Body-Weight Fluctuations and Outcomes in Coronary Disease Bangalore, Sripal; Fayyad, Rana; Laskey, Rachel ...
New England journal of medicine/The New England journal of medicine,
04/2017, Letnik:
376, Številka:
14
Journal Article
Recenzirano
Odprti dostop
This secondary analysis of findings from a trial that assessed the effect of low-density lipoprotein cholesterol levels in patients with coronary artery disease shows that body-weight fluctuation was ...associated with an increased risk of death and cardiovascular events.
Obesity is an independent risk factor for cardiovascular death and disease.
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Among participants in the Framingham Heart Study who were between 35 and 75 years of age and were followed for up to 44 years, overweight and obese participants were at a higher risk for the development of cardiovascular disease than participants of normal weight.
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Weight gain is strongly associated with an increased risk of death and disease among participants without evident cardiovascular disease at baseline.
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,
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Indeed, in obese persons, bariatric surgery followed by weight loss reduces the risk of cardiovascular disease, including hypertension, hypercholesterolemia, and diabetes.
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– . . .
Abstract Background The 2014 Eighth Joint National Committee panel recommended a therapeutic target of systolic blood pressure (BP) <150 mm Hg in patients ≥60 years of age, a departure from prior ...recommendation of <140 mm Hg. Objectives This study assessed the efficacy and safety of intensive BP-lowering strategies in older (age ≥65 years) hypertensive patients. Methods The MEDLINE, Scopus, EMBASE, and Cochrane databases were searched for all relevant randomized controlled trials from 1965 through July 1, 2016. Cardiovascular (major adverse cardiovascular events MACE, cardiovascular mortality, stroke, myocardial infarction, and heart failure), and safety (serious adverse events and renal failure) were evaluated. Random and fixed effects analysis were used to calculate pooled relative risks (RRs) and 95% confidence intervals (CIs). Results We identified 4 high-quality trials involving 10,857 older hypertensive patients with a mean follow-up of 3.1 years. Intensive BP lowering was associated with a 29% reduction in MACE (RR: 0.71; 95% CI: 0.60 to 0.84), 33% in cardiovascular mortality (RR: 0.67; 95% CI: 0.45 to 0.98), and 37% in heart failure (RR: 0.63; 95% CI: 0.43 to 0.99) compared with standard BP lowering. Rates of myocardial infarction and stroke did not differ between the 2 groups. There was no significant difference in the incidence of serious adverse events (RR: 1.02; 95% CI: 0.94 to 1.09) or renal failure (RR: 1.81; 95% CI: 0.86 to 3.80) between the 2 groups. The fixed effects model yielded largely similar results, except for an increase in the risk of renal failure (RR: 2.03; 95% CI: 1.30 to 3.18) with intensive BP-lowering therapy. Conclusions In older hypertensive patients, intensive BP control (systolic BP <140 mm Hg) decreased MACE, including cardiovascular mortality and heart failure. Data on adverse events were limited, but suggested an increased risk of renal failure. When considering intensive BP control, clinicians should carefully weigh benefits against potential risks.
In a registry study involving 9223 matched pairs of patients, outcomes after PCI with everolimus-eluting stents or CABG were compared. There was no difference in the risk of death, but PCI was ...associated with higher risks of MI and repeat revascularization and lower risk of stroke.
Coronary-artery bypass grafting (CABG) and percutaneous coronary intervention (PCI) are treatment options for patients with multivessel coronary artery disease. Prior studies have shown a mortality benefit of CABG, as compared with PCI.
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However, these studies compared CABG with balloon angioplasty, bare-metal stents, or first-generation drug-eluting stents. Second-generation drug-eluting stents have thinner struts and have thinner and more biocompatible polymer with more uniform polymer coating of the strut surface, resulting in less inflammation and thrombogenicity, as compared with the first-generation drug-eluting stents and even bare-metal stents.
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Consequently, the newer-generation drug-eluting stents, especially the everolimus-eluting stent, have been shown to reduce . . .
Abstract Background Studies demonstrate that lowering low-density lipoprotein cholesterol (LDL-C) using a statin is associated with significant reduction in cardiovascular events. Whether ...visit-to-visit variability in LDL-C levels affects cardiovascular outcomes is unknown. Objectives This study sought to evaluate the role of visit-to-visit variability in LDL-C levels on cardiovascular outcomes. Methods We evaluated patients with coronary artery disease and LDL-C <130 mg/dl enrolled in the TNT (Treating to New Targets) trial, randomly assigned to receive atorvastatin 80 mg/day versus 10 mg/day and with at least one post-baseline measurement of LDL-C. Visit-to-visit LDL-C variability was evaluated from 3 months into random assignment through the use of various measurements of LDL-C variability: SD, average successive variability (ASV), coefficient of variation, and variation independent of mean, with the first 2 measurements used as the primary measurements. Primary outcome was any coronary event, and secondary outcomes were any cardiovascular event, death, myocardial infarction, or stroke. Results Among 9,572 patients, SD and ASV were significantly lower with atorvastatin 80 mg/day versus 10 mg/day (SD: 12.03 ± 9.70 vs. 12.52 ± 7.43; p = 0.005; ASV: 12.84 ± 10.48 vs. 13.76 ± 8.69; p < 0.0001). In the adjusted model, each 1-SD increase in LDL-C variability (by ASV) increased the risk of any coronary event by 16% (hazard ratio HR: 1.16; 95% confidence interval CI: 1.10 to 1.23; p < 0.0001), any cardiovascular event by 11% (HR: 1.11; 95% CI: 1.07 to 1.15; p < 0.0001), death by 23% (HR: 1.23; 95% CI: 1.14 to 1.34; p < 0.0001), myocardial infarction by 10% (HR: 1.10; 95% CI: 1.02 to 1.19; p = 0.02), and stroke by 17% (HR: 1.17; 95% CI: 1.04 to 1.31; p = 0.01), independent of treatment effect and achieved LDL-C levels. Results were largely consistent when adjusted for medication adherence. Conclusions In subjects with coronary artery disease, visit-to-visit LDL-C variability is an independent predictor of cardiovascular events.
Abstract Background The optimal blood pressure (BP) target has been a matter of debate. The recent SPRINT trial showed significant benefits of a BP target of <120 mm Hg albeit with an increase in ...serious adverse effects related to low BP. Methods PUBMED, EMBASE, and CENTRAL were searched for randomized trials comparing treating to different BP targets. Trial arms were grouped into five systolic BP target categories: 1) <160 mm Hg; 2) <150 mm Hg; 3) <140 mm Hg; 4) <130 mm Hg and 5) <120 mm Hg. Efficacy outcomes of stroke, myocardial infarction, death, cardiovascular death, heart failure and safety outcomes of serious adverse effects were evaluated using a network meta-analysis. Results Seventeen trials that enrolled 55,163 patients with 204,103 patient-years of follow-up were included. There was a significant decrease in stroke (RR=0.54; 95% CI 0.29-1.00) and myocardial infarction (RR=0.68; 95% CI 0.47-1.00) with systolic BP <120 mm Hg (vs. <160 mm Hg). Sensitivity analysis using achieved systolic BP showed a 72%, 97% and 227% increase in stroke with systolic BP of <140 mm Hg, <150 mm Hg and <160 mm respectively, when compared with systolic BP <120 mm Hg. There was no difference in death, cardiovascular death or heart failure when comparing any of the BP targets. However, the point estimate favored lower BP targets (<120 mm Hg, <130 mm Hg) when compared with higher BP targets (<140 mm Hg or <150 mm Hg). BP targets of <120 mm Hg and <130 mm Hg ranked #1 and #2 respectively, as the most efficacious target. There was a significant increase in serious adverse effects with systolic BP <120 mm Hg vs. <150 mm Hg (RR=1.83; 95% CI 1.05-3.20) or vs. <140 mm Hg (RR=2.12; 95% CI 1.46-3.08). BP targets of <140 mm Hg and <150 mm Hg ranked #1 and #2 respectively, as the safest target for the outcome of serious adverse effects. Cluster plots for combined efficacy and safety showed that a systolic BP target of <130 mm Hg had optimal balance between efficacy and safety. Conclusions In patients with hypertension, a systolic BP target of <130 mm Hg achieved optimal balance between efficacy and safety.
...the 2014 American College of Cardiology/American Heart Association guidelines (3) and the 2014 European Society of Cardiology/European Association for Cardio-Thoracic Surgery guidelines recommend ...CABG over PCI in patients with diabetes and multivessel disease (Class I) (4). The ISCHEMIA-CKD (ISCHEMIA-Chronic Kidney Disease) trial (NCT01985360), a parallel trial designed to test the same 2 treatment strategies in patients with chronic kidney disease (estimated glomerular filtration rate <30 ml/min/1.73 m2 or receiving dialysis) and ischemia, a large proportion of whom will have diabetes, will also provide important insights about treatment options in this important patient population. ...the results of these clinical trials are available, the choice between the 3 therapies should be on the basis of the pros and cons of each approach, ability to achieve complete revascularization with PCI, and patient preference.
Ever since Schlaich et al.
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first reported on a patient with a blood pressure of 161/107 mm Hg (despite treatment with seven different antihypertensive drugs) that decreased to 127/81 mm Hg after ...renal denervation, the medical community has been enamored with this procedure. Resistant hypertension evolved into a fashionable diagnosis, and the number of publications pertaining to it grew rapidly.
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Medical-device companies fancied renal denervation as the next big innovation and as a blockbuster therapy for millions of patients. A press release from the American Heart Association even touted renal denervation as a potential “cure” for mild hypertension.
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Trials such . . .
Objective To evaluate the outcomes with use of renin angiotensin system (RAS) blockers compared with other antihypertensive agents in people with diabetes.Design Meta-analysis.Data sources and study ...selection PubMed, Embase, and the Cochrane central register of controlled trials databases for randomized trials of RAS blockers versus other antihypertensive agents in people with diabetes mellitus. Outcomes were death, cardiovascular death, myocardial infarction, angina, stroke, heart failure, revascularization, and end stage renal disease.Results The search yielded 19 randomized controlled trials that enrolled 25 414 participants with diabetes for a total of 95 910 patient years of follow-up. When compared with other antihypertensive agents, RAS blockers were associated with a similar risk of death (relative risk 0.99, 95% confidence interval 0.93 to 1.05), cardiovascular death (1.02, 0.83 to 1.24), myocardial infarction (0.87, 0.64 to 1.18), angina pectoris (0.80, 0.58 to 1.11), stroke (1.04, 0.92 to 1.17), heart failure (0.90, 0.76 to 1.07), and revascularization (0.97, 0.77 to 1.22). There was also no difference in the hard renal outcome of end stage renal disease (0.99, 0.78 to 1.28) (power of 94% to show a 23% reduction in end stage renal disease).Conclusions In people with diabetes, RAS blockers are not superior to other antihypertensive drug classes such as thiazides, calcium channel blockers, and β blockers at reducing the risk of hard cardiovascular and renal endpoints. These findings support the recommendations of the guidelines of the European Society of Cardiology/European Society of Hypertension and eighth Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure to also use other antihypertensive agents in people with diabetes but without kidney disease.
Abstract Background Compliance with treatment is a sine qua non for successful treatment of chronic conditions like hypertension. Fixed-dose combinations are designed to simplify the medication ...regimen and potentially improve compliance. However the data on comparison of fixed-dose combination with free-drug regimen to improve patient’s medication compliance is limited. Methods We conducted a MEDLINE search of studies using the words fixed-dose combinations, compliance and/or adherence. The inclusion criteria were studies which involved fixed-dose combination versus free-drug components of the regimen given separately. Only studies which reported patient’s compliance were included. Results Of the 68 studies on fixed-dose combinations, only 9 studies fulfilled the inclusion criteria. Two studies were in patients with tuberculosis, 4 in the hypertensive population, 1 in patients with human immunodeficiency virus (HIV) disease and 2 in the diabetic population. A total of 11,925 patients on fixed-dose combination were compared against 8317 patients on free-drug component regimen. Fixed-dose combination resulted in a 26% decrease in the risk of non-compliance compared with free-drug component regimen (pooled relative risk RR 0.74; 95% confidence interval CI, 0.69-0.80; P <.0001). There was no evidence of heterogeneity in this analysis (χ2 = 14.49, df = 8; P = .07). A subgroup analysis of the 4 studies on hypertension showed that fixed-dose combination (pooled RR 0.76; 95% CI, 0.71-0.81; P <.0001) decreased the risk of medication non-compliance by 24% compared with free-drug combination regimen. Conclusions Fixed-dose combination decreases the risk of medication non-compliance and should be considered in patients with chronic conditions like hypertension for improving medication compliance which can translate into better clinical outcomes.
Abstract Objectives The authors sought to perform a meta-analysis of randomized clinical trials (RCTs) comparing the safety and efficacy of biodegradable polymer drug-eluting stents (BP-DES) to ...second-generation durable polymer drug-eluting stents (DP-DES). Background Prior meta-analyses have established the superiority of BP-DES over bare-metal stents and first-generation DP-DES; however, their advantage compared with second-generation DP-DES remains controversial. Methods The authors searched PubMed and Scopus databases for RCTs comparing BP-DES to the second-generation DP-DES. Outcomes included target vessel revascularization (TVR) as efficacy outcome and cardiac death, myocardial infarction (MI), and definite or probable stent thrombosis (ST) as safety outcomes. In addition, we performed landmark analysis for endpoints beyond 1 year of follow-up and a subgroup analysis based on the stent characteristics. Results The authors included 16 RCTs comprising 19,886 patients in the meta-analysis. At the longest available follow-up (mean duration 26 months), we observed no significant differences in TVR (p = 0.62), cardiac death (p = 0.46), MI (p = 0.98), or ST (risk ratio: 0.83, 95% confidence interval: 0.64 to 1.09; p = 0.19). Our landmark analysis showed that BP-DES were not associated with a reduction in the risk of very late ST (risk ratio: 0.87, 95% confidence interval: 0.49 to 1.53; p = 0.62). Similar outcomes were seen regardless of the eluting drug (biolimus vs. sirolimus), the stent platform (stainless steel vs. alloy), the kinetics of polymer degradation or drug release (<6 months vs. >6 months), the strut thickness of the BP-DES (thin <100 μm vs. thick >100 μm), or the DAPT duration (≥6 months vs. ≥12 months). Conclusions BP-DES have similar safety and efficacy profiles to second-generation DP-DES.
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