Secondary Prevention of Cardiovascular Disease in Older Adults

Atherosclerotic cardiovascular disease is extremely common in older adults and the potential benefits of secondary prevention are perhaps greater in this population than in younger patients. While there is good evidence that secondary prevention efforts are justified in patients up to 80 years of age, limited data are available on secondary prevention in octogenarians and there is no evidence to guide treatment in patients ≥ 90 years of age. Further, the value of secondary prevention may be confounded by prevalent comorbidities, polypharmacy, and limited life expectancy. It is therefore essential that all management decisions be made in relation to individual preferences and goals of care, with understanding by patients that benefits as well as risks may increase with age. Furthermore, research is needed to refine markers to better delineate which older adults are most likely to benefit from preventive therapies.     

Is ivabradine suitable to control undesirable tachycardia induced by dobutamine in cardiogenic shock treatment?

Inotropic treatment remains the cornerstone for cardiogenic shock, an emergency that requires immediate resuscitative therapy before shock irreversibly damages vital organs. Although the sympathomimetic drug dobutamine is the most widely-used inotropic drug worldwide, it has several side effects including sinus tachycardia. Dobutamine partly restores systolic heart failure (HF); however, it increases the heart rate (HR) which counterbalances the beneficial effects. Ivabradine, a new selective I_f inhibitor, provides specific HR reduction and is indicated in stable coronary artery disease and in stable chronic HF with left ventricular dysfunction. Despite scarce data indicating beneficial effects of ivabradine in sinus tachycardia in various clinical settings, this drug remains contraindicated in acute HF. We propose that ivabradine could help to prevent the dobutamine-induced side effects, and that their combination in clinical practice could lead to pure inotropic effects, useful for the management of cardiogenic shock.     

Thyroid Status and Death Risk in US Veterans With Chronic Kidney Disease

Objective

Given that patients with non–dialysis-dependent chronic kidney disease (NDD-CKD) have a disproportionately higher prevalence of hypothyroidism compared with their non-CKD counterparts, we sought to determine the association between thyroid status, defined by serum thyrotropin (TSH) levels, and mortality among a national cohort of patients with NDD-CKD.

End-Stage Renal Disease and Mortality Outcomes Across Different Glomerulonephropathies in a Large Diverse US Population

Objective

To compare renal function decline, incident end-stage renal disease (ESRD), and mortality among patients with 5 common glomerular diseases in a large diverse population.

Trajectories of fasting plasma glucose variability and mortality in type 2 diabetes

Aim

To investigate the effect of changes in fasting plasma glucose (FPG) variability, as assessed by 2-year trajectories of FPG variability, on mortality risk in patients with type 2 diabetes (T2D).

Renin–angiotensin system inhibition is not associated with increased sudden cardiac death,cardiovascular mortality or all-cause mortality in patients with aortic stenosis

Background

Renin–angiotensin system inhibition (RASI) is frequently avoided in aortic stenosis (AS) patients because of fear of hypotension. We evaluated if RASI with angiotensin-converting enzyme inhibitor (ACEI) or angiotensin receptor blocker (ARB) increased mortality in patients with mild to moderate AS.

Methods

All patients (n = 1873) from the Simvastatin and Ezetimibe in Aortic Stenosis study: asymptomatic patients with AS and preserved left ventricular (LV) ejection fraction were included. Risks of sudden cardiac death (SCD), cardiovascular death and all-cause mortality according to RASI treatment were analyzed by multivariable time-varying Cox models and propensity score matched analyses.

Results

769 (41%) patients received RASI. During a median follow-up of 4.3 ± 0.9 years, 678 patients were categorized as having severe AS, 545 underwent aortic valve replacement, 40 SCDs, 103 cardiovascular and 205 all-cause deaths occurred. RASI was not associated with SCD (HR: 1.19 [95%CI: 0.50–2.83], p = 0.694), cardiovascular (HR: 1.05 [95%CI: 0.62–1.77], p = 0.854) or all-cause mortality (HR: 0.81 [95%CI: 0.55–1.20], p = 0.281). This was confirmed in propensity matched analysis (all p > 0.05). In separate analyses, RASI was associated with larger reduction in systolic blood pressure (p = 0.001) and less progression of LV mass (p = 0.040).

Conclusions

RASI was not associated with SCD, cardiovascular or all-cause mortality in asymptomatic AS patients. However, RASI was associated with a potentially beneficial decrease in blood pressure and reduced LV mass progression.     

Proteinuric renal disease in type 2 diabetes—Is remission of proteinuria associated with improved mortality and morbidity?

Aims

Patients with type 2 diabetes and macroalbuminuria are at high risk for end stage renal disease (ESRD), cardiovascular disease and death, but remission of proteinuria may improve prognosis. We examine the effectiveness of currently recommended treatments on inducing remission of proteinuria, and on morbidity and mortality.

Methods

Observational study of 78 patients with type 2 diabetes (46 male) with mean age (SD) of 61.5 (11) years, with a urinary albumin/creatinine ratio (ACR) ≥ 50 mg/mmol. All were treated with agents blocking the renin–angiotensin system. Follow-up was from recognition of ACR ≥ 50 mg/mmol until death or March 2011 (median 6 years). Remission of proteinuria was defined as ≥70% reduction from peak ACR, sustained for ≥1 year.

Results

Only 22 of 78 patients (28%) achieved remission of proteinuria. Thirty-six (46%) had at least one major event (death, dialysis or cardiovascular). Remission of proteinuria was associated with lower incidence of ESRD/death (9% vs 36%; p = 0.02) but cardiovascular events were not reduced (32% vs 30%). A third of patients had no retinopathy when albuminuria was first recognised, suggesting that non-diabetic renal pathologies were prominent. There was a significant interaction between the severity of diabetic retinopathy and remission of proteinuria on the risk of ESRD/death (p = 0.0003).

Conclusions

Remission of proteinuria was achieved in only a third of patients despite efforts to achieve blood pressure targets <130/80 mmHg. Failure to attain remission of proteinuria was associated with increased risk of ESRD or death, a risk compounded by the presence of severe diabetic retinopathy.