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Rizos EC, Markozannes G, Tsapas A, Mantzoros CS, Ntzani EE. Omega-3 supplementation and cardiovascular disease: formulation-based systematic review and meta-analysis with trial sequential analysis. Heart 2020; 107:150-158. [PMID: 32820013 DOI: 10.1136/heartjnl-2020-316780] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/04/2020] [Revised: 05/14/2020] [Accepted: 05/26/2020] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND Omega-3 supplements are popular for cardiovascular disease (CVD) prevention. We aimed to assess the association between dose-specific omega-3 supplementation and CVD outcomes. DESIGN We included double-blind randomised clinical trials with duration ≥1 year assessing omega-3 supplementation and estimated the relative risk (RR) for all-cause mortality, cardiac death, sudden death, myocardial infarction and stroke. Primary analysis was a stratified random-effects meta-analysis by omega-3 dose in 4 a priori defined categories (<1, 1, 2, ≥3 of 1 g capsules/day). Complementary approaches were trial sequential analysis and sensitivity analyses for triglycerides, prevention setting, intention-to-treat analysis, eicosapentaenoic acid, sample size, statin use, study duration. RESULTS Seventeen studies (n=83 617) were included. Omega-3 supplementation as ≤1 capsule/day was not associated with any outcome under study; futility boundaries were crossed for all-cause mortality and cardiac death. For two capsules/day, we observed a statistically significant reduction of cardiac death (n=3, RR 0.55, 95% CI 0.33 to 0.90, I2=0%); for ≥3 capsules/day we observed a statistically significant reduction of cardiac death (n=3, RR 0.82, 95% CI 0.68 to 0.99, I2=0%), sudden death (n=1, RR 0.70, 95% CI 0.51 to 0.97) and stroke (n=2, RR 0.74, 95% CI 0.57 to 0.95, I2=0%). CONCLUSION Omega-3 supplementation at <2 1 g capsules/day showed no association with CVD outcomes; this seems unlikely to change from future research. Compared with the robust scientific evidence available for low doses, the evidence for higher doses (2-4 1 g capsules/day) is weak. The emerging postulated benefit from high-dose supplementation needs replication and further evaluation as to the precise formulation and indication.
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Affiliation(s)
- Evangelos C Rizos
- Department of Internal Medicine, University Hospital of Ioannina, Ioannina, Greece.,School of Medicine, European University of Cyprus, Nicosia, Cyprus
| | - Georgios Markozannes
- Evidence-Based Medicine Unit, Department of Hygiene and Epidemiology, University of Ioannina School of Medicine, Ioannina, Greece
| | - Apostolos Tsapas
- Clinical Research and Evidence-Based Medicine Unit, Aristotle University of Thessaloniki, Hippokration Hospital, Thessaloniki, Greece.,Harris Manchester College, University of Oxford, Oxford, UK
| | - Christos S Mantzoros
- Department of Medicine, Beth Isreal Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts, USA.,Section of Endocrinology, Boston VA Healthcare System, Harvard Medical School, Boston, Massachusetts, USA
| | - Evangelia E Ntzani
- Evidence-Based Medicine Unit, Department of Hygiene and Epidemiology, University of Ioannina School of Medicine, Ioannina, Greece .,Center for Evidence Synthesis in Health, Department of Health Services, Policy and Practice, School of Public Health, Brown University, Providence, Rhode Island, USA.,Institute of Biosciences, University Research Center of loannina, University of Ioannina, Ioannina, Greece
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29
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Maeda T, Nishi T, Funakoshi S, Tada K, Tsuji M, Satoh A, Kawazoe M, Yoshimura C, Arima H. Residual risks of ischaemic stroke and systemic embolism among atrial fibrillation patients with anticoagulation: large-scale real-world data (F-CREATE project). Heart 2020; 107:217-222. [PMID: 32817313 DOI: 10.1136/heartjnl-2020-317299] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/07/2020] [Revised: 06/26/2020] [Accepted: 07/02/2020] [Indexed: 01/08/2023] Open
Abstract
OBJECTIVE Among patients with atrial fibrillation, the risks of ischaemic stroke and systemic embolism (IS/SE) are high even with effective anticoagulation. Using large-scale, real-world data from Japan, this study aims to clarify residual risks of IS/SE attributable to modifiable risk factors among patients with atrial fibrillation who are taking oral anticoagulants. METHODS The study design we employed was a retrospective cohort. Health check-ups and insurance claims data of Japanese health insurance companies were accumulated from January 2005 to June 2017. We identified 11 848 participants with atrial fibrillation who were on oral anticoagulants during the study period. We set the modifiable risk factors as hypertension, diabetes and dyslipidaemia. A Cox proportional hazards model was used to obtain the effects of the risk factors for IS/SE. RESULTS During an average of 3 years' follow-up, 200 cases of IS/SE occurred (incidence rate 0.57 per 100 person-years). In multivariable analyses, older age (65-74 vs <65 years; adjusted HR 2.02 (95% CI 1.49 to 2.73)), hypertension (adjusted HR 1.41 (1.04 to 1.92)) and dyslipidaemia (adjusted HR 1.46 (1.07 to 1.98)) were significantly associated with increased risk of IS/SE. Percentage of IS/SE risk attributable to modifiable risk factors (hypertension, diabetes and dyslipidaemia) was 30.0% (16.1% to 41.6%). CONCLUSION Among patients with atrial fibrillation on anticoagulant therapy, approximately one-third of the residual risks were estimated to be attributable to modifiable risk factors such as hypertension, diabetes and dyslipidaemia.
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Affiliation(s)
- Toshiki Maeda
- Department of Preventive Medicine and Public Health, Faculty of Medicine, Fukuoka University, Fukuoka, Japan
| | - Takumi Nishi
- Department of Preventive Medicine and Public Health, Faculty of Medicine, Fukuoka University, Fukuoka, Japan.,Department of Research Planning and Information Management, Fukuoka Institute of Health and Environmental Sciences, Fukuoka, Japan
| | - Shunsuke Funakoshi
- Department of Preventive Medicine and Public Health, Faculty of Medicine, Fukuoka University, Fukuoka, Japan
| | - Kazuhiro Tada
- Department of Preventive Medicine and Public Health, Faculty of Medicine, Fukuoka University, Fukuoka, Japan.,Division of Nephrology and Rheumatology, Department of Internal Medicine, Faculty of Medicine, Fukuoka University, Fukuoka, Japan
| | - Masayoshi Tsuji
- Department of Lifestyle and Welfare Information, Kindai University Kyushu Junior College, Fukuoka, Japan
| | - Atsushi Satoh
- Department of Preventive Medicine and Public Health, Faculty of Medicine, Fukuoka University, Fukuoka, Japan
| | - Miki Kawazoe
- Department of Preventive Medicine and Public Health, Faculty of Medicine, Fukuoka University, Fukuoka, Japan
| | - Chikara Yoshimura
- Department of Preventive Medicine and Public Health, Faculty of Medicine, Fukuoka University, Fukuoka, Japan
| | - Hisatomi Arima
- Department of Preventive Medicine and Public Health, Faculty of Medicine, Fukuoka University, Fukuoka, Japan
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Stefanini GG, Chiarito M, Ferrante G, Cannata F, Azzolini E, Viggiani G, De Marco A, Briani M, Bocciolone M, Bragato R, Corrada E, Gasparini GL, Marconi M, Monti L, Pagnotta PA, Panico C, Pini D, Regazzoli D, My I, Kallikourdis M, Ciccarelli M, Badalamenti S, Aghemo A, Reimers B, Condorelli G. Early detection of elevated cardiac biomarkers to optimise risk stratification in patients with COVID-19. Heart 2020; 106:1512-1518. [PMID: 32817312 DOI: 10.1136/heartjnl-2020-317322] [Citation(s) in RCA: 65] [Impact Index Per Article: 16.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/10/2020] [Revised: 07/16/2020] [Accepted: 07/28/2020] [Indexed: 12/16/2022] Open
Abstract
OBJECTIVE Risk stratification is crucial to optimise treatment strategies in patients with COVID-19. We aimed to evaluate the impact on mortality of an early assessment of cardiac biomarkers in patients with COVID-19. METHODS Humanitas Clinical and Research Hospital (Rozzano-Milan, Lombardy, Italy) is a tertiary centre that has been converted to the management of COVID-19. Patients with confirmed COVID-19 were entered in a dedicated database for cohort observational analyses. Outcomes were stratified according to elevated levels (ie, above the upper level of normal) of high-sensitivity cardiac troponin I (hs-TnI), B-type natriuretic peptide (BNP) or both measured within 24 hours after hospital admission. The primary outcome was all-cause mortality. RESULTS A total of 397 consecutive patients with COVID-19 were included up to 1 April 2020. At the time of hospital admission, 208 patients (52.4%) had normal values for cardiac biomarkers, 90 (22.7%) had elevated both hs-TnI and BNP, 59 (14.9%) had elevated only BNP and 40 (10.1%) had elevated only hs-TnI. The rate of mortality was higher in patients with elevated hs-TnI (22.5%, OR 4.35, 95% CI 1.72 to 11.04), BNP (33.9%, OR 7.37, 95% CI 3.53 to 16.75) or both (55.6%, OR 18.75, 95% CI 9.32 to 37.71) as compared with those without elevated cardiac biomarkers (6.25%). A multivariate analysis identified concomitant elevation of both hs-TnI and BNP as a strong independent predictor of all-cause mortality (OR 3.24, 95% CI 1.06 to 9.93). CONCLUSIONS An early detection of elevated hs-TnI and BNP predicts mortality in patients with COVID-19. Cardiac biomarkers should be systematically assessed in patients with COVID-19 at the time of hospital admission in order to optimise risk stratification.
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Affiliation(s)
- Giulio G Stefanini
- Department of Biomedical Sciences, Humanitas University, Pieve Emanuele, Milan, Italy .,Humanitas Clinical and Research Center - IRCCS, Rozzano, Milan, Italy
| | - Mauro Chiarito
- Department of Biomedical Sciences, Humanitas University, Pieve Emanuele, Milan, Italy.,Humanitas Clinical and Research Center - IRCCS, Rozzano, Milan, Italy
| | - Giuseppe Ferrante
- Department of Biomedical Sciences, Humanitas University, Pieve Emanuele, Milan, Italy.,Humanitas Clinical and Research Center - IRCCS, Rozzano, Milan, Italy
| | - Francesco Cannata
- Department of Biomedical Sciences, Humanitas University, Pieve Emanuele, Milan, Italy.,Humanitas Clinical and Research Center - IRCCS, Rozzano, Milan, Italy
| | - Elena Azzolini
- Department of Biomedical Sciences, Humanitas University, Pieve Emanuele, Milan, Italy.,Humanitas Clinical and Research Center - IRCCS, Rozzano, Milan, Italy
| | - Giacomo Viggiani
- Department of Biomedical Sciences, Humanitas University, Pieve Emanuele, Milan, Italy.,Humanitas Clinical and Research Center - IRCCS, Rozzano, Milan, Italy
| | - Andrea De Marco
- Department of Biomedical Sciences, Humanitas University, Pieve Emanuele, Milan, Italy.,Humanitas Clinical and Research Center - IRCCS, Rozzano, Milan, Italy
| | - Martina Briani
- Department of Biomedical Sciences, Humanitas University, Pieve Emanuele, Milan, Italy.,Humanitas Clinical and Research Center - IRCCS, Rozzano, Milan, Italy
| | - Monica Bocciolone
- Department of Biomedical Sciences, Humanitas University, Pieve Emanuele, Milan, Italy.,Humanitas Clinical and Research Center - IRCCS, Rozzano, Milan, Italy
| | - Renato Bragato
- Department of Biomedical Sciences, Humanitas University, Pieve Emanuele, Milan, Italy.,Humanitas Clinical and Research Center - IRCCS, Rozzano, Milan, Italy
| | - Elena Corrada
- Department of Biomedical Sciences, Humanitas University, Pieve Emanuele, Milan, Italy.,Humanitas Clinical and Research Center - IRCCS, Rozzano, Milan, Italy
| | - Gabriele L Gasparini
- Department of Biomedical Sciences, Humanitas University, Pieve Emanuele, Milan, Italy.,Humanitas Clinical and Research Center - IRCCS, Rozzano, Milan, Italy
| | - Manuel Marconi
- Department of Biomedical Sciences, Humanitas University, Pieve Emanuele, Milan, Italy.,Humanitas Clinical and Research Center - IRCCS, Rozzano, Milan, Italy
| | - Lorenzo Monti
- Department of Biomedical Sciences, Humanitas University, Pieve Emanuele, Milan, Italy.,Humanitas Clinical and Research Center - IRCCS, Rozzano, Milan, Italy
| | - Paolo A Pagnotta
- Department of Biomedical Sciences, Humanitas University, Pieve Emanuele, Milan, Italy.,Humanitas Clinical and Research Center - IRCCS, Rozzano, Milan, Italy
| | - Cristina Panico
- Department of Biomedical Sciences, Humanitas University, Pieve Emanuele, Milan, Italy.,Humanitas Clinical and Research Center - IRCCS, Rozzano, Milan, Italy
| | - Daniela Pini
- Department of Biomedical Sciences, Humanitas University, Pieve Emanuele, Milan, Italy.,Humanitas Clinical and Research Center - IRCCS, Rozzano, Milan, Italy
| | - Damiano Regazzoli
- Department of Biomedical Sciences, Humanitas University, Pieve Emanuele, Milan, Italy.,Humanitas Clinical and Research Center - IRCCS, Rozzano, Milan, Italy
| | - Ilaria My
- Department of Biomedical Sciences, Humanitas University, Pieve Emanuele, Milan, Italy.,Humanitas Clinical and Research Center - IRCCS, Rozzano, Milan, Italy
| | - Marinos Kallikourdis
- Department of Biomedical Sciences, Humanitas University, Pieve Emanuele, Milan, Italy.,Humanitas Clinical and Research Center - IRCCS, Rozzano, Milan, Italy
| | - Michele Ciccarelli
- Department of Biomedical Sciences, Humanitas University, Pieve Emanuele, Milan, Italy.,Humanitas Clinical and Research Center - IRCCS, Rozzano, Milan, Italy
| | - Salvatore Badalamenti
- Department of Biomedical Sciences, Humanitas University, Pieve Emanuele, Milan, Italy.,Humanitas Clinical and Research Center - IRCCS, Rozzano, Milan, Italy
| | - Alessio Aghemo
- Department of Biomedical Sciences, Humanitas University, Pieve Emanuele, Milan, Italy.,Humanitas Clinical and Research Center - IRCCS, Rozzano, Milan, Italy
| | - Bernhard Reimers
- Department of Biomedical Sciences, Humanitas University, Pieve Emanuele, Milan, Italy.,Humanitas Clinical and Research Center - IRCCS, Rozzano, Milan, Italy
| | - Gianluigi Condorelli
- Department of Biomedical Sciences, Humanitas University, Pieve Emanuele, Milan, Italy.,Humanitas Clinical and Research Center - IRCCS, Rozzano, Milan, Italy
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31
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Affiliation(s)
- Sam Straw
- Leeds Institute for Cardiovascular and Metabolic Medicine, University of Leeds, Leeds, West Yorkshire, UK
| | - Klaus K Witte
- Leeds Institute for Cardiovascular and Metabolic Medicine, University of Leeds, Leeds, West Yorkshire, UK
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32
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Kang Y, Chen T, Mui D, Ferrari V, Jagasia D, Scherrer-Crosbie M, Chen Y, Han Y. Cardiovascular manifestations and treatment considerations in COVID-19. Heart 2020; 106:1132-1141. [PMID: 32354800 PMCID: PMC7211105 DOI: 10.1136/heartjnl-2020-317056] [Citation(s) in RCA: 238] [Impact Index Per Article: 59.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/04/2020] [Revised: 04/13/2020] [Accepted: 04/15/2020] [Indexed: 02/06/2023] Open
Abstract
Since its recognition in December 2019, covid-19 has rapidly spread globally causing a pandemic. Pre-existing comorbidities such as hypertension, diabetes, and cardiovascular disease are associated with a greater severity and higher fatality rate of covid-19. Furthermore, COVID-19 contributes to cardiovascular complications, including acute myocardial injury as a result of acute coronary syndrome, myocarditis, stress-cardiomyopathy, arrhythmias, cardiogenic shock, and cardiac arrest. The cardiovascular interactions of COVID-19 have similarities to that of severe acute respiratory syndrome, Middle East respiratory syndrome and influenza. Specific cardiovascular considerations are also necessary in supportive treatment with anticoagulation, the continued use of renin-angiotensin-aldosterone system inhibitors, arrhythmia monitoring, immunosuppression or modulation, and mechanical circulatory support.
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Affiliation(s)
- Yu Kang
- Cardiovascular Medicine, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania, USA
| | - Tiffany Chen
- Cardiovascular Medicine, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania, USA
| | - David Mui
- University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania, USA
| | - Victor Ferrari
- Cardiovascular Medicine, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania, USA
| | - Dinesh Jagasia
- Cardiovascular Medicine, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania, USA
| | - Marielle Scherrer-Crosbie
- Cardiovascular Medicine, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania, USA
| | - Yucheng Chen
- Department of Cardiology, West China Hospital, Sichuan University, Chengdu, China
| | - Yuchi Han
- Cardiovascular Medicine, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania, USA
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33
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Li X, Guan B, Su T, Liu W, Chen M, Bin Waleed K, Guan X, Gary T, Zhu Z. Impact of cardiovascular disease and cardiac injury on in-hospital mortality in patients with COVID-19: a systematic review and meta-analysis. Heart 2020; 106:1142-1147. [PMID: 32461330 PMCID: PMC7295861 DOI: 10.1136/heartjnl-2020-317062] [Citation(s) in RCA: 101] [Impact Index Per Article: 25.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/05/2020] [Revised: 04/24/2020] [Accepted: 04/24/2020] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND Coronavirus disease 2019 (COVID-19) has produced a significant health burden worldwide, especially in patients with cardiovascular comorbidities. The aim of this systematic review and meta-analysis was to assess the impact of underlying cardiovascular comorbidities and acute cardiac injury on in-hospital mortality risk. METHODS PubMed, Embase and Web of Science were searched for publications that reported the relationship of underlying cardiovascular disease (CVD), hypertension and myocardial injury with in-hospital fatal outcomes in patients with COVID-19. The ORs were extracted and pooled. Subgroup and sensitivity analyses were performed to explore the potential sources of heterogeneity. RESULTS A total of 10 studies were enrolled in this meta-analysis, including eight studies for CVD, seven for hypertension and eight for acute cardiac injury. The presence of CVD and hypertension was associated with higher odds of in-hospital mortality (unadjusted OR 4.85, 95% CI 3.07 to 7.70; I2=29%; unadjusted OR 3.67, 95% CI 2.31 to 5.83; I2=57%, respectively). Acute cardiac injury was also associated with a higher unadjusted odds of 21.15 (95% CI 10.19 to 43.94; I2=71%). CONCLUSION COVID-19 patients with underlying cardiovascular comorbidities, including CVD and hypertension, may face a greater risk of fatal outcomes. Acute cardiac injury may act as a marker of mortality risk. Given the unadjusted results of our meta-analysis, future research are warranted.
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Affiliation(s)
- Xintao Li
- Department of Cardiology, The First People's Hospital of Changzhou, The Third Affiliated Hospital of Soochow University, Changzhou, Jiangsu, China
| | - Bo Guan
- Department of Cardiology, The First People's Hospital of Changzhou, The Third Affiliated Hospital of Soochow University, Changzhou, Jiangsu, China
| | - Tong Su
- Department of Cardiology, The First People's Hospital of Changzhou, The Third Affiliated Hospital of Soochow University, Changzhou, Jiangsu, China
| | - Wei Liu
- Department of Cardiology, The First People's Hospital of Changzhou, The Third Affiliated Hospital of Soochow University, Changzhou, Jiangsu, China
| | - Mengyao Chen
- Department of Heart Function, The First People's Hospital of Changzhou, The Third Affiliated Hospital of Soochow University, Changzhou, China
| | - Khalid Bin Waleed
- Department of Cardiology, First Affiliated Hospital of Dalian Medical University, Dalian, China
| | - Xumin Guan
- Department of Cardiology, First Affiliated Hospital of Dalian Medical University, Dalian, China
| | - Tse Gary
- Department of Cardiology, Second Hospital of Tianjin Medical University, Tianjin, China
| | - Zhenyan Zhu
- Department of Cardiology, The First People's Hospital of Changzhou, The Third Affiliated Hospital of Soochow University, Changzhou, Jiangsu, China
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34
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Affiliation(s)
- Leah Li
- Population, Policy and Practice Research and Teaching Department, University College London Great Ormond Street Institute of Child Health, London, United Kingdom
| | - Rebecca E Lacey
- Research Department of Epidemiology and Public Health, University College London, London, United Kingdom
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35
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Xia L, Huang L, Feng X, Xiao J, Wei X, Yu X. Chronobiological patterns of acute aortic dissection in central China. Heart 2020; 107:heartjnl-2020-317009. [PMID: 32660983 PMCID: PMC7873417 DOI: 10.1136/heartjnl-2020-317009] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/31/2020] [Revised: 06/04/2020] [Accepted: 06/08/2020] [Indexed: 12/14/2022] Open
Abstract
BACKGROUND Acute aortic dissection (AAD) is a life-threatening emergency with poor clinical outcomes. Understanding the chronological patterns of AAD onset would be helpful for identifying the triggers of AAD and preventing this catastrophic event. METHODS We collected data from 2048 patients diagnosed with AAD at Tongji Hospital (Wuhan, China) from 2011 to 2018. The χ2 test was used to determine whether a specific period had significantly different seasonal/weekly distributions from other periods. Fourier models were used to analyse the rhythmicity in monthly/circadian distribution. RESULTS The mean age was 53.4±10.9 years, and 1161 patients (56.7%) were under 55 years. One thousand six hundred fifty-seven patients (80.9%) were male, and 935 cases (45.7%) were type A dissections. The proportions of patients with comorbid hypertension/diabetes were 60.3% (1234 cases) and 1.8% (36 cases), respectively. A peak was identified in colder periods (winter/December) and a trough in warmer periods (summer/June). No significant variation was observed in weekly distribution. Fourier analysis showed a statistically significant circadian variation (p<0.001) with a nocturnal trough in 2:00-3:00, a morning peak in 9:00-10:00, and an afternoon peak in 16:00-17:00. Subgroup analyses identified circadian rhythmicity in all subgroups except for the female group and younger group (younger than 55 years). CONCLUSION Our results confirmed that the onset of AAD exhibits significant seasonal, monthly and circadian patterns. Patients with AAD with different Stanford-type dissections, sexes, ages and hypertension statuses could present different circadian variations. These findings may provide novel perspectives for identifying the triggers of AAD and better preventing this catastrophic event.
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Affiliation(s)
- Liangtao Xia
- Division of Cardiothoracic and Vascular Surgery, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, Hubei, China
| | - Lu Huang
- Tongji Hospital, Tongji Medical College,Huazhong University of Science and Technology, Wuhan, Hubei, China
| | - Xin Feng
- Division of Cardiothoracic and Vascular Surgery, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, Hubei, China
| | - Jiewen Xiao
- Division of Cardiothoracic and Vascular Surgery, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, Hubei, China
| | - Xiang Wei
- Division of Cardiothoracic and Vascular Surgery, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, Hubei, China
- Key Laboratory of Organ Transplantation, Ministry of Education, Wuhan, Hubei, China
- NHC Key Laboratory of Organ Transplantation, Wuhan, Hubei, China
- Key Laboratory of Organ Transplantation, Chinese Academy of Medical Sciences, Wuhan, Hubei, China
| | - Xinyu Yu
- Division of Cardiothoracic and Vascular Surgery, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, Hubei, China
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36
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Affiliation(s)
- Yao Yu
- Neurology, First Hospital of Jilin University, Changchun, Jilin, China
| | - Fu-Liang Zhang
- Neurology, First Hospital of Jilin University, Changchun, Jilin, China
| | - Zhen-Ni Guo
- Neurology, First Hospital of Jilin University, Changchun, Jilin, China
| | - Yi Yang
- Neurology, First Hospital of Jilin University, Changchun, Jilin, China
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37
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Affiliation(s)
- David E Newby
- Centre for Cardiovascular Sciences, University of Edinburgh, Edinburgh, UK
| | - Kazem Rahimi
- Deep Medicine, Nuffield Department for Women's and Reproductive Health, University of Oxford, Oxford, UK
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38
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Zhang J, Lu S, Wang X, Jia X, Li J, Lei H, Liu Z, Liao F, Ji M, Lv X, Kang J, Tian S, Ma J, Wu D, Gong Y, Xu Y, Dong W. Do underlying cardiovascular diseases have any impact on hospitalised patients with COVID-19? Heart 2020; 106:1148-1153. [PMID: 32451362 PMCID: PMC7253226 DOI: 10.1136/heartjnl-2020-316909] [Citation(s) in RCA: 27] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/15/2020] [Revised: 04/26/2020] [Accepted: 04/27/2020] [Indexed: 12/27/2022] Open
Abstract
Objectives An outbreak of the highly contagious severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) has sickened thousands of people in China. The purpose of this study was to explore the early clinical characteristics of COVID-19 patients with cardiovascular disease (CVD). Methods This is a retrospective analysis of patients with COVID-19 from a single centre. All patients underwent real-time reverse transcription PCR for SARS-CoV-2 on admission. Demographic and clinical factors and laboratory data were reviewed and collected to evaluate for significant associations. Results The study included 541 patients with COVID-19. A total of 144 (26.6%) patients had a history of CVD. The mortality of patients with CVD reached 22.2%, which was higher than that of the overall population of this study (9.8%). Patients with CVD were also more likely to develop liver function abnormality, elevated blood creatinine and lactic dehydrogenase (p<0.05). Symptoms of sputum production were more common in patients with CVD (p=0.026). Lymphocytes, haemoglobin and albumin below the normal range were pervasive in the CVD group (p<0.05). The proportion of critically ill patients in the CVD group (27.8%) was significantly higher than that in the non-CVD group (8.8%). Multivariable logistic regression analysis revealed that CVD (OR: 2.735 (95% CI 1.495 to 5.003), p=0.001) was associated with critical COVID-19 condition, while patients with coronary heart disease were less likely to reach recovery standards (OR: 0.331 (95% CI 0.125 to 0.880), p=0.027). Conclusions Considering the high prevalence of CVD, a thorough CVD assessment at diagnosis and early intervention are recommended in COVID-19 patients with CVD. Patients with CVD are more vulnerable to deterioration.
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Affiliation(s)
- Jixiang Zhang
- Department of Gastroenterology, Renmin Hospital of Wuhan University, Wuhan, Hubei, China
| | - Shimin Lu
- Department of Gastroenterology, Renmin Hospital of Wuhan University, Wuhan, Hubei, China
| | - Xiaoli Wang
- Department of Plastic Surgery, Renmin Hospital of Wuhan University, Wuhan, Hubei, China
| | - Xuemei Jia
- Department of Gastroenterology, Renmin Hospital of Wuhan University, Wuhan, Hubei, China
| | - Jiao Li
- Department of Gastroenterology, Renmin Hospital of Wuhan University, Wuhan, Hubei, China
| | - Hongbo Lei
- Department of Oncology, Renmin Hospital of Wuhan University, Wuhan, Hubei, China
| | - Zhengru Liu
- Department of Gastroenterology, Renmin Hospital of Wuhan University, Wuhan, Hubei, China
| | - Fei Liao
- Department of Gastroenterology, Renmin Hospital of Wuhan University, Wuhan, Hubei, China
| | - Mengyao Ji
- Department of Gastroenterology, Renmin Hospital of Wuhan University, Wuhan, Hubei, China
| | - Xiaoguang Lv
- Department of Gastroenterology, Renmin Hospital of Wuhan University, Wuhan, Hubei, China
| | - Jian Kang
- Department of Gastroenterology, Renmin Hospital of Wuhan University, Wuhan, Hubei, China
| | - Shan Tian
- Department of Gastroenterology, Renmin Hospital of Wuhan University, Wuhan, Hubei, China
| | - Jingjing Ma
- Department of Geriatrics, Renmin Hospital of Wuhan University, Wuhan, Hubei, China
| | - Dandan Wu
- Department of Respirology, Renmin Hospital of Wuhan University, Wuhan, Hubei, China
| | - Yang Gong
- Department of Cardiology, Renmin Hospital of Wuhan University, Wuhan, Hubei, China
| | - Yu Xu
- Department of Otorhinolaryngology, Renmin Hospital of Wuhan University, Wuhan, Hubei, China
| | - Weiguo Dong
- Department of Gastroenterology, Renmin Hospital of Wuhan University, Wuhan, Hubei, China
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39
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Affiliation(s)
- Mohammed N Meah
- British Heart Foundation Centre for Cardiovascular Science, University of Edinburgh, Edinburgh, UK
| | - Marc R Dweck
- British Heart Foundation Centre for Cardiovascular Science, University of Edinburgh, Edinburgh, UK
| | - David E Newby
- British Heart Foundation Centre for Cardiovascular Science, University of Edinburgh, Edinburgh, UK
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40
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Affiliation(s)
- Neal A Chatterjee
- Department of Medicine, Division of Cardiology, University of Washington, Seattle, Washington, DC, USA
| | - Richard K Cheng
- Department of Medicine, Division of Cardiology and Department of Radiology, University of Washington, Seattle, WA, USA
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Abstract
Objectives To assess the risk of in-hospital mortality due to alcohol use disorder (AUD) and other cardiovascular risk factors in arrhythmia inpatients. Methods We included 114,958 patients (age, 15-54 years) by conducting a cross-sectional cohort study using the Nationwide Inpatient Sample (NIS, 2010-2014). These patients were primarily managed for arrhythmia and further grouped by comorbid AUD. A logistic regression model was used to measure the odds ratio (OR) of association of AUD and in-hospital mortality after adjusting for demographic confounders and cardiovascular risk factors. Results Mortality risk statistically increases with age as elders (45-54 years) had two times higher risk (95% confidence interval [CI] 1.49-3.09), whereas men had a lower risk (OR 0.8, 95% CI 0.74-0.96) of inpatient death. Comorbid atherosclerosis (OR 4.5, 95% CI 3.38-5.92) and diabetes (OR 1.4, 95% CI 1.18-1.67) increased mortality risk in arrhythmia inpatients. AUD significantly increased the risk of mortality in arrhythmia inpatients (OR 1.7, 95% CI 1.43-2.07). Conclusions AUD is an independent risk factor for mortality in arrhythmia inpatients, and it is elevated by 72% in such patients. Strategies to reduce alcohol consumption and abstinence should be focused to improve the health-related quality of life of at-risk patients.
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Affiliation(s)
- Khalida Khaliq
- Psychiatry/Medicine, North Tampa Behavioral Health, Tampa, USA
| | - Temitope Ajibawo
- Internal Medicine, Brookdale University Hospital Medical Center, New York City, USA
| | - Renu Bhandari
- Medicine, Manipal College of Medical Sciences, Kaski, NPL
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Koo CY, Aung AT, Chen Z, Kristanto W, Sim HW, Tam WW, Gochuico CF, Tan KA, Kang GS, Sorokin V, Ong PJL, Kojodjojo P, Richards AM, Tan HC, Kofidis T, Lee CH. Sleep apnoea and cardiovascular outcomes after coronary artery bypass grafting. Heart 2020; 106:1495-1502. [PMID: 32423904 PMCID: PMC7509387 DOI: 10.1136/heartjnl-2019-316118] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/16/2019] [Revised: 02/13/2020] [Accepted: 02/20/2020] [Indexed: 12/16/2022] Open
Abstract
OBJECTIVE Patients with advanced coronary artery disease are referred for coronary artery bypass grafting (CABG) and it remains unknown if sleep apnoea is a risk marker. We evaluated the association between sleep apnoea and major adverse cardiac and cerebrovascular events (MACCE) in patients undergoing non-emergent CABG. METHODS This was a prospective cohort study conducted between November 2013 and December 2018. Patients from four public hospitals referred to a tertiary cardiac centre for non-emergent CABG were recruited for an overnight sleep study using a wrist-worn Watch-PAT 200 device prior to CABG. RESULTS Among the 1007 patients who completed the study, sleep apnoea (defined as apnoea-hypopnoea index ≥15 events per hour) was diagnosed in 513 patients (50.9%). Over a mean follow-up period of 2.1 years, 124 patients experienced the four-component MACCE (2-year cumulative incidence estimate, 11.3%). There was a total of 33 cardiac deaths (2.5%), 42 non-fatal myocardial infarctions (3.7%), 50 non-fatal strokes (4.9%) and 36 unplanned revascularisations (3.2%). The crude incidence of MACCE was higher in the sleep apnoea group than the non-sleep apnoea group (2-year estimate, 14.7% vs 7.8%; p=0.002). Sleep apnoea predicted the incidence of MACCE in unadjusted Cox regression analysis (HR 1.69; 95% CI 1.18 to 2.43), and remained statistically significant (adjusted HR 1.57; 95% CI 1.09 to 2.25), after adjustment for age, sex, body mass index, left ventricular ejection fraction, diabetes mellitus, hypertension, chronic kidney disease and excessive daytime sleepiness. CONCLUSION Sleep apnoea is independently associated with increased MACCE in patients undergoing CABG. TRIAL REGISTRATION NUMBER NCT02701504.
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Affiliation(s)
- Chieh Yang Koo
- Department of Cardiology, National University Heart Centre, Singapore
| | - Aye-Thandar Aung
- Department of Cardiology, National University Heart Centre, Singapore
| | - Zhengfeng Chen
- Department of Cardiology, National University Heart Centre, Singapore
| | | | - Hui-Wen Sim
- Department of Cardiology, National University Heart Centre, Singapore
| | - Wilson W Tam
- Alice Lee Centre for Nursing Studies, National University of Singapore, Singapore
| | - Carlo F Gochuico
- Department of Cardiology, National University Heart Centre, Singapore
| | - Kent Anthony Tan
- Department of Cardiology, National University Heart Centre, Singapore
| | - Giap-Swee Kang
- Department of Cardiac, Thoracic, and Vascular Surgery, National University Heart Centre, Singapore
| | - Vitaly Sorokin
- Department of Cardiac, Thoracic, and Vascular Surgery, National University Heart Centre, Singapore
| | | | - Pipin Kojodjojo
- Department of Cardiology, National University Heart Centre, Singapore.,Department of Cardiology, Ng Teng Fong General Hospital, Singapore
| | - Arthur Mark Richards
- Department of Cardiology, National University Heart Centre, Singapore.,Yong Loo Lin School of Medicine, National University of Singapore, Singapore.,Cardiovascular Research Institute, National University of Singapore, Singapore
| | - Huay-Cheem Tan
- Department of Cardiology, National University Heart Centre, Singapore
| | - Theodoros Kofidis
- Department of Cardiac, Thoracic, and Vascular Surgery, National University Heart Centre, Singapore.,Yong Loo Lin School of Medicine, National University of Singapore, Singapore.,Cardiovascular Research Institute, National University of Singapore, Singapore
| | - Chi-Hang Lee
- Department of Cardiology, National University Heart Centre, Singapore.,Yong Loo Lin School of Medicine, National University of Singapore, Singapore.,Cardiovascular Research Institute, National University of Singapore, Singapore
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43
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Affiliation(s)
- Tone M Norekvål
- Department of Heart Disease, Haukeland University Hospital, Bergen, Norway .,Department of Clinical Science, University of Bergen, Bergen, Norway
| | - Heather G Allore
- Department of Internal Medicine, Yale School of Medicine, Yale University, New Haven, Connecticut, USA.,Department of Biostatistics, Yale School of Public Health, Yale University, New Haven, Connecticut, USA
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45
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Gronewold J, Kropp R, Lehmann N, Schmidt B, Weyers S, Siegrist J, Dragano N, Jöckel KH, Erbel R, Hermann DM. Association of social relationships with incident cardiovascular events and all-cause mortality. Heart 2020; 106:1317-1323. [PMID: 32165451 PMCID: PMC7476279 DOI: 10.1136/heartjnl-2019-316250] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/15/2019] [Revised: 01/07/2020] [Accepted: 02/17/2020] [Indexed: 11/19/2022] Open
Abstract
Objective To examine how different aspects of social relationships are associated with incident cardiovascular events and all-cause mortality. Methods In 4139 participants from the population-based Heinz Nixdorf Recall study without previous cardiovascular disease (mean (SD) age 59.1 (7.7) years, 46.7% men), the association of self-reported instrumental, emotional and financial support and social integration at baseline with incident fatal and non-fatal cardiovascular events and all-cause mortality during 13.4-year follow-up was assessed in five different multivariable Cox proportional hazards regression models: minimally adjusted model (adjusting for age, sex, social integration or social support, respectively); biological model (minimally adjusted+systolic blood pressure, low-density and high-density lipoprotein cholesterol, glycated haemoglobin, body mass index, antihypertensive medication, lipid-lowering medication and antidiabetic medication); health behaviour model (minimally adjusted+alcohol consumption, smoking and physical activity); socioeconomic model (minimally adjusted+income, education and employment); and depression model (minimally adjusted+depression, antidepressants and anxiolytics). Results 339 cardiovascular events and 530 deaths occurred during follow-up. Lack of financial support was associated with an increased cardiovascular event risk (minimally adjusted HR=1.30(95% CI 1.01 to 1.67)). Lack of social integration (social isolation) was associated with increased mortality (minimally adjusted HR=1.47 (95% CI 1.09 to 1.97)). Effect estimates did not decrease to a relevant extent in any regression model. Conclusions Perceiving a lack of financial support is associated with a higher cardiovascular event incidence, and being socially isolated is associated with increased all-cause mortality. Future studies should investigate how persons with deficient social relationships could benefit from targeted interventions.
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Affiliation(s)
- Janine Gronewold
- Department of Neurology, University Hospital Essen, Essen, Germany
| | - Rene Kropp
- Department of Neurology, University Hospital Essen, Essen, Germany
| | - Nils Lehmann
- Institute for Medical Informatics, Biometry and Epidemiology, University Duisburg-Essen, Essen, Germany
| | - Börge Schmidt
- Institute for Medical Informatics, Biometry and Epidemiology, University Duisburg-Essen, Essen, Germany
| | - Simone Weyers
- Institute for Medical Sociology, Medical Faculty, Heinrich-Heine-University Düsseldorf, Düsseldorf, Germany
| | - Johanne Siegrist
- Institute for Medical Sociology, Medical Faculty, Heinrich-Heine-University Düsseldorf, Düsseldorf, Germany
| | - Nico Dragano
- Institute for Medical Sociology, Medical Faculty, Heinrich-Heine-University Düsseldorf, Düsseldorf, Germany
| | - Karl-Heinz Jöckel
- Institute for Medical Informatics, Biometry and Epidemiology, University Duisburg-Essen, Essen, Germany
| | - Raimund Erbel
- Institute for Medical Informatics, Biometry and Epidemiology, University Duisburg-Essen, Essen, Germany
| | - Dirk M Hermann
- Department of Neurology, University Hospital Essen, Essen, Germany
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Heuts S, Adriaans BP, Rylski B, Mihl C, Bekkers SCAM, Olsthoorn JR, Natour E, Bouman H, Berezowski M, Kosiorowska K, Crijns HJGM, Maessen JG, Wildberger J, Schalla S, Sardari Nia P. Evaluating the diagnostic accuracy of maximal aortic diameter, length and volume for prediction of aortic dissection. Heart 2020; 106:892-897. [PMID: 32152004 DOI: 10.1136/heartjnl-2019-316251] [Citation(s) in RCA: 30] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/15/2019] [Revised: 02/07/2020] [Accepted: 02/10/2020] [Indexed: 12/23/2022] Open
Abstract
OBJECTIVE Management of thoracic aortic aneurysms (TAAs) comprises regular diameter follow-up until the indication criterion for prophylactic surgery is reached. However, this approach is unable to predict the majority of acute type A aortic dissections (ATAADs). The current study aims to evaluate the diagnostic accuracy of ascending aortic diameter, length and volume for occurrence of ATAAD. METHODS This two-centre observational cohort study retrospectively screened 477 consecutive patients who presented with ATAAD between 2009 and 2018. Of those, 25 (5.2%) underwent CT angiography (CTA) within 2 years before dissection onset. Aortic diameter, length and volume of these patients ('pre-ATAAD') were compared with those of TAA controls (n=75). Receiver operating curve analysis was performed to evaluate the predictive accuracy of the three different measurements. RESULTS 96% of patients with pre-ATAAD did not meet the surgical diameter threshold of 55 mm before dissection onset. Maximal aortic diameters (45 (40-49) mm vs 46 (44-49) mm, p=0.075) and volume (126 (95-157) cm3 vs 124 (102-136) cm3, p=0.909) were comparable between patients with pre-ATAAD and TAA controls. Conversely, ascending aortic length (84±9 mm vs 90±16 mm, p=0.031) was significantly larger in patients with pre-ATAAD. All three parameters had an area under the curve of >0.800. At the 55 mm cut-off point, the maximal diameter yielded a positive predictive value (PPV) of 20%. While maintaining same specificity levels, measurements of aortic volume and length showed superior diagnostic accuracy (PPV 55% and 70%, respectively). CONCLUSION Measurements of aortic volume and length have superior diagnostic accuracy compared with the maximal diameter and could improve the timely identification of patients at risk for ATAAD.
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Affiliation(s)
- Samuel Heuts
- Department of Cardiothoracic Surgery, Maastricht University Medical Center, Maastricht, Limburg, The Netherlands .,Cardiovascular Research Institute Maastricht (CARIM), Maastricht University, Maastricht, Limburg, The Netherlands
| | - Bouke P Adriaans
- Cardiovascular Research Institute Maastricht (CARIM), Maastricht University, Maastricht, Limburg, The Netherlands.,Department of Radiology and Nuclear Medicine, Maastricht University Medical Center, Maastricht, The Netherlands.,Department of Cardiology, Maastricht University Medical Center, Maastricht, Limburg, The Netherlands
| | - Bartosz Rylski
- Department of Cardiovascular Surgery, Heart Centre Freiburg University, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Casper Mihl
- Cardiovascular Research Institute Maastricht (CARIM), Maastricht University, Maastricht, Limburg, The Netherlands.,Department of Radiology and Nuclear Medicine, Maastricht University Medical Center, Maastricht, The Netherlands
| | - Sebastiaan C A M Bekkers
- Cardiovascular Research Institute Maastricht (CARIM), Maastricht University, Maastricht, Limburg, The Netherlands.,Department of Radiology and Nuclear Medicine, Maastricht University Medical Center, Maastricht, The Netherlands.,Department of Cardiology, Maastricht University Medical Center, Maastricht, Limburg, The Netherlands
| | - Jules R Olsthoorn
- Department of Cardiothoracic Surgery, Maastricht University Medical Center, Maastricht, Limburg, The Netherlands.,Department of Cardiothoracic Surgery, Catharina Hospital, Eindhoven, The Netherlands
| | - Ehsan Natour
- Department of Cardiothoracic Surgery, Maastricht University Medical Center, Maastricht, Limburg, The Netherlands.,Department of Thoracic and Cardiovascular Surgery, Uniklinik RWTH Aachen, Aachen, Germany
| | - Heleen Bouman
- Department of Internal Medicine, Maastricht University Medical Center, Maastricht, Limburg, The Netherlands
| | - Mikolaj Berezowski
- Department of Cardiac Surgery, Wroclaw Medical University, Wroclaw, Poland
| | - Kinga Kosiorowska
- Department of Cardiac Surgery, Wroclaw Medical University, Wroclaw, Poland
| | - Harry J G M Crijns
- Cardiovascular Research Institute Maastricht (CARIM), Maastricht University, Maastricht, Limburg, The Netherlands.,Department of Cardiology, Maastricht University Medical Center, Maastricht, Limburg, The Netherlands
| | - Jos G Maessen
- Department of Cardiothoracic Surgery, Maastricht University Medical Center, Maastricht, Limburg, The Netherlands.,Cardiovascular Research Institute Maastricht (CARIM), Maastricht University, Maastricht, Limburg, The Netherlands
| | - Joachim Wildberger
- Cardiovascular Research Institute Maastricht (CARIM), Maastricht University, Maastricht, Limburg, The Netherlands.,Department of Radiology and Nuclear Medicine, Maastricht University Medical Center, Maastricht, The Netherlands
| | - Simon Schalla
- Cardiovascular Research Institute Maastricht (CARIM), Maastricht University, Maastricht, Limburg, The Netherlands.,Department of Radiology and Nuclear Medicine, Maastricht University Medical Center, Maastricht, The Netherlands.,Department of Cardiology, Maastricht University Medical Center, Maastricht, Limburg, The Netherlands
| | - Peyman Sardari Nia
- Department of Cardiothoracic Surgery, Maastricht University Medical Center, Maastricht, Limburg, The Netherlands.,Cardiovascular Research Institute Maastricht (CARIM), Maastricht University, Maastricht, Limburg, The Netherlands
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47
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Clarson LE, Bajpai R, Whittle R, Belcher J, Abdul Sultan A, Kwok CS, Welsh V, Mamas M, Mallen CD. Interstitial lung disease is a risk factor for ischaemic heart disease and myocardial infarction. Heart 2020; 106:916-922. [PMID: 32114515 PMCID: PMC7282497 DOI: 10.1136/heartjnl-2019-315511] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/03/2019] [Revised: 12/02/2019] [Accepted: 12/09/2019] [Indexed: 11/15/2022] Open
Abstract
Objectives Despite many shared risk factors and pathophysiological pathways, the risk of ischaemic heart disease (IHD) and myocardial infarction (MI) in interstitial lung disease (ILD) remains poorly understood. This lack of data could be preventing patients who may benefit from screening for these cardiovascular diseases from receiving it. Methods A population-based cohort study used electronic patient records from the Clinical Practice Research Datalink and linked Hospital Episode Statistics to identify 68 572 patients (11 688 ILD exposed (mean follow-up: 3.8 years); 56 884 unexposed controls (mean follow-up: 4.0 years), with 349 067 person-years of follow-up. ILD-exposed patients (pulmonary sarcoidosis (PS) or idiopathic pulmonary fibrosis (PF)) were matched (by age, sex, registered general practice and available follow-up time) to patients without ILD or IHD/MI. Rates of incident MI and IHD were estimated. HRs were modelled using multivariable Cox proportional hazards regression accounting for potential confounders. Results ILD was independently associated with IHD (HR 1.85, 95% CI 1.56 to 2.18) and MI (HR 1.74, 95% CI 1.44 to 2.11). In all disease categories, risk of both IHD and MI peaked between ages 60 and 69 years, except for the risk of MI in PS which was greatest <50 years. Men with PF were at greatest risk of IHD, while women with PF were at greatest risk of MI. Conclusions ILD, particularly PF, is independently associated with MI and IHD after adjustment for established cardiovascular risk factors. Our results suggest clinicians should prioritise targeted assessment of cardiovascular risk in patients with ILD, particularly those aged 60–69 years. Further research is needed to understand the impact of such an approach to risk management.
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Affiliation(s)
| | - Ram Bajpai
- School of Primary, Community and Social Care, Keele University, Keele, UK
| | - Rebecca Whittle
- School of Primary, Community and Social Care, Keele University, Keele, UK
| | - John Belcher
- School of Primary, Community and Social Care, Keele University, Keele, UK
| | | | - Chun Shing Kwok
- Cardiovascular Research Group, Keele University, Stoke-on-Trent, UK
| | - Victoria Welsh
- School of Primary, Community and Social Care, Keele University, Keele, UK
| | - Mamas Mamas
- Cardiovascular Research Group, Keele University, Stoke-on-Trent, UK
| | - Christian D Mallen
- School of Primary, Community and Social Care, Keele University, Keele, UK
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48
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Ergatoudes C, Hansson PO, Svärdsudd K, Rosengren A, Östgärd Thunström E, Caidahl K, Pivodic A, Fu M. Comparison of incidence rates and risk factors of heart failure between two male cohorts born 30 years apart. Heart 2020; 106:1672-1678. [PMID: 32114518 DOI: 10.1136/heartjnl-2019-316059] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/03/2019] [Revised: 01/30/2020] [Accepted: 02/06/2020] [Indexed: 11/04/2022] Open
Abstract
OBJECTIVE To compare two cohorts of middle-aged men from the general population born 30 years apart for incidence and predictors of heart failure (HF). METHODS Two population samples of men, born in 1913 (n=855) and in 1943 (n=797), were examined at 50 years of age and followed up for 21 years (1963-1994 and 1993-2014). Cox regression analysis was used to examine the impact of different factors on the risk of developing HF. RESULTS Eighty men born in 1913 (9.4%) and 42 men born in 1943 (5.3%) developed HF during follow-up; adjusted HRs comparing the two cohorts (born 1943 vs 1913) were: 0.46 (95% CI 0.28 to 0.74, p=0.002). In both cohorts, higher body mass index, higher diastolic blood pressure, treatment for hypertension, onset of either atrial fibrillation (AF), ischaemic heart disease and diabetes mellitus were associated with higher risk of HF. Higher heart rate was associated with an increased risk only in men born in 1913, whereas higher systolic blood pressure (SBP), smoking, higher glucose, higher cholesterol and physical inactivity were associated with an increased risk in men born in 1943. AF contributed higher risk of incident HF, whereas SBP and physical inactivity contributed lower risk in men born in 1943 compared with men born in 1913. CONCLUSIONS Men born in 1943 had half the risk of HF after their 50s than those born 30 years earlier. AF, obesity, ischaemic heart disease, diabetes and hypertension remain important precursors of HF.
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Affiliation(s)
- Constantinos Ergatoudes
- Sahlgrenska Universitetssjukhuset Ostra Sjukhuset, Goteborg, Sweden .,Department of Molecular and Clinical Medicine/Emergency and Cardiovascular Medicine Cardiology, Sahlgrenska Academy, Gothenburg, Sweden
| | - Per-Olof Hansson
- Sahlgrenska Universitetssjukhuset Ostra Sjukhuset, Goteborg, Sweden.,Department of Molecular and Clinical Medicine/Emergency and Cardiovascular Medicine Cardiology, Sahlgrenska Academy, Gothenburg, Sweden
| | | | - Annika Rosengren
- Sahlgrenska Universitetssjukhuset Ostra Sjukhuset, Goteborg, Sweden.,Department of Molecular and Clinical Medicine/Emergency and Cardiovascular Medicine Cardiology, Sahlgrenska Academy, Gothenburg, Sweden
| | - Erik Östgärd Thunström
- Sahlgrenska Universitetssjukhuset Ostra Sjukhuset, Goteborg, Sweden.,Department of Molecular and Clinical Medicine/Emergency and Cardiovascular Medicine Cardiology, Sahlgrenska Academy, Gothenburg, Sweden
| | - Kenneth Caidahl
- Molecular Medicine and Surgery, Karolinska Institutet, Stockholm, Sweden
| | - Aldina Pivodic
- Statistiska Konsultgruppen, Gothenburg, Sweden.,Sahlgrenska Academy, Goteborg, Sweden
| | - Michael Fu
- Sahlgrenska Universitetssjukhuset Ostra Sjukhuset, Goteborg, Sweden.,Department of Molecular and Clinical Medicine/Emergency and Cardiovascular Medicine Cardiology, Sahlgrenska Academy, Gothenburg, Sweden
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49
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O'Keeffe LM, Kuh D, Fraser A, Howe LD, Lawlor D, Hardy R. Age at period cessation and trajectories of cardiovascular risk factors across mid and later life. Heart 2020; 106:499-505. [PMID: 32098806 PMCID: PMC7079196 DOI: 10.1136/heartjnl-2019-315754] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/30/2019] [Revised: 11/15/2019] [Accepted: 11/20/2019] [Indexed: 01/23/2023] Open
Abstract
Objective To examine the association between age at period cessation and trajectories of anthropometry, blood pressure, lipids and glycated haemoglobin (HbA1c) from midlife to age 69 years. Methods We used data from the UK Medical Research Council National Survey of Health and Development to examine the association between age at period cessation and trajectories of systolic blood pressure (SBP), diastolic blood pressure (DBP), body mass index (BMI) and waist circumference (WC) from 36 to 69 years and trajectories of triglyceride, low density lipoprotein cholesterol (LDL-C), high density lipoprotein cholesterol (HDL-C) and HbA1c from 53 to 69 years. Results We found no evidence that age at period cessation was associated with trajectories of log triglyceride, LDL-C and HDL-C from 53 to 69 years and trajectories of SBP or DBP from 36 to 69 years, regardless of whether period cessation occurred naturally or due to hysterectomy. While we found some evidence of associations of age at period cessation with log BMI, log WC and log HbA1c, patterns were not consistent and differences were small at age 69 years, with confidence intervals that spanned the null value. Conclusion How and when women experience period cessation is unlikely to adversely affect conventional cardiovascular risk factors across mid and later life. Women and clinicians concerned about the impact of type and timing of period cessation on conventional cardiovascular intermediates from midlife should be reassured that the impact over the long term is small.
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Affiliation(s)
- Linda Marie O'Keeffe
- MRC Integrative Epidemiology Unit, University of Bristol, Bristol, UK .,Population Health Science, Bristol Medical School, Bristol, UK.,School of Public Health, University College Cork, Cork, Ireland
| | - Diana Kuh
- MRC Unit for Lifelong Health and Ageing at UCL, London, UK
| | - Abigail Fraser
- MRC Integrative Epidemiology Unit, University of Bristol, Bristol, UK.,Population Health Science, Bristol Medical School, Bristol, UK
| | - Laura D Howe
- MRC Integrative Epidemiology Unit, University of Bristol, Bristol, UK.,Population Health Science, Bristol Medical School, Bristol, UK
| | - Debbie Lawlor
- MRC Integrative Epidemiology Unit, University of Bristol, Bristol, UK.,Population Health Science, Bristol Medical School, Bristol, UK
| | - Rebecca Hardy
- MRC Unit for Lifelong Health and Ageing at UCL, London, UK.,CLOSER, UCL Institute of Education, London, UK
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50
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Diamantino AC, Nascimento BR, Beaton AZ, Nunes MCP, Oliveira KKB, Rabelo LC, Barbosa MM, Tompsett AR, Olivieri L, Mata MD, Costa WAA, Pereira AF, Diamantino LC, Ribeiro ALP, Sable C, Brant LCC. Atrial fibrillation detection with a portable device during cardiovascular screening in primary care. Heart 2020; 106:1261-1266. [PMID: 32019822 DOI: 10.1136/heartjnl-2019-316277] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/18/2019] [Revised: 12/29/2019] [Accepted: 01/03/2020] [Indexed: 11/03/2022] Open
Abstract
INTRODUCTION A novel handheld dual-electrode stick is a portable atrial fibrillation (AF) screening device (AFSD). We evaluated AFSD performance in primary care patients referred for echocardiogram (echo). METHODS The AFSD has a light indication of irregular rhythm and single-lead ECG recording. Patients were instructed to hold the device for 1 min, and AF indication was recorded. A 12-lead ECG was performed for all AFSD-positive patients and 250 patients with negative AFSD screen. Echos were performed based on a clinical risk score: all high-risk patients and a sampling of low-risk patients underwent complete echo. Intermediate risk patients first had a screening echocardiogram, with a follow-up complete study if abnormality was suspected. RESULTS In 5 days, 1518 patients underwent clinical evaluation and cardiovascular risk stratification: mean age 58±16 years, 66% women. The AFSD was positive in 6.4%: 12.6% high risk, 6.1% intermediate risk and 2.2% low risk. Older age was a risk factor (9.3% vs 4.8% in those more than and less than 65 years, p=0.001). AFSD positive was independently associated with heart disease in echo (OR=3.9, 95% CI 2.1 to 7.2, p<0.001). Compared with 12-lead ECG, the AFSD had sensitivity of 90.2% (95% CI 77.0% to 97.3%) and specificity of 84.0% (95% CI 79.3% to 88.0%) for AF detection. CONCLUSION AFSD demonstrated high sensitivity for AF detection in primary care patients referred for echo. AF prevalence was substantial and independently associated with structural or functional heart disease, suggesting that AFSD screening could be a useful primary care tool to stratify risk and prioritise echo.
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Affiliation(s)
- Adriana C Diamantino
- Serviço de Cardiologia e Cirurgia Cardiovascular e Centro de Telessaúde do Serviço de Cardiologia e Cirurgia Cardiovascular e Centro de Telessaúde do, Hospital das Clinicas da Universidade Federal de Minas Gerais, Belo Horizonte, Minas Gerais, Brazil
| | - Bruno R Nascimento
- Serviço de Cardiologia e Cirurgia Cardiovascular e Centro de Telessaúde do Serviço de Cardiologia e Cirurgia Cardiovascular e Centro de Telessaúde do, Hospital das Clinicas da Universidade Federal de Minas Gerais, Belo Horizonte, Minas Gerais, Brazil .,Departamento de Clínica Médica, Faculdade de Medicina da Universidade Federal de Minas Gerais, Belo Horizonte, Minas Gerais, Brazil
| | - Andrea Z Beaton
- The Heart Institute, Cincinnati Childrens Hospital Medical Center, Cincinnati - OH, United States, Cincinnati Childrens Hospital Medical Center, Cincinnati, Ohio, United States
| | - Maria Carmo P Nunes
- Serviço de Cardiologia e Cirurgia Cardiovascular e Centro de Telessaúde do Serviço de Cardiologia e Cirurgia Cardiovascular e Centro de Telessaúde do, Hospital das Clinicas da Universidade Federal de Minas Gerais, Belo Horizonte, Minas Gerais, Brazil.,Departamento de Clínica Médica, Faculdade de Medicina da Universidade Federal de Minas Gerais, Belo Horizonte, Minas Gerais, Brazil
| | - Kaciane K B Oliveira
- Serviço de Cardiologia e Cirurgia Cardiovascular e Centro de Telessaúde do Serviço de Cardiologia e Cirurgia Cardiovascular e Centro de Telessaúde do, Hospital das Clinicas da Universidade Federal de Minas Gerais, Belo Horizonte, Minas Gerais, Brazil
| | - Lara C Rabelo
- Serviço de Cardiologia e Cirurgia Cardiovascular e Centro de Telessaúde do Serviço de Cardiologia e Cirurgia Cardiovascular e Centro de Telessaúde do, Hospital das Clinicas da Universidade Federal de Minas Gerais, Belo Horizonte, Minas Gerais, Brazil
| | - Marcia M Barbosa
- Serviço de Cardiologia e Cirurgia Cardiovascular e Centro de Telessaúde do Serviço de Cardiologia e Cirurgia Cardiovascular e Centro de Telessaúde do, Hospital das Clinicas da Universidade Federal de Minas Gerais, Belo Horizonte, Minas Gerais, Brazil
| | - Alison R Tompsett
- Department of Cardiology, Children's National Health System, Washington, District of Columbia, USA
| | - Laura Olivieri
- Department of Cardiology, Children's National Health System, Washington, District of Columbia, USA
| | - Mariana D Mata
- Departamento de Clínica Médica, Faculdade de Medicina da Universidade Federal de Minas Gerais, Belo Horizonte, Minas Gerais, Brazil
| | - Waydder Antônio A Costa
- Departamento de Clínica Médica, Faculdade de Medicina da Universidade Federal de Minas Gerais, Belo Horizonte, Minas Gerais, Brazil
| | - Augusto F Pereira
- Departamento de Clínica Médica, Faculdade de Medicina da Universidade Federal de Minas Gerais, Belo Horizonte, Minas Gerais, Brazil
| | - Luciana C Diamantino
- Serviço de Cardiologia e Cirurgia Cardiovascular e Centro de Telessaúde do Serviço de Cardiologia e Cirurgia Cardiovascular e Centro de Telessaúde do, Hospital das Clinicas da Universidade Federal de Minas Gerais, Belo Horizonte, Minas Gerais, Brazil
| | - Antonio Luiz P Ribeiro
- Serviço de Cardiologia e Cirurgia Cardiovascular e Centro de Telessaúde do Serviço de Cardiologia e Cirurgia Cardiovascular e Centro de Telessaúde do, Hospital das Clinicas da Universidade Federal de Minas Gerais, Belo Horizonte, Minas Gerais, Brazil.,Departamento de Clínica Médica, Faculdade de Medicina da Universidade Federal de Minas Gerais, Belo Horizonte, Minas Gerais, Brazil
| | - Craig Sable
- Department of Cardiology, Children's National Health System, Washington, District of Columbia, USA
| | - Luisa C C Brant
- Serviço de Cardiologia e Cirurgia Cardiovascular e Centro de Telessaúde do Serviço de Cardiologia e Cirurgia Cardiovascular e Centro de Telessaúde do, Hospital das Clinicas da Universidade Federal de Minas Gerais, Belo Horizonte, Minas Gerais, Brazil.,Departamento de Clínica Médica, Faculdade de Medicina da Universidade Federal de Minas Gerais, Belo Horizonte, Minas Gerais, Brazil
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