Application of AMR in evaluating microvascular dysfunction after ST-elevation myocardial infarction

BACKGROUND

A guidewire-free angiography-derived microcirculatory resistance (AMR) derived from Quantitative flow ratio (QFR) exhibits good diagnostic accuracy for assessing coronary microvascular dysfunction (CMD), but there are no relevant studies supporting the specific application of AMR in patients with ST-elevation myocardial infarction (STEMI). The study aims to evaluate CMD in patients with STEMI using the AMR index.

METHODS

This study included patients with STEMI who underwent percutaneous coronary intervention (PCI) from June 1, 2020 to September 28, 2021. All patients were divided into two groups: the CMD (n = 215) and non-CMD (n = 291) groups. After matching, there were 382 patients in both groups.1-year follow-up major adverse cardiac events (MACEs) were evaluated.

RESULTS

After matching, the primary endpoint was achieved in 41 patients (10.7%), with 27 and 14 patients in the CMD and non-CMD groups, respectively (HR 1.954 [95% CI 1.025-3.726]; 14.1% versus 7.3%, p = .042). Subgroup analysis revealed that 18 patients (4.7%) were readmitted for heart failure, with 15 and 3 in the CMD and non-CMD groups, respectively (HR 5.082 [95% CI 1.471-17.554]; 7.9% versus 1.6%, p = .010). Post-PCI AMR ≥ 250 was significantly associated with a higher risk of the primary endpoint and was its independent predictor (HR 2.265 [95% CI 1.136-4.515], p = .020).

CONCLUSION

The retrospective use of AMR with a cutoff value of ≥250 after PCI in patients with STEMI can predict a significant difference in the 1-year MACE rates when compared with a propensity score-matched group with normal AMR.

Cardiovascular Risk in Prostate Cancer Patients Using Luteinizing Hormone-Releasing Hormone Agonists or a Gonadotropin-Releasing Hormone Antagonist

PURPOSE

Luteinizing hormone-releasing hormone (LHRH) agonists are believed to have higher cardiovascular risk relative to gonadotropin-releasing hormone (GnRH) antagonists. However, previous studies have not consistently demonstrated this. We used real-world clinical practice data to evaluate differences in major adverse cardiovascular events (MACE) risk between LHRH agonists compared to a GnRH antagonist following androgen deprivation therapy (ADT) initiation.

MATERIALS AND METHODS

We performed a retrospective analysis of data in the Decision Resources Group (now Clarivate) Real World Evidence repository, which represents >300 million US patients from 1991 to 2020 across all US regions. Patients with prostate cancer who received at least 1 injection of ADT were included. The risks of MACE and all-cause mortality as independent endpoints were evaluated, Kaplan-Meier curves were constructed, and associations between MACE and all available confounding risk factors were evaluated by Cox regression analysis using Statistical Package for the Social Sciences.

RESULTS

A total of 45,059 men with prostate cancer treated with ADT were analyzed. Overall, the risks of MACE and all-cause mortality were slightly lower in the first year after ADT initiation compared to subsequent years. MACE risk was higher for the GnRH antagonist compared to LHRH agonists (HR=1.62; 95% CI 1.21-2.18, P = .001). The risk of all-cause mortality was also higher for the GnRH antagonist vs LHRH agonists (HR=1.87; 95% CI 1.39-2.51, P < .001).

CONCLUSIONS

The adjusted incidence of MACE was higher for men treated with the GnRH antagonist compared to the LHRH agonists. The demographic and risk factors with the greatest impact on MACE risk were higher age, baseline metastasis, oncology (vs urology) setting, personal MACE history, antagonist (vs agonist), tobacco history, White (vs Black) race, and lower BMI.

Effect of quantitative parameters of contrast-enhanced ultrasound on the long-term prognosis of patients with chronic coronary syndrome

Background

Ultrasound is one of the most commonly used examination methods in patients with coronary artery disease (CAD) and is valuable in evaluating patient prognosis. Although contrast-enhanced ultrasound (CEUS) can assess more in depth the vascular lesions of patients, there is still a lack of relevant research on the value of quantitative parameters of CEUS in predicting the long-term prognosis of patients with chronic coronary syndrome (CCS), thus, we designed this study.

Methods

From January 2016 to December 2017, a total of 473 patients with CCS admitted to Yueyang People's Hospital were retrospectively enrolled. The patients were followed up for five years. According to whether the patients had major adverse cardiovascular events (MACE), patients were divided into the MACE group (n=113) and the control group (n=360). The CEUS was performed to detect the myocardial perfusion status. The value of quantitative parameters of CEUS in predicting the MACE in patients with CCS was analyzed using the receiver operating characteristic (ROC) curve.

Results

Peak intensity of contrast agent at platform stage, rising rate of microbubble reperfusion, and left ventricular ejection fraction (LVEF) were found to be valuable in predicting the risk of MACE in patients with CCS. Among them, the peak intensity of contrast agent at platform stage had the highest predictive value, and the area under the curve (AUC) was 0.860 [95% confidence interval (CI): 0.827-0.894, P<0.001]. Multivariate logistics regression analysis showed that the peak intensity of contrast agent at platform stage <4.54 dB and rising rate of microbubble reperfusion <0.275 s were independent risk factors of MACE in patients with CCS. The relative risks were 12.238 (95% CI: 6.632-22.585) and 5.724 (95% CI: 3.149-10.405), respectively.

Conclusions

Quantitative parameters of CEUS can be used as predictors of MACE in patients with CCS, and strengthening the management of such high-risk patients may be beneficial to reduce the incidence of MACE.

A systematic review of the applicability of emergency department assessment of chest pain score-accelerated diagnostic protocol for risk stratification of patients with chest pain

The emergency department assessment of chest pain score-accelerated diagnostic protocol (EDACS-ADP) are commonly used for risk stratification in undifferentiated patients with acute chest pain. This systematic review aimed to investigate EDACS-ADP for risk stratification of emergency department (ED) patients with chest pain. The PubMed, Web of Science, Medline, Cochrane Library, China National Knowledge Infrastructure, and Wanfang databases were searched for related studies without restrictions on the publication year. The Quality Assessment of Diagnostic Accuracy Studies 2 tool was used to assess the risk of bias, and Stata 16.0 was used to determine the combined sensitivity, specificity, positive diagnostic likelihood ratio (DLR), and negative DLR. Twelve studies comprising 14 290 patients were identified. Of these, 7537 (52.74%) patients were considered low risk, and 67 (0.89%) had major adverse cardiovascular events (MACE), including myocardial infarction, stroke, and cardiovascular death within 30 days of the patients' ED presentation. EDACS-ADP showed a combined sensitivity of 0.97 (95% confidence interval [CI]: 0.95-0.99); specificity, 0.58 (0.53-0.63); positive DLR, 2.34 (2.08-2.63); negative DLR, 0.04 (0.02-0.09); diagnostic odds ratio, 53.11 (26.45-106.63); and summary receiver operating characteristic area under the curve, 0.83 (0.79-0.86). Despite the large statistical heterogeneity of the results, EDACS-ADP identified a considerable number of low-risk patients for early discharge, with a specificity >50% and an incidence of MACE within 30-days of patients' ED presentation <1%. Thus, it is a useful tool with a potential for clinical application.

Survival Benefit of Kidney Transplantation in Patients With End-Stage Kidney Disease and Prior Acute Myocardial Infarction

Patients with end stage kidney disease (ESKD) and a previous acute myocardial infarction (AMI) have less access to KT. Data on ESKD patients with an AMI history who underwent first KT or dialysis between January 2007 and December 2018 were extracted from the Korean National Health Insurance Service. Patients who underwent KT (n = 423) were chronologically matched in a 1:3 ratio with those maintained on dialysis (n = 1,269) at the corresponding dates, based on time-conditional propensity scores. The 1, 5, and 10 years cumulative incidences for all-cause mortality were 12.6%, 39.1%, and 60.1% in the dialysis group and 3.1%, 7.2%, and 14.5% in the KT group. Adjusted hazard ratios (HRs) of KT versus dialysis were 0.17 (95% confidence interval [CI], 0.12-0.24; p < 0.001) for mortality and 0.38 (95% CI, 0.23-0.51; p < 0.001) for major adverse cardiovascular events (MACE). Of the MACE components, KT was most protective against cardiovascular death (HR, 0.23; 95% CI, 0.12-0.42; p < 0.001). Protective effects of KT for all-cause mortality and MACE were consistent across various subgroups, including patients at higher risk (e.g., age >65 years, recent AMI [<6 months], congestive heart failure). KT is associated with lower all-cause mortality and MACE than maintenance dialysis patients with a prior AMI.

Heart Failure and Major Adverse Cardiovascular Events in Atrial Fibrillation Patients: A Retrospective Primary Care Cohort Study

BACKGROUND

Atrial fibrillation (AF) is a common cardiac arrhythmia that is associated with an increased risk of major adverse cardiovascular events (MACE). The main goal was to analyze the links and associations between AF and MACE.

METHODS

A multicenter, observational, retrospective, community-based study of a cohort (n = 40,297) of the general population aged 65-95 years between 1 January 2015 and 31 December 2021 without a previous diagnosis of AF or MACE in the Primary Care setting.

RESULTS

2574 people (6.39%) developed a first AF event, resulting in an overall incidence of 8.9/1000 people-years [CI95% 8.6-9.2]. The incidence of MACE among those with AF was 75.1/1000 people-years [CI95% 70.8-79.5], whereas among those without AF, it was 20.6/1000 people-years [CI 95% 20.2-21.1], resulting in a rate ratio of 3.65 [CI 95% 3.43-3.88, p < 0.001]. Besides, the incidence of HF with AF was 40.1 people-years [CI 95% 37.1-43.2], while in the group without AF, it was 8.3 people-years [CI 95% 7.9-8.6, p < 0.001], with a rate ratio of 4.85 [CI 95% 4.45-55.3, p < 0.001]. Before an AF diagnosis, there is already a higher risk of chronic kidney disease, ischemic cardiopathy, and peripheral artery disease. A higher risk of poor nutritional status was detected among those with MACE (49.7% vs. 26.6%, p < 0.001).

CONCLUSIONS

AF diagnosis increases the incidence of heart failure fourfold. Additional information is required to establish the connection between AF, major adverse cardiovascular events, and nutritional status.

Antithrombotic Therapy in Peripheral Artery Disease: Current Evidence and Future Directions

Patients with peripheral artery disease (PAD) are at an increased risk of major adverse cardiovascular events, and those with disease in the lower extremities are at risk of major adverse limb events primarily driven by atherothrombosis. Traditionally, PAD refers to diseases of the arteries outside of the coronary circulation, including carotid, visceral and lower extremity peripheral artery disease, and the heterogeneity of PAD patients is represented by different atherothrombotic pathophysiology, clinical features and related antithrombotic strategies. The risk in this diverse population includes systemic risk of cardiovascular events as well as risk related to the diseased territory (e.g., artery to artery embolic stroke for patients with carotid disease, lower extremity artery to artery embolism and atherothrombosis in patients with lower extremity disease). Moreover, until the last decade, clinical data on antithrombotic management of PAD patients have been drawn from subanalyses of randomized clinical trials addressing patients affected by coronary artery disease. The high prevalence and related poor prognosis in PAD patients highlight the pivotal role of tailored antithrombotic therapy in patients affected by cerebrovascular, aortic and lower extremity peripheral artery disease. Thus, the proper assessment of thrombotic and hemorrhagic risk in patients with PAD represents a key clinical challenge that must be met to permit the optimal antithrombotic prescription for the various clinical settings in daily practice. The aim of this updated review is to analyze different features of atherothrombotic disease as well as current evidence of antithrombotic management in asymptomatic and secondary prevention in PAD patients according to each arterial bed.

The Cytochrome P450 2C19 Polymorphism Associated with Major Adverse Cardiovascular Events Risk in Kazak Patients Undergoing Percutaneous Coronary Intervention and Receiving Clopidogrel

BACKGROUND

Clopidogrel activity is influenced by cytochrome P450 (CYP450). CYP2C19 polymorphisms vary by ethnicity and region.

OBJECTIVE

The aim of the study is to assess the effect of genetic polymorphisms in CYP2C19*2 and *3 and clinical and demographic factors on major adverse cardiovascular events (MACE) in Kazak patients following percutaneous coronary intervention (PCI).

METHODS

397 patients with PCI treated with clopidogrel and aspirin for at least 12 months were enrolled and outcomes within 1 year were recorded. Approximately 2 ml of peripheral venous blood samples were used for genotype detection. Multivariable logistic regression analyses were performed to identify factors associated with MACE.

RESULTS

95 patients (23.9%) suffered MACE during the period. Logistic regression analysis revealed CYP2C19*2 carriers (odds ratio [OR]: 2.431, 95% [confidence interval] CI: 1.136- 5.275, P = 0.027) and poor metabolizers (OR: 2.128, 95% CI: 0.899-4.82, P = 0.043) to be significantly associated with MACE.

CONCLUSION

The CYP2C19*2 allele variants and poor metabolizers were found to be associated with MACE in a clopidogrel-treated Kazak population with acute coronary syndrome following PCI.

Impact of low-density lipoprotein cholesterol and lipoprotein(a) on mid-term clinical outcomes following coronary artery bypass grafting: A secondary analysis of the DACAB trial

Purpose

The objective was to evaluate the influence of low-density lipoprotein cholesterol (LDL-C) and lipoprotein(a) [Lp(a)] on clinical outcomes in patients undergoing coronary artery bypass grafting (CABG).

Methods

This is a secondary analysis of a 5-year follow-up of the DACAB trial (NCT02201771), in which 500 patients who underwent primary isolated CABG were randomized to three-antiplatelet therapy for 1 year after surgery. Of them, 459 patients were recruited in this secondary analysis. Baseline LDL-C and Lp(a) levels were collected, and repeated measurement of LDL-C levels during the follow-up were recorded. Cut-off values for LDL-C were set at 1.8 and 2.6 mmol/L; thus, the patients were stratified into LDL-C <1.8, 1.8-<2.6, and ≥2.6 mmol/L subgroups. Cut-off value for Lp(a) was 30 mg/dL; thus, the patients were divided into Lp(a) <30 and ≥30 mg/dL subgroups. The primary outcome was 4-point major adverse cardiovascular events (MACE-4), a composite of all-cause death, myocardial infarction, stroke, and repeated revascularization. Median follow-up time was 5.2 (interquartile range, 4.2-6.1) years.

Results

During the follow-up, 129 (28.1%) patients achieved the attainment of LDL-C <1.8 mmol/L, 186 (40.5%) achieved LDL-C 1.8-<2.6 mmol/L, and 144 (31.4%) remained LDL-C ≥2.6 mmol/L. Compared with the postoperative LDL-C <1.8 mmol/L group, the risk of MACE-4 was significantly higher in the LDL-C 1.8-<2.6 mmol/L group [adjusted hazard ratio (aHR) = 1.92, 95% CI, 1.12-3.29; P = 0.019] and LDL-C ≥2.6 mmol/L group (aHR = 3.90, 95% CI, 2.29-6.64; P < 0.001). Baseline Lp(a) ≥30 mg/dL was identified in 131 (28.5%) patients and was associated with an increased risk of MACE-4 (aHR = 1.52, 95% CI, 1.06-2.18; P = 0.022).

Conclusions

For CABG patients, exposure to increased levels of postoperative LDL-C or baseline Lp(a) was associated with worse mid-term clinical outcomes. Our findings suggested the necessity of achieving LDL-C target and potential benefit of adding Lp(a) targeted lipid-lowering therapy in CABG population.

CYP2C19 genotype and platelet aggregation test-guided dual antiplatelet therapy after off-pump coronary artery bypass grafting: A retrospective cohort study

Background

Dual antiplatelet therapy (DAPT) is recommended in patients undergoing off-pump coronary artery bypass graft surgery (OPCAB). Clopidogrel is less effective among patients with loss-of-function (LoF) of CYP2C19 alleles, while ticagrelor has direct effects on P2Y₁₂ receptor. Whether a CYP2C19 genotype plus platelet aggregation test (PAgT)-guided DAPT after CABG could improve clinical outcomes remain uncertain.

Materials and methods

From August 2019 to December 2020, 1,134 consecutive patients who underwent OPCAB received DAPT for 1 year after surgery in Ruijin Hospital, Shanghai Jiao Tong University School of Medicine. According to the actual treatment they received in real-world, 382 (33.7%) of them received a traditional DAPT: aspirin 100 mg qd + clopidogrel 75 mg qd, no matter the CYP2C19 genotype and response in platelet aggregation test (PAgT). The other 752 (66.3%) patients received an individual DAPT based on CYP2C19 genotype and PAgT: aspirin 100 mg qd + clopidogrel 75 mg qd if CYP2C19 was extensive metabolizer, or moderate metabolizer but normal response in PAgT; aspirin 100 mg qd + ticagrelor 90 mg bid if CYP2C19 was poor metabolizer, or moderate metabolizer but no or low response in PAgT. One-year follow-up was achieved for all patients. The primary outcome was major adverse cardiovascular events (MACE), a composite of cardiovascular death, myocardial infarction, and stroke. The safety outcome was thrombolysis in myocardial infarction (TIMI) criteria major bleeding.

Results

Compared with the traditional DAPT group, the risk of MACE in the individual DAPT group was significantly lower (5.5 vs. 9.2%, HR 0.583; 95% CI, 0.371-0.915; P = 0.019), mainly due to the decreased risk of MI (1.7 vs. 4.2%, HR 0.407; 95% CI, 0.196-0.846; P = 0.016). The risk of TIMI major bleeding events was similar between the two groups (5.3 vs. 6.0%, RR 0.883; 95% CI, 0.537-1.453; P = 0.626).

Conclusion

For patients who underwent OPCAB, individual DAPT (CYP2C19 genotype plus PAgT-guided strategy) was associated with a lower risk of MACE and a similar risk of major bleeding.

Effect of Rivaroxaban and Aspirin in Patients with Peripheral Artery Disease Undergoing Surgical Revascularization: Insights from the VOYAGER PAD Trial

Background: Patients with peripheral artery disease (PAD) requiring lower extremity revascularization (LER) are at high risk of adverse limb and cardiovascular events. VOYAGER PAD demonstrated that rivaroxaban significantly reduced this risk. The efficacy and safety of rivaroxaban has not been described in patients who underwent surgical LER. Methods: The VOYAGER PAD trial randomized patients with PAD after surgical and endovascular LER to rivaroxaban 2.5mg twice daily plus aspirin or matching placebo plus aspirin and followed for a median of 28 months. The primary endpoint was a composite of acute limb ischemia, major vascular amputation, myocardial infarction, ischemic stroke, or cardiovascular death. The principal safety outcome was Thrombolysis in Myocardial Infarction (TIMI) major bleeding. International Society on Thrombosis and Haemostasis (ISTH) bleeding was a secondary safety outcome. All efficacy and safety outcomes were adjudicated by a blinded independent committee. Results: Of the 6564 randomized, 2185 (33%) underwent surgical LER and 4379 (67%) endovascular. Compared to placebo, rivaroxaban reduced the primary endpoint consistently regardless of LER method (p-interaction 0.43). Following surgical LER, the primary efficacy outcome occurred in 199 (18.4%) patients in the rivaroxaban group and 242 (22.0%) patients in the placebo group with a cumulative incidence at 3 years of 19.7% and 23.9%, respectively (HR 0.81, 95% CI 0.67 - 0.98; p=0.026). In the overall trial, TIMI major bleeding and ISTH major bleeding were increased with rivaroxaban. There was no heterogeneity for TIMI major bleeding (p-interaction 0.17) or ISTH major bleeding (p-interaction 0.73) based on LER approach. Following surgical LER, the principal safety outcome occurred in 11 (1.0%) patients in the rivaroxaban group and 13 (1.2%) patients in the placebo group; 3-year cumulative incidence 1.3% and 1.4% respectively (HR 0.88, 95% CI 0.39-1.95; p=0.75) Among surgical patients, the composite of fatal bleeding or intracranial hemorrhage (p=0.95) and postprocedural bleeding requiring intervention (p=0.93) were not significantly increased. Conclusions: The efficacy of rivaroxaban is associated with a benefit in surgical LER patients. While bleeding was increased with rivaroxaban plus aspirin, the incidence was low, with no significant increase in fatal bleeding, intracranial hemorrhage or postprocedural bleeds requiring intervention. Clinical Trial Registration: URL: https://clinicaltrials.gov Unique Identifier: NCT02504216.

Major Adverse Cardiovascular Events During Invasive Pneumococcal Disease Are Serotype Dependent

BACKGROUND

Up to 30% of patients admitted to hospitals with invasive pneumococcal disease (IPD) experience major adverse cardiovascular event (MACE) including new/worsening heart failure, new/worsening arrhythmia, and/or myocardial infarction. Streptococcus pneumoniae (Spn) is the most frequently isolated bacterial pathogen among community-acquired pneumonia (CAP) patients and the only etiological agent linked independently to MACE. Nevertheless, no clinical data exist identifying which serotypes of Spn are principally responsible for MACE.

METHODS

This was an observational multicenter retrospective study conducted through the Public Health Secretary of Bogotá, Colombia. We included patients with a confirmed clinical diagnosis of IPD with record of pneumococcal serotyping and clinical information between 2012 and 2019. Spn were serotyped using the quellung method by the National Center of Microbiology. MACE were determined by a retrospective chart review.

RESULTS

The prevalence of MACE was 23% (71/310) in IPD patients and 28% (53/181) in patients admitted for CAP. The most prevalent S. pneumoniae serotype identified in our study was the 19A, responsible for the 13% (42/310) of IPD in our cohort, of which 21% (9/42) presented MACE. Serotypes independently associated with MACE in IPD patients were serotype 3 (odds ratio [OR] 1, 48; 95% confidence interval [CI] [1.21-2.27]; P = .013) and serotype 9n (OR 1.29; 95% CI [1.08-2.24]; P = .020). Bacteremia occurred in 87% of patients with MACE. Moreover, serum concentrations of C-reactive protein were elevated in patients with MACE versus in non-MACE patients (mean [standard deviation], 138 [145] vs 73 [106], P = .01).

CONCLUSIONS

MACE are common during IPD with serotype 3 and 9n independently of frequency.

Association Between Plasma ADAMTS-9 Levels and Severity of Coronary Artery Disease

Genome-wide association studies have shown that a disintegrin and metalloproteinase with thrombospondin motifs 9 (ADAMTS-9) is associated with the development of atherosclerosis. We assessed the level of ADAMTS-9 in patients with coronary artery disease (CAD) and its severity and prognosis. We selected 666 participants who underwent coronary angiography in our hospital and met the inclusion and exclusion criteria; participants included non-CAD patients, patients with stable angina pectoris (SAP), unstable angina, non-ST-segment elevation myocardial infarction, or ST-segment elevation myocardial infarction. The serum level of ADAMTS-9 was higher in patients with CAD than in non-CAD patients (37.53 ± 8.55 ng/mL vs 12.04 ± 7.02 ng/mL, P < .001) and was an independent predictor for CAD (odds ratio = 1.871, 95% CI: 1.533-2.283, P < .001). Subgroup analysis showed that compared with the SAP group, the acute coronary syndrome groups had higher serum levels of ADAMTS-9. In addition, the level of ADAMTS-9 was related to the SYNTAX score (r = 0.523, P < .001). Patients with acute myocardial infarction (AMI) with elevated levels of ADAMTS-9 had a higher risk of major adverse cardiovascular events (MACE) within 12 months than those with lower levels (log-rank = 4.490, P = .034). Plasma ADAMTS-9 levels may be useful for the diagnosis of CAD and as predictors of MACE in AMI patients.

Comparative Effectiveness of Renin-Angiotensin System Inhibitors and Calcium Channel Blockers in Individuals With Advanced CKD: A Nationwide Observational Cohort Study

RATIONALE & OBJECTIVE

It is unknown whether initiating renin-angiotensin system (RAS) inhibitor therapy in patients with advanced chronic kidney disease (CKD) is superior to alternative antihypertensive agents such as calcium channel blockers (CCBs). We compared the risks for kidney replacement therapy (KRT), mortality, and major adverse cardiovascular events (MACE) in patients with advanced CKD in routine nephrology practice who were initiating either RAS inhibitor or CCB therapy.

STUDY DESIGN

Observational study in the Swedish Renal Registry, 2007 to 2017.

SETTINGS & PARTICIPANTS

2,458 new users of RAS inhibitors and 2,345 CCB users with estimated glomerular filtration rates<30mL/min/1.73m² (CKD G4-G5 without KRT) who were being followed up by a nephrologist. As a positive control cohort, new users of the same drugs with CKD G3 (estimated glomerular filtration rate, 30-60mL/min/1.73m²) were evaluated.

EXPOSURES

RAS inhibitor versus CCB therapy initiation.

OUTCOME

Initiation of KRT (maintenance dialysis or transplantation), all-cause mortality, and MACE (composite of cardiovascular death, myocardial infarction, or stroke).

ANALYTICAL APPROACH

HRs with 95% CIs were estimated using propensity score-weighted Cox proportional hazards regression adjusting for demographic, clinical, and laboratory covariates.

RESULTS

Median age was 74 years, 38% were women, and median follow-up was 4.1 years. After propensity score weighting, there was significantly lower risk for KRT after new use of RAS inhibitors compared with new use of CCBs (adjusted HR, 0.79 [95% CI, 0.69-0.89]) but similar risks for mortality (adjusted HR, 0.97 [95% CI, 0.88-1.07]) and MACE (adjusted HR, 1.00 [95% CI, 0.88-1.15]). Results were consistent across subgroups and in as-treated analyses. The positive control cohort of patients with CKD G3 showed similar KRT risk reduction (adjusted HR, 0.67 [95% CI, 0.56-0.80]) with RAS inhibitor therapy compared with CCBs.

LIMITATIONS

Potential confounding by indication.

CONCLUSIONS

Our findings provide evidence from real-world clinical practice that initiation of RAS inhibitor therapy compared with CCBs may confer kidney benefits among patients with advanced CKD, with similar cardiovascular protection.

Long-Term Effects of Spironolactone on Kidney Function and Hyperkalemia-Associated Hospitalization in Patients with Chronic Kidney Disease

Background: Spironolactone, a non-selective mineralocorticoid receptor antagonist, can protect against cardiac fibrosis and left ventricular dysfunction, and improve endothelial dysfunction and proteinuria. However, the safety and effects of spironolactone on patient-centered cardiovascular and renal endpoints remain unclear. Methods: We identified predialysis stage 3–4 chronic kidney disease (CKD) patients between 2000 and 2013 from the Longitudinal Health Insurance Database 2005 (LHID 2005). The outcomes of interest were end-stage renal disease (ESRD), major adverse cardiovascular events (MACE), hospitalization for heart failure (HHF), hyperkalemia-associated hospitalization (HKAH), all-cause mortality and cardiovascular mortality. The Fine and Gray sub-distribution hazards approach was adopted to adjust for the competing risk of death. Results: After the propensity score matching, 693 patients with stage 3–4 CKD were spironolactone users and 1386 were nonusers. During the follow-up period, spironolactone users had a lower incidence rate for ESRD than spironolactone non-users (39.2 vs. 53.69 per 1000 person-years) and a higher incidence rate for HKAH (54.79 vs. 18.57 per 1000 person-years). The adjusted hazard ratios for ESRD of spironolactone users versus non-users were 0.66 (95% CI, 0.51–0.84; p value < 0.001) and 3.17 (95% CI, 2.41–4.17; p value < 0.001) for HKAH. A dose-response relationship was found between spironolactone use and risk of ESRD and HKAH. There were no statistical differences in MACE, HHF, all-cause mortality and cardiovascular mortality between spironolactone users and non-users. Conclusion: Spironolactone represented a promising treatment option to retard CKD progression to ESRD amongst stage 3–4 CKD patients, but strategic treatments to prevent hyperkalemia should be enforced.

Statin therapy for preventing cardiovascular diseases in patients treated with tacrolimus after kidney transplantation

Background

Lipid abnormalities are prevalent in tacrolimus-treated patients. The aim of the study was to evaluate the preventive effects of statin therapy on major adverse cardiovascular events (MACE) in patients treated with tacrolimus-based immunosuppression after kidney transplantation (KT), and to identify the risk factors.

Methods

This observational cohort study included adult patients who underwent KT and were treated with tacrolimus. Patients who received any lipid-lowering agents except statins, or had a history of immunosuppressant use before transplantation were excluded. The primary outcome was the adjusted risk of the first occurrence of MACE. The secondary outcomes included the risk of individual cardiovascular disease (CVD) and changes in cholesterol level. Subgroup analyses were performed in the statin-user group according to the dosage and/or type of statin.

Results

Compared with the control group (n=73), the statin-users (n=92) had a significantly reduced risk of MACE (adjusted HR, 0.31; 95% CI, 0.13–0.74). In the Cox regression analysis, old age, history of CVD, and comorbid hypertension were identified as independent factors associated with increased MACE. The total cholesterol levels were not significantly different between the two groups. Subjects with higher cumulative defined daily dose of statins had significantly lower risks of MACE.

Conclusion

Statin therapy in patients treated with tacrolimus after KT significantly lowered the risk of MACE. Long-term statin therapy is clearly indicated in older kidney transplant recipients for secondary prevention.