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1.
Chiara Melloni Allison Dunning Christopher B. Granger Laine Thomas Michel G. Khouri David A. Garcia Elaine M. Hylek Michael Hanna Lars Wallentin Bernard J. Gersh Pamela S. Douglas John H. Alexander Renato D. Lopes 《The American journal of medicine》2017,130(12):1440-1448.e1
Background
Cancer is associated with a prothrombotic state and increases the risk of thrombotic events in patients with atrial fibrillation. We described the clinical characteristics and outcomes and assessed the safety and efficacy of apixaban versus warfarin in patients with atrial fibrillation and cancer in the Apixaban for Reduction in Stroke and Other Thromboembolic Events in Atrial Fibrillation (ARISTOTLE) trial.Methods
The association between cancer and clinical outcomes was assessed using Cox regression models. At baseline, 1236 patients (6.8%) had a history of cancer; 12.7% had active cancer, and 87.3% had remote cancer.Results
There were no significant associations between history of cancer and stroke/systemic embolism, major bleeding, or death. The effect of apixaban versus warfarin for the prevention of stroke/systemic embolism was consistent among patients with a history of cancer (event/100 patient-years = 1.4 vs 1.2; hazard ratio [HR], 1.09; 95% confidence interval [CI], 0.53-2.26) and no cancer (1.3 vs 1.6; HR, 0.77; 95% CI, 0.64-0.93) (P interaction = .37). The safety and efficacy of apixaban versus warfarin were preserved among patients with and without active cancer. Apixaban was associated with a greater benefit for the composite of stroke/systemic embolism, myocardial infarction, and death in active cancer (HR, 0.30; 95% CI, 0.11-0.83) versus without cancer (HR, 0.86; 95% CI, 0.78-0.95), but not in remote cancer (HR, 1.46; 95% CI, 1.01-2.10) (interaction P = .0028).Conclusions
Cancer was not associated with a higher risk of stroke. The superior efficacy and safety of apixaban versus warfarin were consistent in patients with and without cancer. Our positive findings regarding apixaban use in patients with atrial fibrillation and cancer are exploratory and promising, but warrant further evaluation. 相似文献2.
Mark M. Brodie Jill C. Newman Tyler Smith Don C. Rockey 《The American journal of medicine》2018,131(5):573.e9-573.e15
Background
Direct-acting oral anticoagulants (DOACs), which have gained approval for stroke prevention in nonvalvular atrial fibrillation and treatment of venous thromboembolism, have become increasingly preferred over warfarin given their predictable pharmacodynamics, lack of required monitoring, and superior outcomes. Direct-acting oral anticoagulants have been shown to be associated with an increased frequency of gastrointestinal bleeding compared with warfarin, but the severity and characteristics of gastrointestinal bleeding in these patients is poorly understood.Methods
We retrospectively evaluated electronic medical records of patients with gastrointestinal bleeding (n = 8496) from 2010-2016. We identified 61 patients with gastrointestinal bleeding episodes while treated with DOACs (rivaroxaban, dabigatran, or apixaban) and 123 patients with gastrointestinal bleeding while taking warfarin. We randomly selected a control group of 296 patients with gastrointestinal bleeding who were not receiving anticoagulation treatment from the same sample. Outcomes included the need for hospitalization, blood transfusion, endoscopic or surgical intervention, and 30-day mortality.Results
The DOAC and warfarin groups were similar in terms of age and underlying comorbidity (assessed using the Charlson Comorbidity Index), but the DOAC group had greater concomitant aspirin use. Gastrointestinal bleeding was classified as upper (n = 186), lower (n = 88), anorectal (n = 183), small bowel (n = 9), and indeterminate (n = 14). After adjusting for differences in baseline variables, the DOAC group had fewer hospitalizations and required fewer transfusions than the warfarin group. The DOAC and control groups were not statistically different for all outcomes. There were no significant mortality differences among groups.Conclusion
Although prior studies have shown a higher frequency of gastrointestinal bleeding in patients treated with DOACs compared with warfarin, our data suggest that gastrointestinal bleeding in patients taking DOACs may be less severe. These differences occurred despite significantly greater concomitant aspirin use in the DOAC group compared with warfarin users. 相似文献3.
Craig I. Coleman Alexander G.G. Turpie Thomas J. Bunz Jan Beyer-Westendorf 《The American journal of medicine》2018,131(8):933-938.e1
Purpose
Frailty predicts poorer outcomes in patients receiving anticoagulation. We assessed the effectiveness and safety of rivaroxaban vs warfarin in frail patients experiencing venous thromboembolism.Methods
Using US MarketScan claims data from January 2012-December 2016, we identified frail patients (using the Johns Hopkins Claims-Based Frailty Indicator score) who had ≥1 primary hospitalization/emergency department visit diagnosis codes for venous thromboembolism, received rivaroxaban or warfarin as their first outpatient oral anticoagulant within 30 days of the index event, and had ≥12 months of insurance prior to the index venous thromboembolism. Differences in baseline covariates between cohorts were adjusted using inverse probability of treatment weights based on propensity scores. The primary endpoint was the composite of recurrent venous thromboembolism or major bleeding. Patient claims were tracked for up to 12 months after the index venous thromboembolism or until endpoint occurrence oral anticoagulant discontinuation/switch, insurance disenrollment, or end of follow-up. Cox regression was used to calculate hazard ratios (HRs) with 95% confidence intervals (CIs).Results
Of 58,089 incident venous thromboembolism patients identified, 6869 (1365 rivaroxaban and 5504 warfarin users) were classified as frail. Rivaroxaban reduced patients' hazard of the composite of recurrent venous thromboembolism or major bleeding (HR 0.75; 95% CI, 0.57-0.98) and recurrent venous thromboembolism alone (HR 0.65; 95% CI, 0.44-0.97) compared with warfarin. No significant difference in major bleeding was observed between cohorts (HR 0.88; 95% CI, 0.61-1.27).Conclusions
Frail patients experiencing a venous thromboembolism and given rivaroxaban experience less recurrent venous thromboembolism, with at least as good bleeding outcomes, as patients prescribed warfarin. 相似文献4.
Patrícia O. Guimarães Renato D. Lopes Daniel M. Wojdyla Azmil H. Abdul-Rahim Stuart J. Connolly Greg C. Flaker Junyuan Wang Michael Hanna Christopher B. Granger Lars Wallentin Kennedy R. Lees John H. Alexander John J.V. McMurray 《Cardiovascular drugs and therapy / sponsored by the International Society of Cardiovascular Pharmacotherapy》2017,31(3):295-301
Purpose
Vitamin K antagonists (VKAs) are the standard of care for stroke prevention in patients with atrial fibrillation (AF); therefore, there is not equipoise when comparing newer oral anticoagulants with placebo in this setting.Methods
To explore the effect of apixaban on mortality in patients with AF, we performed a meta-analysis of apixaban versus placebo using a putative placebo analysis based on randomized controlled clinical trials that compared warfarin, aspirin, and no antithrombotic control. We used data from two prospective randomized controlled trials for our comparison of apixaban versus warfarin (Apixaban for Reduction in Stroke and Other Thromboembolic Events in Atrial Fibrillation) and apixaban versus aspirin (Apixaban Versus Acetylsalicylic Acid to Prevent Stroke in Atrial Fibrillation Patients Who Have Failed or Are Unsuitable for Vitamin K Antagonist Treatment). Using meta-analysis approaches, we indirectly compared apixaban with an imputed placebo with respect to the risk of death in patients with AF. We used results from meta-analyses of randomized trials as our reference for the comparison between warfarin and placebo/no treatment, and aspirin and placebo/no treatment.Results
In these meta-analyses, a lower rate of death was seen both with warfarin (odds ratio [OR] 0.74, 95% confidence interval [CI] 0.57–0.97) and aspirin (OR 0.86, 95% CI 0.69–1.07) versus placebo/no treatment. Using data from ARISTOTLE and AVERROES, apixaban reduced the risk of death by 34% (95% CI 12–50%; p = 0.004) and 33% (95% CI 6–52%; p = 0.02), respectively, when compared with an imputed placebo. The pooled reduction in all-cause death with apixaban compared with an imputed placebo was 34% (95% CI 18–47%; p = 0.0002).Conclusions
In patients with AF, indirect comparisons suggest that apixaban reduces all-cause death by approximately one third compared with an imputed placebo.5.
Maria Cecilia Bahit Renato D. Lopes Daniel M. Wojdyla Stefan H. Hohnloser John H. Alexander Basil S. Lewis Philip E. Aylward Freek W.A. Verheugt Matyas Keltai Rafael Diaz Michael Hanna Christopher B. Granger Lars Wallentin 《International journal of cardiology》2013
Background
A substantial portion of patients with atrial fibrillation (AF) also have coronary artery disease (CAD) and are at risk for coronary events. Warfarin is known to reduce these events, but increase the risk of bleeding. We assessed the effects of apixaban compared with warfarin in AF patients with and without prior CAD.Methods and results
In ARISTOTLE, 18,201 patients with AF were randomized to apixaban or warfarin. History of CAD was defined as documented CAD, prior myocardial infarction, and/or history of coronary revascularization. We analyzed baseline characteristics and clinical outcomes of patients with and without prior CAD and compared outcomes by randomized treatment using Cox models. A total of 6639 (36.5%) patients had prior CAD. These patients were more often male, more likely to have prior stroke, diabetes, and hypertension, and more often received aspirin at baseline (42.2% vs. 24.5%). The effects of apixaban were similar among patients with and without prior CAD on reducing stroke or systemic embolism and death from any cause (hazard ratio [HR] 0.95, 95% confidence interval [CI] 0.71–1.27, P for interaction = 0.12; HR 0.96, 95% CI 0.81–1.13, P for interaction = 0.28). Rates of myocardial infarction were numerically lower with apixaban than warfarin among patients with and without prior CAD. The effect of apixaban on reducing major bleeding and intracranial hemorrhage was consistent in patients with and without CAD.Conclusions
In patients with AF, apixaban more often prevented stroke or systemic embolism and death and caused less bleeding than warfarin, regardless of the presence of prior CAD. Given the common occurrence of AF and CAD and the higher rates of cardiovascular events and death, our results indicate that apixaban may be a better treatment option than warfarin for these high-risk patients. 相似文献6.
Yutao Guo Hang Zhu Yundai Chen Gregory Y.H. Lip 《The American journal of medicine》2018,131(2):185-192
Background
There is uncertainty whether a focus on modifiable bleeding risk factors offers better prediction of major bleeding than other existing bleeding risk scores.Methods
This study compared a score based on numbers of the modifiable bleeding risk factors recommended in the 2016 European guidelines (“European risk score”) versus other published bleeding risk scores that have been derived and validated in atrial fibrillation subjects (HEMORR2HAGES, HAS-BLED, ATRIA, and ORBIT) in a large hospital-based cohort of Chinese inpatients with atrial fibrillation.Results
The European score had modest predictive ability for major bleeding (c-index 0.63, 95% confidence interval 0.56-0.69) and intracranial hemorrhage (0.72, 0.65-0.79) but nonsignificantly (and poorly) predicted extracranial bleeding (0.55, 0.54-0.56; P = .361). The HAS-BLED score was superior to predict bleeding events compared with the European score, with the differences between c-indexes of 0.10-0.12 (Delong test, all P < .05), net reclassification improvement values of 13.0%-34.5% (all P < .05), and integrated discrimination improvement values of 0.7%-1.4% (all P < .05). The European score had similar predictive value to other bleeding risk schemes (HEMORR2HAGES, ATRIA, and ORBIT) for major bleeding and intracranial hemorrhage (all P > .05). Decision curve analysis clearly shows that HAS-BLED had better net benefit of predicting major bleeding compared with the European score.Conclusions
Relying on bleeding risk assessment using modifiable bleeding risk factors alone is an inferior strategy for predicting atrial fibrillation patients for major bleeding. Our observations reaffirm the Asian guideline recommendations with HAS-BLED for bleeding risk assessment in patients with atrial fibrillation. 相似文献7.
Florentino Lupercio Jorge Romero Bradley Peltzer Carola Maraboto David Briceno Pedro Villablanca Kevin Ferrick Jay N. Gross Soo Kim John Fisher Luigi Di Biase Andrew Krumerman 《The American journal of medicine》2018,131(5):573.e1-573.e8
Background
Direct oral anticoagulants (DOACs) and amiodarone are widely used in the treatment of nonvalvular atrial fibrillation. The DOACs are P-glycoprotein (P-gp) and cytochrome p-450 (CYP3A4) substrates. Direct oral anticoagulant levels may be increased by the concomitant use of potent dual P-gp/CYP3A4 inhibitors, such as amiodarone, which can potentially translate into adverse clinical outcomes. We aimed to assess the efficacy and safety of drug–drug interaction by the concomitant use of DOACs and amiodarone.Methods
We performed a systematic review of MEDLINE, the Cochrane Central Register of Clinical Trials, and Embase, limiting our search to randomized controlled trials of patients with atrial fibrillation that have compared DOACs versus warfarin for prophylaxis of stroke or systemic embolism, to analyze the impact on stroke or systemic embolism, major bleeding, and intracranial bleeding risk in patients with concomitant use of amiodarone. Risk ratio (RR) 95% confidence intervals were measured using the Mantel-Haenszel method. The fixed effects model was used owing to heterogeneity (I2) < 25%.Results
Four trials with a total of 71,683 patients were analyzed, from which 5% of patients (n = 3212) were concomitantly taking DOAC and amiodarone. We found no statistically significant difference for any of the clinical outcomes (stroke or systemic embolism [RR 0.85; 95% CI, 0.67-1.06], major bleeding [RR 0.91; 95% CI, 0.77-1.07], or intracranial bleeding [RR 1.10; 95% CI, 0.68-1.78]) among patients taking DOAC and amiodarone versus DOAC without amiodarone.Conclusion
On the basis of the results of this meta-analysis, co-administration of DOACs and amiodarone, a dual P-gp/CYP3A4 inhibitor, does not seem to affect efficacy or safety outcomes in patients with atrial fibrillation. 相似文献8.
Thiazolidinediones and Risk of Atrial Fibrillation Among Patients with Diabetes and Coronary Disease
Jannik Langtved Pallisgaard Maria Mori Brooks Bernard R. Chaitman Derek B. Boothroyd Marco Perez Mark A. Hlatky 《The American journal of medicine》2018,131(7):805-812
Background
We sought to determine whether insulin-sensitizing therapy (thiazolidinediones or metformin) decreased the risk of developing atrial fibrillation compared with insulin-providing therapy (insulin, sulfonylurea, or a meglitinide). Thiazolidinediones are insulin sensitizers that also decrease the inflammatory response. Because inflammation is a risk factor for atrial fibrillation, we hypothesized that treating diabetes with thiazolidinediones might decrease the risk of developing atrial fibrillation.Methods
The Bypass Angioplasty Revascularization Investigation 2 Diabetes (BARI 2D) trial enrolled patients with type 2 diabetes and documented coronary artery disease. All patients were randomized to insulin-sensitizing therapy or insulin-providing therapy.Results
A total of 2319 patients entered the study, with 1160 assigned to the insulin-sensitization strategy and 1159 assigned to the insulin-provision strategy. Over a median follow-up of 4.2 years, 90 patients (3.9%) developed new-onset atrial fibrillation. In the intention-to-treat analysis, the incidence of atrial fibrillation was 8.7 per 1000 person-years in patients assigned to insulin sensitization compared with 9.5 in patients assigned to insulin provision with a hazard ratio (HR) of 0.91 (95% confidence interval [CI], 0.60-1.38, P = .66). In a time-varying exposure analysis, the incidence rate per 1000 person-years was 7.2 while exposed to thiazolidinediones and 9.7 while not exposed to thiazolidinediones with an adjusted HR of 0.80 (95% CI, 0.33-1.94, P = .62). In a subset of patients matched on propensity to receive a thiazolidinediones, the HR was 0.75 (95% CI, 0.43-1.30, P = .30).Conclusions
We did not find a significant reduction of atrial fibrillation incidence with use of thiazolidinediones. 相似文献9.
Tania T. Von Visger Kristin K. Kuntz Gary S. Phillips Vedat O. Yildiz Namita Sood 《Heart & lung : the journal of critical care》2018,47(2):115-121
Background
Pulmonary arterial hypertension (PAH) has a delay in diagnosis that makes time since diagnosis of interest in this population.Objectives
To assess psychological conditions, perceived stress, QOL, and interpersonal support and to explore whether these factors may correlate with time since diagnosis in patients with PAH.Methods
Participants at an academic medical center (n = 108) completed psychological questionnaires (Cambridge Pulmonary Hypertension Outcome Review, Patient Health Questionnaire-9, Perceived Stress Scale-10, and Interpersonal Support Evaluation List-Short Form).Results
Prevalence of psychiatric disorder, major depression, and “other depressive disorder” were 29.6%, 15.7%, and 9.3%, respectively. Participants reported adequate social support, high perceived stress, and average quality of life. Time since diagnosis was positively associated with greater perceived social support (ρ = 0.174, p = .075) and greater perceived stress (ρ = 0.191, p = .048), but no other psychological factor.Conclusions
Routine psychological assessment and timely referral for mental health services are suggested. Social support may buffer patients from stress. 相似文献10.
Ubolrat Piamjariyakul Noreen C. Thompson Christy Russell Carol E. Smith 《Heart & lung : the journal of critical care》2018,47(3):211-215
Background
African Americans with heart failure (HF) have the highest rates of depression among all ethnicities in the USA.Objectives
To compare the effects by race on depressive symptoms and topics discussed in the first clinic appointment after HF hospitalization.Methods
This study is a secondary analysis of data from a randomized clinical trial testing a patient group discussion of HF self-management with 93 Caucasians and 77 African Americans.Results
Reduction in depressive symptoms was significantly greater among African American patients within the intervention group (F = 3.99, p = .047) than controls. There were significant differences by race in four topics (dietitian referral, appointment date, help preparing discussion questions, and advice on worsening HF symptoms) concerning patient-physician discussions.Conclusion
The intervention showed greater effect in reducing depressive symptoms among African Americans than Caucasians. Preparing patients for discussions at physician appointments on diet, depressive symptoms, and HF symptoms is recommended. 相似文献11.
Jayne Rosenberger Susan McCrudden Carol McCullough Lu Wang Joni Kime Nancy M. Albert 《Heart & lung : the journal of critical care》2018,47(2):100-106
Background
Experts recommend obtaining one-time dual- (inter)-arm blood pressure (BP) measurements to predict cardiovascular morbidity risk.Objectives
To determine differences in inter-arm systolic (S)/diastolic (D) BPs obtained simultaneously and sequentially and examine associations between patient factors and clinical outcomes and inter-arm BP differences.Method
A comparative study of adults treated in intensive care; multivariable logistic models were created to determine the extent that inter-arm BP differences predicted outcomes.Results
Of 427 adults in intensive care units, 31.8% had differences of >10 mmHg on simultaneous measurement and 35.1% had differences of >10 mmHg on sequential measurement; differences >15 mmHg were 17.9% and 19.8%, respectively. After controlling for patient factors, simultaneous inter-arm DBP differences >15 mmHg were associated with shorter hospital and longer intensive care length of stay (p = 0.031 and 0.029, respectively) and a 79% reduction in the likelihood of discharge to home (p = 0.009).Conclusions
Simultaneous inter-arm DBP differences >15 mmHg were associated with clinical outcomes. 相似文献12.
Renato D. Lopes Jan Steffel Manuela Di Fusco Allison Keshishian Xuemei Luo Xiaoyan Li Cristina Masseria Melissa Hamilton Keith Friend Kiran Gupta Jack Mardekian Xianying Pan Onur Baser W. Schuyler Jones 《The American journal of medicine》2018,131(9):1075-1085.e4
Background
Direct oral anticoagulants (DOAC) are at least non-inferior to warfarin in efficacy and safety among patients with nonvalvular atrial fibrillation. Limited evidence is available regarding outcomes for nonvalvular atrial fibrillation patients with coronary/peripheral artery disease.Methods
Non-valvular atrial fibrillation patients aged ≥65 years diagnosed with coronary/peripheral artery disease in the US Medicare population, newly initiating DOACs (apixaban, rivaroxaban, dabigatran) or warfarin were selected from January 1, 2013 to September 30, 2015. Propensity score matching was used to compare DOACs vs warfarin. Cox proportional hazards models were used to estimate the risk of stroke/systemic embolism, major bleeding, and composite of stroke/myocardial infarction/all-cause mortality.Results
There were 15,527 apixaban-warfarin, 6,962 dabigatran-warfarin, and 25,903 rivaroxaban-warfarin–matched pairs, with a mean follow-up of 5-6 months. Compared with warfarin, apixaban was associated with lower rates of stroke/systemic embolism (hazard ratio [HR] 0.48; 95% confidence interval [CI], 0.37-0.62), major bleeding (HR 0.66; 95% CI, 0.58-0.75), and stroke/myocardial infarction/all-cause mortality (HR 0.63; 95% CI, 0.58-0.69); dabigatran and rivaroxaban were associated with lower rates of stroke/myocardial infarction/all-cause mortality (HR 0.79; 95% CI, 0.70-0.90 and HR 0.87; 95% CI, 0.81-0.92, respectively). Rivaroxaban was associated with a lower rate of stroke/systemic embolism (HR 0.72; 95% CI, 0.60-0.89) and a higher rate of major bleeding (HR 1.14; 95% CI, 1.05-1.23) vs warfarin.Conclusions
All DOACs were associated with lower stroke/myocardial infarction/all-cause mortality rates compared with warfarin; differences were observed in rates of stroke/systemic embolism and major bleeding. Findings from this observational analysis provide important insights about oral anticoagulation therapy among non-valvular atrial fibrillation patients with coronary/peripheral artery disease and may help physicians in the decision-making process when treating this high-risk group of patients. 相似文献13.
Quin E. Denfeld James O. Mudd Wohaib Hasan Jill M. Gelow Shirin O. Hiatt Kerri Winters-Stone Christopher S. Lee 《Heart & lung : the journal of critical care》2018,47(4):281-284
Background
The relationship between physical heart failure (HF) symptoms and pathophysiological mechanisms is unclear.Objective
To quantify the relationship between plasma β-adrenergic receptor kinase-1 (βARK1) and physical symptoms among adults with HF.Methods
We performed a secondary analysis of data collected from two studies of adults with HF. Plasma βARK1 was quantified using an enzyme-linked immunosorbent assay. Physical symptoms were measured with the HF Somatic Perception Scale (HFSPS). Generalized linear modeling was used to quantify the relationship between βARK1 and HFSPS scores.Results
The average age (n = 94) was 54.5 ± 13.1 years, 76.6% were male, and a majority (83.0%) had Class III or IV HF. βARK1 was significantly associated with HFSPS scores (β = 0.22 ± 0.10, p = 0.038), adjusting for other predictors of physical symptoms (model R2 = 0.250, F(7, 70) = 3.34, p = 0.004).Conclusions
Higher βARK1 is associated with worse physical HF symptoms, pinpointing a potential pathophysiologic underpinning. 相似文献14.
Candace Wu Avinainder Singh Bradley Collins Amber Fatima Arman Qamar Ankur Gupta Jon Hainer Josh Klein Petr Jarolim Marcelo Di Carli Khurram Nasir Deepak L. Bhatt Ron Blankstein 《The American journal of medicine》2018,131(3):284-292.e1
Background
While increased serum troponin levels are often due to myocardial infarction, increased levels may also be found in a variety of other clinical scenarios. Although these causes of troponin elevation have been characterized in several studies in older adults, they have not been well characterized in younger individuals.Methods
We conducted a retrospective review of patients 50 years of age or younger who presented with elevated serum troponin levels to 2 large tertiary care centers between January 2000 and April 2016. Patients with prior known coronary artery disease were excluded. The cause of troponin elevation was adjudicated via review of electronic medical records. All-cause death was determined using the Social Security Administration's death master file.Results
Of the 6081 cases meeting inclusion criteria, 3574 (58.8%) patients had a myocardial infarction, while 2507 (41.2%) had another cause of troponin elevation. Over a median follow-up of 8.7 years, all-cause mortality was higher in patients with nonmyocardial infarction causes of troponin elevation compared with those with myocardial infarction (adjusted hazard ratio [HR] 1.30; 95% confidence interval [CI], 1.15-1.46; P < .001). Specifically, mortality was higher in those with central nervous system pathologies (adjusted HR 2.21; 95% CI, 1.85-2.63; P < .001), nonischemic cardiomyopathies (adjusted HR 1.66; 95% CI, 1.37-2.02; P < .001), and end-stage renal disease (adjusted HR 1.36; 95% CI, 1.07-1.73; P = .013). However, mortality was lower in patients with myocarditis compared with those with an acute myocardial infarction (adjusted HR 0.43; 95% CI:, 0.31-0.59; P < .001).Conclusion
There is a broad differential for troponin elevation in young patients, which differs based on demographic features. Most nonmyocardial infarction causes of troponin elevation are associated with higher all-cause mortality compared with acute myocardial infarction. 相似文献15.
Ieva Slivovskaja Ligita Ryliskyte Pranas Serpytis Rokas Navickas Jolita Badarienė Jelena Celutkiene Roma Puronaite Kristina Ryliskiene Alma Cypiene Egidija Rinkuniene Vaida Sileikiene Birute Petrauskiene Alvydas Juocevicius Aleksandras Laucevicius 《The American journal of medicine》2018,131(2):148-155
Background
Metabolic syndrome, physical inactivity, and central obesity contribute to early vascular aging, which leads to increased risk of cardiovascular disease. This study aimed to assess the effect of heart rate (HR)-targeted aerobic exercise training on the indices of early vascular aging, in particular, arterial stiffness, and on anthropometric and clinical profile of metabolic syndrome subjects.Methods
There were 126 metabolic syndrome subjects randomly selected. Anthropometric parameters, blood pressure (BP), blood sample, and arterial wall functional and structural parameters were obtained prior to and after the 8-week (84 patients) supervised training program. The age- and sex-matched control group (42 patients) followed the same protocol, except for the HR-targeted training program.Results
In the study group, HR-targeted training was associated with decreased aortic pulse wave velocity (8.47 ± 1.40 vs 8.01 ± 1.06 m/s; P = .005), HR (P < .001), systolic (P < .015) and diastolic (P < .004) BP, waist circumference (P < .004), total and low-density-lipid cholesterol (respectively, 6.42 ± 1.41 vs 5.89 ± 1.32, P = .003 and 4.2 ± 1.18 vs 3.8 ± 1.21, P = .002), and an increase in aerobic capacity (P < .001). In the control group there were no statistically significant changes of arterial stiffness parameters. Multivariate analysis revealed that reduction of arterial stiffness was BP dependent.Conclusions
In subjects with metabolic syndrome, HR-targeted exercise training is associated with BP-dependent decrease in aortic stiffness and improvement of metabolic and fitness parameters. 相似文献16.
Marcin Waligóra Anna Tyrka Tomasz Miszalski-Jamka Małgorzata Urbańczyk-Zawadzka Piotr Podolec Grzegorz Kopeć 《Heart & lung : the journal of critical care》2018,47(3):237-242
Background
Right atrial (RA) enlargement is a common finding in patients with pulmonary arterial hypertension (PAH) and an important predictor of mortality, however its relation to the risk of atrial arrhythmias has not been assessed.Objectives
To assess whether RA enlargement is associated with supraventricular arrhythmias (SVA) and whether it predicts new clinically significant SVA (csSVA).Methods
Patients with PAH were recruited between January 2010 and December 2014 and followed until January 2017. csSVA was diagnosed if it resulted in hospitalization. To assess predictors of new csSVA, only patients without a history of SVA at baseline were analyzed.Results
Among 97 patients, any SVA was observed in 45 (46.4%) and included permanent atrial fibrillation(AF, n = 8), paroxysmal AF (n = 10), permanent atrial flutter (AFl, n = 1), paroxysmal AFl (n = 2) or other types of supraventricular tachycardia (n = 24). Patients with SVA as compared to patients without SVA were characterized by older age, lower distance in a 6-minute test, higher NT-proBNP, higher RA area index (RAai), left atrial area index, mean right atrial pressure (mRAP) and were more commonly treated with β-blocker. Eighty five patients who were in sinus rhythm at baseline assessment and had no history of significant SVA were observed for 37 ± 19.9 months. During that time csSVA occurred in 15.3%. In univariate models, the occurrence of csSVA were predicted by age, right ventricular ejection fraction, right ventricular end diastolic index, RAai and mRAP, but in multivariate model only RAai remained significant predictor for csSVA (HR of 1.23, 95%CI: 1.11–1.36, p < 0.001). The optimal threshold for RA enlargement as discriminator of csSVA was 21.7 cm2/m2.Conclusions
In PAH patients RA enlargement is associated with increased prevalence of SVA. RAai is an independent predictor of hospitalization due to csSVA. 相似文献17.
Nancy M. Albert James F. Bena Denise Buxbaum Linda Martensen Shannon L. Morrison Marilyn A. Prasun Kelly D. Stamp 《Heart & lung : the journal of critical care》2018,47(3):184-191
Background
Research findings on the value of nurse certification were based on subjective perceptions or biased by correlations of certification status and global clinical factors. In heart failure, the value of certification is unknown.Objectives
Examine the value of certification based nurses' decision-making.Methods
Cross-sectional study of nurses who completed heart failure clinical vignettes that reflected decision-making in clinical heart failure scenarios. Statistical tests included multivariable linear, logistic and proportional odds logistic regression models.Results
Of nurses (N = 605), 29.1% were heart failure certified, 35.0% were certified in another specialty/job role and 35.9% were not certified. In multivariable modeling, nurses certified in heart failure (versus not heart failure certified) had higher clinical vignette scores (p = 0.002), reflecting higher evidence-based decision making; nurses with another specialty/role certification (versus no certification) did not (p = 0.62).Conclusions
Heart failure certification, but not in other specialty/job roles was associated with decisions that reflected delivery of high-quality care. 相似文献18.
Vasilios Papademetriou Eric S. Nylen Michael Doumas Jeff Probstfield Johannes F.E. Mann Richard E. Gilbert Hertzel C. Gerstein 《The American journal of medicine》2017,130(12):1465.e27-1465.e39
Background
Early stages of chronic kidney disease are associated with an increased cardiovascular risk in patients with established type 2 diabetes and macrovascular disease. The role of early stages of chronic kidney disease on macrovascular outcomes in prediabetes and early type 2 diabetes mellitus is not known. In the Outcome Reduction with an Initial Glargine Intervention (ORIGIN) trial, the introduction of insulin had no effect on cardiovascular outcomes compared with standard therapy. In this post hoc analysis of ORIGIN, we compared cardiovascular outcomes in subjects without to those with mild (Stages 1-2) or moderate chronic kidney disease (Stage 3).Methods
Τwo co-primary composite cardiovascular outcomes were assessed. The first was the composite end point of nonfatal myocardial infarction, nonfatal stroke, or death from cardiovascular causes; and the second was a composite of any of these events plus a revascularization procedure, or hospitalization for heart failure. Several secondary outcomes were prespecified, including microvascular outcomes, incident diabetes, hypoglycemia, weight, and cancers.Results
Complete renal function data were available in 12,174 of 12,537 ORIGIN participants. A total of 8114 (67%) had no chronic kidney disease, while 4060 (33%) had chronic kidney disease stage 1-3. When compared with nonchronic kidney disease participants, the risk of developing the composite primary outcome (nonfatal myocardial infarction, nonfatal stroke, or cardiovascular death) in those with mild to moderate chronic kidney disease was 87% higher; hazard ratio (HR) 1.87; 95% confidence interval (CI), 1.71-2.04 (P < .0001). The presence of chronic kidney disease 1-3 was also associated with a greater than twofold higher risk for both all-cause mortality (HR 2.17; 95% CI, 1.98-2.38; P < .0001) and cardiovascular mortality (HR 2.39; 95% CI, 2.13-2.69; P < .0001). Moreover, patients with mild to moderate chronic kidney disease had significantly higher risk for nonfatal myocardial infarction (50%), nonfatal stroke (68%), any stroke (84%), the above composite primary end point plus revascularization or heart failure requiring hospitalization (59%), or a major coronary artery disease event (56%). Furthermore, in patients with chronic kidney disease and early diabetes mellitus type 2, the primary end point occurred 83% more frequently as compared with nonchronic kidney disease participants (HR 1.83; 95% CI, 1.67-2.01; P < .001) and in patients with prediabetes and chronic kidney disease 67% more frequently (HR 1.67; 95% CI,1.25-2.24; P < .001).Conclusions
In high-risk patients with dysglycemia (prediabetes and early diabetes), mild and moderate chronic kidney disease significantly increased cardiovascular events. 相似文献19.
Wenjia Guo Tingting Lv Fei She Guobin Miao Yuanwei Liu Rong He Yajun Xue Nang Kham Nu Jing Yang Kun Li Ping Zhang 《Heart & lung : the journal of critical care》2018,47(5):516-524
Background
Heart rate variability (HRV), modulated by cardiac autonomic function, is impaired in obstructive sleep apnea (OSA). However, the effect of continuous positive airway pressure (CPAP) on HRV is debated.Objectives
To investigate the associations between CPAP and HRV in OSA.Methods
Based on literature from five databases published through August 2017, we performed a meta-analysis of cohort studies of OSA treated with CPAP. The change of low-frequency band (LF), high-frequency band (HF) and the ratio between LF and HF (LHR) were analyzed.Results
Eleven studies were included. Decreased LF (SMD = ?0.32, 95%CI: ?0.62,?0.01; P = 0.043) and HF (SMD = ?0.51, 95%CI: ?0.95, ?0.08, P = 0.020) were shown while measured on CPAP. When measured off CPAP, HF was increased remarkably (SMD: 0.31, 95%CI: 0.02, 0.60, P = 0.034).Conclusions
CPAP can improve autonomic activity, which might be one mechanism to reduce the risk of cardiovascular diseases in OSA. 相似文献20.
Morgan Humphrey Sonia Everhart Desiree Kosmisky William E. Anderson 《Heart & lung : the journal of critical care》2018,47(4):387-391