Background Whether the use of sevelamer rather than a calcium-containing phosphate binder improves cardiovascular (CV) survival in patients receiving dialysis remains to be elucidated. Study Design ...Open-label randomized controlled trial with parallel groups. Settings & Participants 466 incident hemodialysis patients recruited from 18 centers in Italy. Intervention Study participants were randomly assigned in a 1:1 fashion to receive either sevelamer or a calcium-containing phosphate binder (although not required by the protocol, all patients in this group received calcium carbonate) for 24 months. Outcomes All individuals were followed up until completion of 36 months of follow-up or censoring. CV death due to cardiac arrhythmias was regarded as the primary end point. Measurements Blind event adjudication. Results At baseline, patients allocated to sevelamer had higher serum phosphorus (mean, 5.6 ± 1.7 SD vs 4.8 ± 1.4 mg/dL) and C-reactive protein levels (mean, 8.8 ± 13.4 vs 5.9 ± 6.8 mg/dL) and lower coronary artery calcification scores (median, 19 IQR, 0-30 vs 30 IQR, 7-180). At study completion, serum phosphate levels were lower in the sevelamer arm (median dosages, 4,800 and 2,000 mg/d for sevelamer and calcium carbonate, respectively). After a mean follow-up of 28 ± 10 months, 128 deaths were recorded (29 and 88 due to cardiac arrhythmias and all-cause CV death). Sevelamer-treated patients experienced lower CV mortality due to cardiac arrhythmias compared with patients treated with calcium carbonate (HR, 0.06; 95% CI, 0.01-0.25; P < 0.001). Similar results were noted for all-cause CV mortality and all-cause mortality, but not for non-CV mortality. Adjustments for potential confounders did not affect results. Limitations Open-label design, higher baseline coronary artery calcification burden in calcium carbonate–treated patients, different mineral metabolism control in sevelamer-treated patients, overall lower than expected mortality. Conclusions These results show that sevelamer compared to a calcium-containing phosphate binder improves survival in a cohort of incident hemodialysis patients. However, the better outcomes in the sevelamer group may be due to better phosphate control rather than reduction in calcium load.
Patients with acute or chronic decompensated heart failure (ADHF) present with various degrees of heart and kidney dysfunction characterizing cardiorenal syndrome (CRS). CRS can be generally defined ...as a pathophysiologic disorder of the heart and kidneys whereby acute or chronic dysfunction of 1 organ may induce acute or chronic dysfunction of the other. ADHF is a challenge in the management of heart failure. This review provides an overview the pathophysiology of type 1 CRS together with new approaches to treatment in patients with heart failure with worsening renal function or acute kidney disease.
Women with coronary heart disease (CHD) have higher mortality compared with men. Atherosclerotic imaging risk markers are associated with higher mortality and relative risk of CHD events in women ...compared with men. However, data on the predictive accuracy of coronary artery calcium (CAC) in women are scarce. We performed a systematic review of the published literature from 2003 to 2006 on the prognostic value of CAC in women and men. Two investigators reviewed Medline for prospective registries on annual rates of CHD death or myocardial infarction (MI) by CAC results. Three studies in 6,481 women and 13,697 men reported results by gender. We also analyzed 2 observational registries for annual all-cause death rates by CAC scores in women (n = 17,779) and men (n = 17,850). Summary relative risk ratios and 95% confidence intervals were calculated using a random effects model. For all-cause mortality, rates were 0.1% to 1.6% per year for women and 0.1% to 2.6% for men with CAC scores from 0 to 10 to ≥1,000, respectively (p <0.0001). For CHD death or MI, annual rates were 0.2% to 1.3% in women and 0.3% to 2.4% for men with low- to high-risk CAC scores. For women with a CAC score of 0, annual CHD death or MI rates were 0.16%, similar to that of men (p = 0.55). Summary relative risk ratios increased 4.9-fold (p = 0.006), 5.5-fold (p = 0.002), and 8.7-fold (p <0.0001) for mild-, moderate-, and high-risk CAC scores, respectively. A comparative analysis of gender differences showed no significant differences between women and men for mild- to high-risk CAC scores (p = 0.66), suggesting an equivalent ability to risk stratify by gender. In conclusion, this meta- and pooled analysis revealed that CAC screening is equally accurate in stratifying risk in women and men.
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GEOZS, IJS, IMTLJ, KILJ, KISLJ, NUK, OILJ, PNG, SAZU, SBCE, SBJE, UL, UM, UPCLJ, UPUK
Age and chronic kidney disease are major risk factors for poor cardiovascular outcome; however, renal function is often estimated on the basis of serum creatinine levels, and advanced renal ...impairment may be hidden behind near normal creatinine levels. We assessed the impact of estimated glomerular filtration rate (GFR) on in-hospital mortality in young (<65 years old), old (65 to 84 years old), and very old (≥85 years old) patients undergoing percutaneous coronary intervention (PCI) for acute myocardial infarction. The adjusted risk of death was calculated in 169,826 patients from the American College of Cardiology National Cardiovascular Data Registry undergoing primary PCI for acute myocardial infarction. Younger patients had fewer co-morbidities, higher estimated GFR, less frequent multivessel disease, and lower unadjusted mortality rates than older patients (p <0.0001 for all comparisons). However, the adjusted risk of in-hospital mortality for patients with severe renal insufficiency (estimated GFR <30 ml/min/1.73 m2 ) compared with those with normal renal function (estimated GFR ≥60 ml/min/1.73 m2 ) was higher in young patients (adjusted odds ratio = 7.58, 95% confidence interval 6.18 to 9.29) than old (adjusted odds ratio = 4.75, 95% confidence interval 4.14 to 5.45) and very old patients (adjusted odds ratio = 3.50, confidence interval 2.50 to 4.89). In conclusion, severe renal insufficiency is associated with a greater risk of in-hospital mortality in young than old and very old patients after primary PCI. Risk stratification for patients with acute myocardial infarction should incorporate an assessment of renal function with estimated GFR values rather than absolute serum creatinine levels as done in the currently utilized risk scoring algorithms.
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GEOZS, IJS, IMTLJ, KILJ, KISLJ, NUK, OILJ, PNG, SAZU, SBCE, SBJE, UL, UM, UPCLJ, UPUK
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The Importance of Ventricular-Vascular Uncoupling Raggi, Paolo, MD; Bellasi, Antonio, MD
JACC. Heart failure,
2015, January 2015, 2015-Jan, 2015-01-00, 20150101, Volume:
3, Issue:
1
Journal Article
Peer reviewed
Open access
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GEOZS, IJS, IMTLJ, KILJ, KISLJ, NLZOH, NUK, OILJ, PNG, SAZU, SBCE, SBJE, UILJ, UL, UM, UPCLJ, UPUK, ZAGLJ, ZRSKP
Background Chronic kidney disease (CKD) is a predictor of morbidity and mortality in patients undergoing percutaneous coronary interventions (PCIs), and African American (AA) patients have been ...reported to have worse outcomes after PCI. Methods We assessed whether CKD affects the rate of death and major adverse cardiovascular events (MACE = myocardial infarction, revascularization, and death) differently in AA and white (CC) patients 1 year after PCI. Accordingly, we reviewed the database of all patients referred for PCI in the Emory Healthcare System between January 2001 and December 2004. Results We identified 800 CC and 116 AA patients with CKD among 4,372 patients referred for PCI. Chronic kidney disease was defined as an estimated glomerular filtration rate (eGFR) <60 mL/(min 1.73 m2 ) calculated by means of the Cockcroft-Gault equation. The AA patients with CKD were younger and had a larger number of comorbidities than the CC subjects. However, neither mortality nor MACE differed between races (14.7% vs 13.1%, P = .65 and 31.9% vs 31.3%, P = .89, respectively). In multivariable models, eGFR and emergency PCI were the best predictors of any adverse event, whereas prior PCI or coronary artery bypass surgery was a predictor of MACE alone. A test for interaction failed to show a significant effect of race and CKD on outcome. Conclusions In a tertiary referral center, AA and CC patients with CKD had a similar mortality rate and MACE at 1 year after PCI. Race was not a determinant of outcome, whereas CKD was.
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GEOZS, IJS, IMTLJ, KILJ, KISLJ, NUK, OILJ, PNG, SAZU, SBCE, SBJE, UL, UM, UPCLJ, UPUK
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