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1.
BMJ ; 368: m456, 2020 03 04.
Artículo en Inglés | MEDLINE | ID: mdl-32131999

RESUMEN

OBJECTIVES: To evaluate the associations of habitual fish oil supplementation with cardiovascular disease (CVD) and mortality in a large prospective cohort. DESIGN: Population based, prospective cohort study. SETTING: UK Biobank. PARTICIPANTS: A total of 427 678 men and women aged between 40 and 69 who had no CVD or cancer at baseline were enrolled between 2006 and 2010 and followed up to the end of 2018. MAIN EXPOSURE: All participants answered questions on the habitual use of supplements, including fish oil. MAIN OUTCOME MEASURES: All cause mortality, CVD mortality, and CVD events. RESULTS: At baseline, 133 438 (31.2%) of the 427 678 participants reported habitual use of fish oil supplements. The multivariable adjusted hazard ratios for habitual users of fish oil versus non-users were 0.87 (95% confidence interval 0.83 to 0.90) for all cause mortality, 0.84 (0.78 to 0.91) for CVD mortality, and 0.93 (0.90 to 0.96) for incident CVD events. For CVD events, the association seemed to be stronger among those with prevalent hypertension (P for interaction=0.005). CONCLUSIONS: Habitual use of fish oil seems to be associated with a lower risk of all cause and CVD mortality and to provide a marginal benefit against CVD events among the general population.


Asunto(s)
Enfermedades Cardiovasculares/mortalidad , Enfermedades Cardiovasculares/prevención & control , Suplementos Dietéticos/estadística & datos numéricos , Aceites de Pescado/administración & dosificación , Adulto , Anciano , Femenino , Humanos , Masculino , Persona de Mediana Edad , Estudios Prospectivos , Factores de Riesgo , Reino Unido/epidemiología
2.
Medicine (Baltimore) ; 99(12): e19534, 2020 Mar.
Artículo en Inglés | MEDLINE | ID: mdl-32195956

RESUMEN

BACKGROUND: Whether or not increased hospitalizations and/or deaths due to cardiovascular disease during major football tournaments (MFTs) remains controversial. We undertook a systematic review and meta-analysis of published studies to assess the relationships of cardiovascular events and MFTs. METHODS: Observational studies reporting relationship of cardiovascular disease morbidity and mortality with MFTs during the days of games or within 2 weeks after game season were included. Relative risk ratios (RR) with 95% confidence interval (CI) were pooled and analyzed using a random/fixed-effects model. RESULTS: Nineteen cross-sectional observational studies that examined the association between MFTs and non-fetal cardiovascular events and mortality were found to be eligible from 3419 references, for inclusion in the systematic review and meta-analysis. Of the 10 studies reported hospitalizations due to non-fetal acute cardiovascular events, the pooled RR was 1.17 (95% CI 1.01-1.36). Of the 10 studies reported cardiovascular mortality the pooled RR was 1.03 (95% CI 1.00-1.05). Of the studies examining the mortality, 6 studies reported the lost or win of the national team. Pooling of four studies where their national teams lost the MFTs produced a RR for the mortality of 1.19 (95% CI: 1.09-1.30), and 4 studies of the 6 whose national teams won produced a pooled RR for cardiovascular mortality of 0.88 (0.79-0.98). CONCLUSION: This systematic review and meta-analysis showed an increased risk of hospitalization due to non-fetal acute cardiovascular events and cardiovascular mortality with watching MFTs.


Asunto(s)
Enfermedades Cardiovasculares/mortalidad , Fútbol Americano/estadística & datos numéricos , Hospitalización/tendencias , Enfermedad Aguda , Enfermedades Cardiovasculares/epidemiología , Enfermedad Coronaria/epidemiología , Estudios Transversales , Muerte Súbita Cardíaca/epidemiología , Humanos , Morbilidad , Infarto del Miocardio/epidemiología , Estudios Observacionales como Asunto , Medición de Riesgo
3.
BMJ ; 368: m688, 2020 03 18.
Artículo en Inglés | MEDLINE | ID: mdl-32188587

RESUMEN

OBJECTIVE: To investigate the association of macronutrient intake with all cause mortality and cardiovascular disease (CVD), and the implications for dietary advice. DESIGN: Prospective population based study. SETTING: UK Biobank. PARTICIPANTS: 195 658 of the 502 536 participants in UK Biobank completed at least one dietary questionnaire and were included in the analyses. Diet was assessed using Oxford WebQ, a web based 24 hour recall questionnaire, and nutrient intakes were estimated using standard methodology. Cox proportional models with penalised cubic splines were used to study non-linear associations. MAIN OUTCOME MEASURES: All cause mortality and incidence of CVD. RESULTS: 4780 (2.4%) participants died over a mean 10.6 (range 9.4-13.9) years of follow-up, and 948 (0.5%) and 9776 (5.0%) experienced fatal and non-fatal CVD events, respectively, over a mean 9.7 (range 8.5-13.0) years of follow-up. Non-linear associations were found for many macronutrients. Carbohydrate intake showed a non-linear association with mortality; no association at 20-50% of total energy intake but a positive association at 50-70% of energy intake (3.14 v 2.75 per 1000 person years, average hazard ratio 1.14, 95% confidence interval 1.03 to 1.28 (60-70% v 50% of energy)). A similar pattern was observed for sugar but not for starch or fibre. A higher intake of monounsaturated fat (2.94 v 3.50 per 1000 person years, average hazard ratio 0.58, 0.51 to 0.66 (20-25% v 5% of energy)) and lower intake of polyunsaturated fat (2.66 v 3.04 per 1000 person years, 0.78, 0.75 to 0.81 (5-7% v 12% of energy)) and saturated fat (2.66 v 3.59 per 1000 person years, 0.67, 0.62 to 0.73 (5-10% v 20% of energy)) were associated with a lower risk of mortality. A dietary risk matrix was developed to illustrate how dietary advice can be given based on current intake. CONCLUSION: Many associations between macronutrient intake and health outcomes are non-linear. Thus dietary advice could be tailored to current intake. Dietary guidelines on macronutrients (eg, carbohydrate) should also take account of differential associations of its components (eg, sugar and starch).


Asunto(s)
Enfermedades Cardiovasculares/mortalidad , Dieta , Carbohidratos de la Dieta , Grasas de la Dieta , Ingestión de Energía , Adulto , Anciano , Fibras de la Dieta , Femenino , Humanos , Incidencia , Masculino , Persona de Mediana Edad , Política Nutricional , Modelos de Riesgos Proporcionales , Estudios Prospectivos , Factores de Riesgo , Reino Unido/epidemiología
4.
Lancet ; 395(10225): 709-733, 2020 02 29.
Artículo en Inglés | MEDLINE | ID: mdl-32061315

RESUMEN

BACKGROUND: Health system planning requires careful assessment of chronic kidney disease (CKD) epidemiology, but data for morbidity and mortality of this disease are scarce or non-existent in many countries. We estimated the global, regional, and national burden of CKD, as well as the burden of cardiovascular disease and gout attributable to impaired kidney function, for the Global Burden of Diseases, Injuries, and Risk Factors Study 2017. We use the term CKD to refer to the morbidity and mortality that can be directly attributed to all stages of CKD, and we use the term impaired kidney function to refer to the additional risk of CKD from cardiovascular disease and gout. METHODS: The main data sources we used were published literature, vital registration systems, end-stage kidney disease registries, and household surveys. Estimates of CKD burden were produced using a Cause of Death Ensemble model and a Bayesian meta-regression analytical tool, and included incidence, prevalence, years lived with disability, mortality, years of life lost, and disability-adjusted life-years (DALYs). A comparative risk assessment approach was used to estimate the proportion of cardiovascular diseases and gout burden attributable to impaired kidney function. FINDINGS: Globally, in 2017, 1·2 million (95% uncertainty interval [UI] 1·2 to 1·3) people died from CKD. The global all-age mortality rate from CKD increased 41·5% (95% UI 35·2 to 46·5) between 1990 and 2017, although there was no significant change in the age-standardised mortality rate (2·8%, -1·5 to 6·3). In 2017, 697·5 million (95% UI 649·2 to 752·0) cases of all-stage CKD were recorded, for a global prevalence of 9·1% (8·5 to 9·8). The global all-age prevalence of CKD increased 29·3% (95% UI 26·4 to 32·6) since 1990, whereas the age-standardised prevalence remained stable (1·2%, -1·1 to 3·5). CKD resulted in 35·8 million (95% UI 33·7 to 38·0) DALYs in 2017, with diabetic nephropathy accounting for almost a third of DALYs. Most of the burden of CKD was concentrated in the three lowest quintiles of Socio-demographic Index (SDI). In several regions, particularly Oceania, sub-Saharan Africa, and Latin America, the burden of CKD was much higher than expected for the level of development, whereas the disease burden in western, eastern, and central sub-Saharan Africa, east Asia, south Asia, central and eastern Europe, Australasia, and western Europe was lower than expected. 1·4 million (95% UI 1·2 to 1·6) cardiovascular disease-related deaths and 25·3 million (22·2 to 28·9) cardiovascular disease DALYs were attributable to impaired kidney function. INTERPRETATION: Kidney disease has a major effect on global health, both as a direct cause of global morbidity and mortality and as an important risk factor for cardiovascular disease. CKD is largely preventable and treatable and deserves greater attention in global health policy decision making, particularly in locations with low and middle SDI. FUNDING: Bill & Melinda Gates Foundation.


Asunto(s)
Enfermedades Cardiovasculares/epidemiología , Carga Global de Enfermedades , Gota/epidemiología , Insuficiencia Renal Crónica/epidemiología , África/epidemiología , Asia/epidemiología , Australasia/epidemiología , Teorema de Bayes , Enfermedades Cardiovasculares/mortalidad , Enfermedades Cardiovasculares/fisiopatología , Causas de Muerte , Nefropatías Diabéticas/epidemiología , Nefropatías Diabéticas/fisiopatología , Europa (Continente)/epidemiología , Gota/fisiopatología , Encuestas Epidemiológicas , Humanos , Incidencia , América Latina/epidemiología , Mortalidad , América del Norte/epidemiología , Oceanía/epidemiología , Prevalencia , Años de Vida Ajustados por Calidad de Vida , Sistema de Registros , Insuficiencia Renal Crónica/mortalidad , Insuficiencia Renal Crónica/fisiopatología , Medición de Riesgo
5.
Lancet ; 395(10225): 698-708, 2020 02 29.
Artículo en Inglés | MEDLINE | ID: mdl-32050090

RESUMEN

BACKGROUND: Observational studies have suggested that accelerated surgery is associated with improved outcomes in patients with a hip fracture. The HIP ATTACK trial assessed whether accelerated surgery could reduce mortality and major complications. METHODS: HIP ATTACK was an international, randomised, controlled trial done at 69 hospitals in 17 countries. Patients with a hip fracture that required surgery and were aged 45 years or older were eligible. Research personnel randomly assigned patients (1:1) through a central computerised randomisation system using randomly varying block sizes to either accelerated surgery (goal of surgery within 6 h of diagnosis) or standard care. The coprimary outcomes were mortality and a composite of major complications (ie, mortality and non-fatal myocardial infarction, stroke, venous thromboembolism, sepsis, pneumonia, life-threatening bleeding, and major bleeding) at 90 days after randomisation. Patients, health-care providers, and study staff were aware of treatment assignment, but outcome adjudicators were masked to treatment allocation. Patients were analysed according to the intention-to-treat principle. This study is registered at ClinicalTrials.gov (NCT02027896). FINDINGS: Between March 14, 2014, and May 24, 2019, 27 701 patients were screened, of whom 7780 were eligible. 2970 of these were enrolled and randomly assigned to receive accelerated surgery (n=1487) or standard care (n=1483). The median time from hip fracture diagnosis to surgery was 6 h (IQR 4-9) in the accelerated-surgery group and 24 h (10-42) in the standard-care group (p<0·0001). 140 (9%) patients assigned to accelerated surgery and 154 (10%) assigned to standard care died, with a hazard ratio (HR) of 0·91 (95% CI 0·72 to 1·14) and absolute risk reduction (ARR) of 1% (-1 to 3; p=0·40). Major complications occurred in 321 (22%) patients assigned to accelerated surgery and 331 (22%) assigned to standard care, with an HR of 0·97 (0·83 to 1·13) and an ARR of 1% (-2 to 4; p=0·71). INTERPRETATION: Among patients with a hip fracture, accelerated surgery did not significantly lower the risk of mortality or a composite of major complications compared with standard care. FUNDING: Canadian Institutes of Health Research.


Asunto(s)
Artroplastia de Reemplazo de Cadera/métodos , Intervención Médica Temprana/métodos , Fijación Interna de Fracturas/métodos , Hemiartroplastia/métodos , Fracturas de Cadera/cirugía , Complicaciones Posoperatorias/epidemiología , Tiempo de Tratamiento/estadística & datos numéricos , Actividades Cotidianas , Anciano , Anciano de 80 o más Años , Enfermedades Cardiovasculares/mortalidad , Comorbilidad , Delirio/epidemiología , Demencia/epidemiología , Diabetes Mellitus/epidemiología , Femenino , Fracturas del Cuello Femoral/epidemiología , Fracturas del Cuello Femoral/cirugía , Fracturas de Cadera/epidemiología , Humanos , Internacionalidad , Masculino , Persona de Mediana Edad , Mortalidad , Isquemia Miocárdica/epidemiología , Casas de Salud , Reducción Abierta/métodos , Hemorragia Posoperatoria/epidemiología , Modelos de Riesgos Proporcionales , Características de la Residencia/estadística & datos numéricos , Sepsis/epidemiología , Resultado del Tratamiento
6.
BMJ ; 368: l7078, 2020 Feb 05.
Artículo en Inglés | MEDLINE | ID: mdl-32024657

RESUMEN

OBJECTIVES: To conduct a systematic review and meta-analysis of the effects of rosiglitazone treatment on cardiovascular risk and mortality using multiple data sources and varying analytical approaches with three aims in mind: to clarify uncertainties about the cardiovascular risk of rosiglitazone; to determine whether different analytical approaches are likely to alter the conclusions of adverse event meta-analyses; and to inform efforts to promote clinical trial transparency and data sharing. DESIGN: Systematic review and meta-analysis of randomized controlled trials. DATA SOURCES: GlaxoSmithKline's (GSK's) ClinicalStudyDataRequest.com for individual patient level data (IPD) and GSK's Study Register platforms, MEDLINE, PubMed, Embase, Web of Science, Cochrane Central Registry of Controlled Trials, Scopus, and ClinicalTrials.gov from inception to January 2019 for summary level data. ELIGIBILITY CRITERIA FOR SELECTING STUDIES: Randomized, controlled, phase II-IV clinical trials that compared rosiglitazone with any control for at least 24 weeks in adults. DATA EXTRACTION AND SYNTHESIS: For analyses of trials for which IPD were available, a composite outcome of acute myocardial infarction, heart failure, cardiovascular related death, and non-cardiovascular related death was examined. These four events were examined independently as secondary analyses. For analyses including trials for which IPD were not available, myocardial infarction and cardiovascular related death were examined, which were determined from summary level data. Multiple meta-analyses were conducted that accounted for trials with zero events in one or both arms with two different continuity corrections (0.5 constant and treatment arm) to calculate odds ratios and risk ratios with 95% confidence intervals. RESULTS: 33 eligible trials were identified from ClinicalStudyDataRequest.com for which IPD were available (21 156 patients). Additionally, 103 trials for which IPD were not available were included in the meta-analyses for myocardial infarction (23 683 patients), and 103 trials for which IPD were not available contributed to the meta-analyses for cardiovascular related death (22 772 patients). Among 29 trials for which IPD were available and that were included in previous meta-analyses using GSK's summary level data, more myocardial infarction events were identified by using IPD instead of summary level data for 26 trials, and fewer cardiovascular related deaths for five trials. When analyses were limited to trials for which IPD were available, and a constant continuity correction of 0.5 and a random effects model were used to account for trials with zero events in only one arm, patients treated with rosiglitazone had a 33% increased risk of a composite event compared with controls (odds ratio 1.33, 95% confidence interval 1.09 to 1.61; rosiglitazone population: 274 events among 11 837 patients; control population: 219 events among 9319 patients). The odds ratios for myocardial infarction, heart failure, cardiovascular related death, and non-cardiovascular related death were 1.17 (0.92 to 1.51), 1.54 (1.14 to 2.09), 1.15 (0.55 to 2.41), and 1.18 (0.60 to 2.30), respectively. For analyses including trials for which IPD were not available, odds ratios for myocardial infarction and cardiovascular related death were attenuated (1.09, 0.88 to 1.35, and 1.12, 0.72 to 1.74, respectively). Results were broadly consistent when analyses were repeated using trials with zero events across both arms and either of the two continuity corrections was used. CONCLUSIONS: The results suggest that rosiglitazone is associated with an increased cardiovascular risk, especially for heart failure events. Although increased risk of myocardial infarction was observed across analyses, the strength of the evidence varied and effect estimates were attenuated when summary level data were used in addition to IPD. Because more myocardial infarctions and fewer cardiovascular related deaths were reported in the IPD than in the summary level data, sharing IPD might be necessary when performing meta-analyses focused on safety. SYSTEMATIC REVIEW REGISTRATION: OSF Home https://osf.io/4yvp2/.


Asunto(s)
Enfermedades Cardiovasculares/inducido químicamente , Hipoglucemiantes/efectos adversos , Rosiglitazona/efectos adversos , Enfermedades Cardiovasculares/mortalidad , Humanos , Hipoglucemiantes/farmacología , Difusión de la Información , Ensayos Clínicos Controlados Aleatorios como Asunto , Factores de Riesgo , Rosiglitazona/farmacología
8.
Adv Exp Med Biol ; 1216: 29-38, 2020.
Artículo en Inglés | MEDLINE | ID: mdl-31894544

RESUMEN

This chapter focuses on the epidemiology of cardiovascular diseases in elderly adults who are 65 or older. Risk factors for morbidity and mortality, as well as variables associated with disability and physical and social functional decline in the elderly individuals are considered. Modifiable risk factors, such as life habits are differentiated from unmodifiable ones, such as age and sex. The chapter concentrates in particular on the impact of hypertension, dyslipidemia and diabetes on cardiovascular diseases and mortality, as well as the effect of cigarettes smoking, physical activity, obesity and isolation on cardiovascular diseases and quality of life. The results demonstrate that cardiovascular diseases are not necessarily a consequence of aging; instead, they are often linked to modifiable risk factors. We can conclude that specific, targeted prevention interventions should preferably be implemented when individuals are young, but they are also useful in the elderly not only to prolong life but also to improve their quality of life.


Asunto(s)
Enfermedades Cardiovasculares/epidemiología , Anciano , Anciano de 80 o más Años , Enfermedades Cardiovasculares/mortalidad , Diabetes Mellitus Tipo 2/epidemiología , Dislipidemias/epidemiología , Anciano Frágil , Humanos , Hipertensión/epidemiología , Calidad de Vida , Factores de Riesgo
9.
Zhonghua Yu Fang Yi Xue Za Zhi ; 54(1): 104-107, 2020 Jan 06.
Artículo en Chino | MEDLINE | ID: mdl-31914577

RESUMEN

From 1987 to 2017, cardiovascular disease (CVD) had been ranking the first cause of death in Suzhou, and the mortality rate showed an upward trend annual percentage changes (APC=0.62%, P=0.001), while the standardized mortality rate showed a downward trend (APC=-2.65%, P<0.001). The probability of premature death of CVD declined consistently from 7.06% in 1987 to 2.00% in 2017 (APC=-4.45%, P<0.001). When the life expectancy was set at 70, the potential years of life lost rate (PYLLR) decreased from 6.35‰ in 1987 to 3.30‰ in 2017, and the standardized PYLLR decreased from 7.30‰ to 2.68‰. When the life expectancy was set at 75, the PYLLR decreased from 10.12‰ to 5.19‰, and the standardized PYLLR decreased from 11.44‰ to 3.88‰. With the increase of years, all PYLLR and standardized PYLLR showed a significantly downward trend (APC=-2.51%--3.89%, P<0.001).


Asunto(s)
Enfermedades Cardiovasculares/mortalidad , Esperanza de Vida/tendencias , Mortalidad Prematura/tendencias , China/epidemiología , Humanos , Probabilidad
10.
N Engl J Med ; 382(1): 9, 2020 01 02.
Artículo en Inglés | MEDLINE | ID: mdl-31738483

RESUMEN

BACKGROUND: The use of intensive lipid-lowering therapy by means of statin medications is recommended after transient ischemic attack (TIA) and ischemic stroke of atherosclerotic origin. The target level for low-density lipoprotein (LDL) cholesterol to reduce cardiovascular events after stroke has not been well studied. METHODS: In this parallel-group trial conducted in France and South Korea, we randomly assigned patients with ischemic stroke in the previous 3 months or a TIA within the previous 15 days to a target LDL cholesterol level of less than 70 mg per deciliter (1.8 mmol per liter) (lower-target group) or to a target range of 90 mg to 110 mg per deciliter (2.3 to 2.8 mmol per liter) (higher-target group). All the patients had evidence of cerebrovascular or coronary-artery atherosclerosis and received a statin, ezetimibe, or both. The composite primary end point of major cardiovascular events included ischemic stroke, myocardial infarction, new symptoms leading to urgent coronary or carotid revascularization, or death from cardiovascular causes. RESULTS: A total of 2860 patients were enrolled and followed for a median of 3.5 years; 1430 were assigned to each LDL cholesterol target group. The mean LDL cholesterol level at baseline was 135 mg per deciliter (3.5 mmol per liter), and the mean achieved LDL cholesterol level was 65 mg per deciliter (1.7 mmol per liter) in the lower-target group and 96 mg per deciliter (2.5 mmol per liter) in the higher-target group. The trial was stopped for administrative reasons after 277 of an anticipated 385 end-point events had occurred. The composite primary end point occurred in 121 patients (8.5%) in the lower-target group and in 156 (10.9%) in the higher-target group (adjusted hazard ratio, 0.78; 95% confidence interval, 0.61 to 0.98; P = 0.04). The incidence of intracranial hemorrhage and newly diagnosed diabetes did not differ significantly between the two groups. CONCLUSIONS: After an ischemic stroke or TIA with evidence of atherosclerosis, patients who had a target LDL cholesterol level of less than 70 mg per deciliter had a lower risk of subsequent cardiovascular events than those who had a target range of 90 mg to 110 mg per deciliter. (Funded by the French Ministry of Health and others; Treat Stroke to Target ClinicalTrials.gov number, NCT01252875.).


Asunto(s)
Anticolesterolemiantes/uso terapéutico , Enfermedades Cardiovasculares/prevención & control , LDL-Colesterol/sangre , Ezetimiba/uso terapéutico , Inhibidores de Hidroximetilglutaril-CoA Reductasas/uso terapéutico , Ataque Isquémico Transitorio/tratamiento farmacológico , Accidente Cerebrovascular/tratamiento farmacológico , Adulto , Anciano , Anticolesterolemiantes/efectos adversos , Aterosclerosis/complicaciones , Aterosclerosis/tratamiento farmacológico , Isquemia Encefálica/tratamiento farmacológico , Enfermedades Cardiovasculares/mortalidad , Quimioterapia Combinada , Femenino , Humanos , Análisis de Intención de Tratar , Ataque Isquémico Transitorio/complicaciones , Estimación de Kaplan-Meier , Masculino , Persona de Mediana Edad , Accidente Cerebrovascular/sangre
11.
N Engl J Med ; 382(2): 120-129, 2020 01 09.
Artículo en Inglés | MEDLINE | ID: mdl-31733180

RESUMEN

BACKGROUND: Whether the direct factor Xa inhibitor rivaroxaban can prevent thromboembolic events after transcatheter aortic-valve replacement (TAVR) is unclear. METHODS: We randomly assigned 1644 patients without an established indication for oral anticoagulation after successful TAVR to receive rivaroxaban at a dose of 10 mg daily (with aspirin at a dose of 75 to 100 mg daily for the first 3 months) (rivaroxaban group) or aspirin at a dose of 75 to 100 mg daily (with clopidogrel at a dose of 75 mg daily for the first 3 months) (antiplatelet group). The primary efficacy outcome was the composite of death or thromboembolic events. The primary safety outcome was major, disabling, or life-threatening bleeding. The trial was terminated prematurely by the data and safety monitoring board because of safety concerns. RESULTS: After a median of 17 months, death or a first thromboembolic event (intention-to-treat analysis) had occurred in 105 patients in the rivaroxaban group and in 78 patients in the antiplatelet group (incidence rates, 9.8 and 7.2 per 100 person-years, respectively; hazard ratio with rivaroxaban, 1.35; 95% confidence interval [CI], 1.01 to 1.81; P = 0.04). Major, disabling, or life-threatening bleeding (intention-to-treat analysis) had occurred in 46 and 31 patients, respectively (4.3 and 2.8 per 100 person-years; hazard ratio, 1.50; 95% CI, 0.95 to 2.37; P = 0.08). A total of 64 deaths occurred in the rivaroxaban group and 38 in the antiplatelet group (5.8 and 3.4 per 100 person-years, respectively; hazard ratio, 1.69; 95% CI, 1.13 to 2.53). CONCLUSIONS: In patients without an established indication for oral anticoagulation after successful TAVR, a treatment strategy including rivaroxaban at a dose of 10 mg daily was associated with a higher risk of death or thromboembolic complications and a higher risk of bleeding than an antiplatelet-based strategy. (Funded by Bayer and Janssen Pharmaceuticals; GALILEO ClinicalTrials.gov number, NCT02556203.).


Asunto(s)
Aspirina/uso terapéutico , Clopidogrel/uso terapéutico , Inhibidores del Factor Xa/uso terapéutico , Inhibidores de Agregación Plaquetaria/uso terapéutico , Rivaroxabán/uso terapéutico , Reemplazo de la Válvula Aórtica Transcatéter , Anciano , Anciano de 80 o más Años , Aspirina/efectos adversos , Fibrilación Atrial/tratamiento farmacológico , Enfermedades Cardiovasculares/mortalidad , Clopidogrel/efectos adversos , Quimioterapia Combinada , Inhibidores del Factor Xa/efectos adversos , Femenino , Prótesis Valvulares Cardíacas , Hemorragia/inducido químicamente , Humanos , Análisis de Intención de Tratar , Estimación de Kaplan-Meier , Masculino , Inhibidores de Agregación Plaquetaria/efectos adversos , Rivaroxabán/efectos adversos , Tromboembolia/mortalidad
12.
N Engl J Med ; 382(2): 130-139, 2020 01 09.
Artículo en Inglés | MEDLINE | ID: mdl-31733182

RESUMEN

BACKGROUND: Subclinical leaflet thickening and reduced leaflet motion of bioprosthetic aortic valves have been documented by four-dimensional computed tomography (CT). Whether anticoagulation can reduce these phenomena after transcatheter aortic-valve replacement (TAVR) is not known. METHODS: In a substudy of a large randomized trial, we randomly assigned patients who had undergone successful TAVR and who did not have an indication for long-term anticoagulation to a rivaroxaban-based antithrombotic strategy (rivaroxaban [10 mg] plus aspirin [75 to 100 mg] once daily) or an antiplatelet-based strategy (clopidogrel [75 mg] plus aspirin [75 to 100 mg] once daily). Patients underwent evaluation by four-dimensional CT at a mean (±SD) of 90±15 days after randomization. The primary end point was the percentage of patients with at least one prosthetic valve leaflet with grade 3 or higher motion reduction (i.e., involving >50% of the leaflet). Leaflet thickening was also assessed. RESULTS: A total of 231 patients were enrolled. At least one prosthetic valve leaflet with grade 3 or higher motion reduction was found in 2 of 97 patients (2.1%) who had scans that could be evaluated in the rivaroxaban group, as compared with 11 of 101 (10.9%) in the antiplatelet group (difference, -8.8 percentage points; 95% confidence interval [CI], -16.5 to -1.9; P = 0.01). Thickening of at least one leaflet was observed in 12 of 97 patients (12.4%) in the rivaroxaban group and in 33 of 102 (32.4%) in the antiplatelet group (difference, -20.0 percentage points; 95% CI, -30.9 to -8.5). In the main trial, the risk of death or thromboembolic events and the risk of life-threatening, disabling, or major bleeding were higher with rivaroxaban (hazard ratios of 1.35 and 1.50, respectively). CONCLUSIONS: In a substudy of a trial involving patients without an indication for long-term anticoagulation who had undergone successful TAVR, a rivaroxaban-based antithrombotic strategy was more effective than an antiplatelet-based strategy in preventing subclinical leaflet-motion abnormalities. However, in the main trial, the rivaroxaban-based strategy was associated with a higher risk of death or thromboembolic complications and a higher risk of bleeding than the antiplatelet-based strategy. (Funded by Bayer; GALILEO-4D ClinicalTrials.gov number, NCT02833948.).


Asunto(s)
Válvula Aórtica/fisiopatología , Aspirina/farmacología , Clopidogrel/farmacología , Inhibidores del Factor Xa/farmacología , Prótesis Valvulares Cardíacas , Inhibidores de Agregación Plaquetaria/farmacología , Rivaroxabán/farmacología , Reemplazo de la Válvula Aórtica Transcatéter , Anciano , Anciano de 80 o más Años , Válvula Aórtica/efectos de los fármacos , Válvula Aórtica/patología , Aspirina/efectos adversos , Aspirina/uso terapéutico , Fibrilación Atrial/tratamiento farmacológico , Enfermedades Cardiovasculares/mortalidad , Clopidogrel/efectos adversos , Clopidogrel/uso terapéutico , Quimioterapia Combinada , Inhibidores del Factor Xa/efectos adversos , Inhibidores del Factor Xa/uso terapéutico , Femenino , Tomografía Computarizada Cuatridimensional , Hemorragia/inducido químicamente , Humanos , Análisis de Intención de Tratar , Masculino , Inhibidores de Agregación Plaquetaria/efectos adversos , Inhibidores de Agregación Plaquetaria/uso terapéutico , Rivaroxabán/efectos adversos , Rivaroxabán/uso terapéutico , Tromboembolia/etiología , Tromboembolia/mortalidad
13.
N Engl J Med ; 382(2): 111-119, 2020 01 09.
Artículo en Inglés | MEDLINE | ID: mdl-31733181

RESUMEN

BACKGROUND: The timing and indications for surgical intervention in asymptomatic patients with severe aortic stenosis remain controversial. METHODS: In a multicenter trial, we randomly assigned 145 asymptomatic patients with very severe aortic stenosis (defined as an aortic-valve area of ≤0.75 cm2 with either an aortic jet velocity of ≥4.5 m per second or a mean transaortic gradient of ≥50 mm Hg) to early surgery or to conservative care according to the recommendations of current guidelines. The primary end point was a composite of death during or within 30 days after surgery (often called operative mortality) or death from cardiovascular causes during the entire follow-up period. The major secondary end point was death from any cause during follow-up. RESULTS: In the early-surgery group, 69 of 73 patients (95%) underwent surgery within 2 months after randomization, and there was no operative mortality. In an intention-to-treat analysis, a primary end-point event occurred in 1 patient in the early-surgery group (1%) and in 11 of 72 patients in the conservative-care group (15%) (hazard ratio, 0.09; 95% confidence interval [CI], 0.01 to 0.67; P = 0.003). Death from any cause occurred in 5 patients in the early-surgery group (7%) and in 15 patients in the conservative-care group (21%) (hazard ratio, 0.33; 95% CI, 0.12 to 0.90). In the conservative-care group, the cumulative incidence of sudden death was 4% at 4 years and 14% at 8 years. CONCLUSIONS: Among asymptomatic patients with very severe aortic stenosis, the incidence of the composite of operative mortality or death from cardiovascular causes during the follow-up period was significantly lower among those who underwent early aortic-valve replacement surgery than among those who received conservative care. (Funded by the Korean Institute of Medicine; RECOVERY ClinicalTrials.gov number, NCT01161732.).


Asunto(s)
Estenosis de la Válvula Aórtica/cirugía , Válvula Aórtica/cirugía , Tratamiento Conservador , Anciano , Estenosis de la Válvula Aórtica/mortalidad , Estenosis de la Válvula Aórtica/terapia , Enfermedades Asintomáticas/terapia , Enfermedades Cardiovasculares/mortalidad , Femenino , Estudios de Seguimiento , Humanos , Incidencia , Estimación de Kaplan-Meier , Masculino , Persona de Mediana Edad , Gravedad del Paciente , Complicaciones Posoperatorias/mortalidad
14.
Medicine (Baltimore) ; 98(49): e18245, 2019 Dec.
Artículo en Inglés | MEDLINE | ID: mdl-31804352

RESUMEN

BACKGROUND: Optimal glycemic control is required to restrain the increase of cardiovascular events in patients with type 2 diabetes. The effects of sodium-glucose cotransporter-2 (SGLT-2) inhibitors on cardiovascular events and mortality in those patients are not well established. This meta-analysis was conducted to assess the effects of SGLT2 inhibitors on cardiovascular events and mortality in patients with type 2 diabetes. METHODS: We conducted a systematic literature search of Medline, Embase and Cochrane Library and included randomized controlled trials (RCTs) of 3 different SGLT2 inhibitors (canagliflozin, dapagliflozin and empagliflozin) that evaluated the effects on cardiovascular outcomes and mortality in the final meta-analysis. The intervention arm was defined either as SGLT2 inhibitor monotherapy or as SGLT2 inhibitor add-on to other non-SGLT2 inhibitor antidiabetic agents (ADAs). RESULTS: Forty-two trials with a total of 61,076 patients with type 2 diabetes were included in the meta-analysis. Compared with the control, SGLT2 inhibitor treatment was associated with a reduction in the incidence of major adverse cardiovascular events (MACEs) (OR = 0.86, 95% CI 0.80-0.93, P < .0001), myocardial infarction (OR = 0.86, 95% CI 0.79-0.94, P = .001), cardiovascular mortality (OR = 0.74, 95% CI 0.67-0.81, P < .0001) and all cause mortality (OR = 0.85, 95% CI 0.79-0.92, P < .0001). However, the risk of ischemic stroke was not reduced after SGLT2 inhibitor treatment in patients with type 2 diabetes (OR = 0.95, 95% CI 0.85-1.07, P = .42). CONCLUSION: These data suggest a decreased risk of harm with SGLT2 inhibitor as a class with respect to cardiovascular events and mortality.


Asunto(s)
Enfermedades Cardiovasculares/etiología , Enfermedades Cardiovasculares/prevención & control , Diabetes Mellitus Tipo 2/complicaciones , Diabetes Mellitus Tipo 2/tratamiento farmacológico , Inhibidores del Cotransportador de Sodio-Glucosa 2/uso terapéutico , Enfermedades Cardiovasculares/mortalidad , Diabetes Mellitus Tipo 2/mortalidad , Humanos
15.
Medicina (B Aires) ; 79(6): 438-444, 2019.
Artículo en Inglés | MEDLINE | ID: mdl-31829945

RESUMEN

Cardiovascular disease (CVD) is the leading cause of death in Argentina. Computer simulation models allow to extrapolate evidence to broader populations than the originally studied, over longer timeframes, and to compare different subpopulations. The Cardiovascular Disease Policy Model (CVDPM) is a computer simulation state transition model used to represent and project future CVD mortality and morbidity in the population 35 years-old and older. The objective of this study was to update Argentina's version of the CVDPM. For this purpose, information from the 2010 National Census, the 2013 National Risk Factor Survey, CESCAS I study, and PrEViSTA study were used to update the dynamics of population size, demographics, and CVD risk factor distributions over time. Model projections were later calibrated by comparing them to actual data on CVD events and mortality in the year 2010 (baseline year) in Argentina. Country statistics for people 35 years-old and older reported for 2010 a total of 41 219 myocardial infarctions (MIs), 58 658 strokes, and 281 710 total deaths. The CVDPM, in turn, predicted 41 265 MIs (difference: 0.11%), 58 584 strokes (difference: 0.13%), and 280 707 total deaths (difference: 0.36%) in the same population. In all cases, the final version of the model predicted the actual number of events with an accuracy superior to 99.5%, and could be used to forecast the changes in CVD incidence and mortality after the implementation of public policies.


Asunto(s)
Enfermedades Cardiovasculares/mortalidad , Simulación por Computador , Mortalidad/tendencias , Medición de Riesgo/métodos , Adulto , Distribución por Edad , Factores de Edad , Anciano , Anciano de 80 o más Años , Argentina/epidemiología , Calibración , Femenino , Predicción , Humanos , Incidencia , Masculino , Persona de Mediana Edad , Reproducibilidad de los Resultados , Factores de Riesgo , Distribución por Sexo , Factores Sexuales , Factores de Tiempo
16.
Cardiovasc Ther ; 2019: 3824823, 2019.
Artículo en Inglés | MEDLINE | ID: mdl-31885691

RESUMEN

In statin therapy, the prognostic role of achieved low-density lipoprotein cholesterol (LDL-C) and high-sensitivity C-reactive protein (hsCRP) in cardiovascular outcomes has not been fully elucidated. A total of 4,803 percutaneous coronary intervention (PCI)-naïve patients who prescribed moderate intensity of statin therapy were followed up. Total and each component of major adverse cardiovascular events (MACE) according to LDL-C and hsCRP quartiles were compared. The incidence of 5-year total MACEs in the highest quartile group according to the followed-up hsCRP was higher than that in the lowest quartile (hazard ratio (HR) = 2.16, p < 0.001). However, there was no difference between the highest and lowest quartiles of the achieved LDL-C (HR = 0.95, p = 0.743). After adjustment of potential confounders, the incidence of total death, de novo PCI, atrial fibrillation, and heart failure in the highest quartile of followed-up hsCRP, was higher than that in the lowest quartile (all p < 0.05). However, other components except for de novo PCI in the highest quartile by achieved LDL-C was not different to that in the lowest quartile. These results suggest that followed-up hsCRP can be more useful for predicting future cardiovascular outcome than achieved LDL-C in PCI-naïve patients with statin therapy.


Asunto(s)
Antiinflamatorios/uso terapéutico , Proteína C-Reactiva/metabolismo , Enfermedades Cardiovasculares/prevención & control , LDL-Colesterol/sangre , Dislipidemias/tratamiento farmacológico , Inhibidores de Hidroximetilglutaril-CoA Reductasas/uso terapéutico , Inflamación/tratamiento farmacológico , Anciano , Antiinflamatorios/efectos adversos , Biomarcadores/sangre , Enfermedades Cardiovasculares/sangre , Enfermedades Cardiovasculares/diagnóstico , Enfermedades Cardiovasculares/mortalidad , Regulación hacia Abajo , Dislipidemias/sangre , Dislipidemias/diagnóstico , Dislipidemias/mortalidad , Femenino , Humanos , Inhibidores de Hidroximetilglutaril-CoA Reductasas/efectos adversos , Incidencia , Inflamación/sangre , Inflamación/diagnóstico , Inflamación/mortalidad , Masculino , Persona de Mediana Edad , Sistema de Registros , Medición de Riesgo , Factores de Riesgo , Factores de Tiempo , Resultado del Tratamiento
17.
Zhonghua Fu Chan Ke Za Zhi ; 54(12): 826-832, 2019 Dec 25.
Artículo en Chino | MEDLINE | ID: mdl-31874472

RESUMEN

Objective: To analyze risk factors, cardiovascular complications, time of death, gestational age of delivery and offspring outcomes in the maternal deaths with cardiovascular diseases (CVD). Methods: Totally 4 112 cases of pregnant women with CVD in Shanghai obstetric heart disease intensive care unit within 26 years (from January 1993 to December 2018) were collected, and 20 maternal deaths within these cases were analyzed retrospectively. Results: (1) Among the 20 deaths, structural heart diseases accounted for 90% (18/20), pregnancy induced heart diseases was 10% (2/20) while there was no dysfunctional heart disease. The mortality of pregnant women with CVD was 0.486% (20/4 112). (2) The following risk factors were common in these women, getting pregnant without counselling (95%, 19/20) , New York Heart Association classⅢ or Ⅳcardiac function (70%, 14/20), complicated with pulmonary hypertension (75%, 15/20) and prior heart events (60%, 12/20). And 85% (17/20) deaths occurred in puerperium, 15% (3/20) occurred before labor,while no death occurred during labor. And 65% (13/20) deaths died due to heart failure, 20% (4/20) deaths were due to pulmonary hypertension crisis, 5% (1/20) died on sudden cardiac arrest, rupture of aortic dissection and sudden death, respectively. Conclusions: Women with CVD should get pregnant after strict evaluation. Pulmonary hypertension is one of the most severe contraindications to pregnancy, especially in patients with moderate to severe pulmonary hypertension. The puerperium period is a critical period that threatens the safety of these patients. Since heart failure is the most common cause of death, it is necessary to prevent and treat heart failure and to monitor heart function dynamically, especially in those with structural abnormal heart diseases. Moreover, it is also of importance to standardize antenatal care and to identify the severity of heart diseases in time.


Asunto(s)
Enfermedades Cardiovasculares/mortalidad , Unidades de Cuidados Intensivos/estadística & datos numéricos , Muerte Materna , Mortalidad Materna , Complicaciones Cardiovasculares del Embarazo/etiología , Adulto , Causas de Muerte , China/epidemiología , Femenino , Humanos , Servicios de Salud Materna/organización & administración , Mortalidad Materna/tendencias , Embarazo , Complicaciones Cardiovasculares del Embarazo/diagnóstico , Complicaciones Cardiovasculares del Embarazo/mortalidad , Resultado del Embarazo , Estudios Retrospectivos , Factores de Riesgo
18.
BMJ ; 367: l6058, 2019 12 18.
Artículo en Inglés | MEDLINE | ID: mdl-31852664

RESUMEN

OBJECTIVES: To evaluate the associations between birth month, birth season, and overall and cardiovascular disease mortality, and to examine the role of familial and socioeconomic factors in these associations. DESIGN: Prospective cohort study. SETTING: Nurses' Health Study, established in 1976, an ongoing prospective cohort study in the United States. PARTICIPANTS: Female registered nurses who reported information on date of birth at study enrolment (n=116 911, 1976-2014, followed for 38 years). EXPOSURE: Birth month and astronomical birth season (based on solstices and equinoxes as boundaries of the season categories). MAIN OUTCOME MEASURES: Age and various multivariable adjusted hazard ratios and 95% confidence intervals for the association between birth months (using November as the reference), astronomical birth season (using autumn as the reference), and overall and cardiovascular disease specific mortality were assessed using Cox proportional hazards models. RESULTS: Among study participants, 43 248 overall deaths were documented during 4 136 364 person years of follow-up since enrolment, including 8360 cardiovascular disease related deaths. In fully adjusted multivariable analyses, no significant association was observed between birth month, birth season, and overall mortality. Compared with women born in November, increased cardiovascular disease mortality was observed among those born from March to July (hazard ratio for March, 1.09, 95% confidence interval 0.98 to 1.21; April, 1.12, 1.00 to 1.24; May, 1.08, 0.98 to 1.20; June, 1.07, 0.96 to 1.19; and July 1.08, 0.98 to 1.20). Those born in April had the highest cardiovascular disease mortality, and those born in December had the lowest (December, 0.95, 0.85 to 1.06). The relative difference between the lowest and highest risk month was 17.89%. Women born in spring (1.10, 1.04 to 1.17) and summer (1.09, 1.03 to 1.16) had a higher cardiovascular disease mortality than women born in the autumn. Adjustment for familial and socioeconomic factors did not change these results. The relative difference between the lowest and highest risk season was 10.00%. CONCLUSION: Participants born in the spring and summer (especially those born in March-July) had a slight but significant increase in cardiovascular disease specific mortality. However, no seasonal birth month effect was observed among women for overall mortality. Familial and socioeconomic factors did not appear to alter these associations. Further studies are required to confirm these findings and reveal mechanisms of these seasonal birth month effects in cardiovascular disease mortality.


Asunto(s)
Enfermedades Cardiovasculares/mortalidad , Estaciones del Año , Factores de Tiempo , Adulto , Femenino , Humanos , Estudios Longitudinales , Persona de Mediana Edad , Modelos de Riesgos Proporcionales , Estudios Prospectivos , Factores de Riesgo , Factores Socioeconómicos
19.
Medicine (Baltimore) ; 98(50): e18126, 2019 Dec.
Artículo en Inglés | MEDLINE | ID: mdl-31852072

RESUMEN

Sudden cardiac death (SCD) is a major cause of mortality in China. This study collected reference data for future programs of prevention of SCD among the ethnic Kazakh and Han populations in Xinjiang, China.From January 1, 2015 to December 31, 2015, 2 monitoring locations in northern Xinjiang China were utilized. These locations were selected based on the geographic, economic, and administrative structures of the ethnic Kazakh settlements in Xinjiang. Investigators were trained to investigate SCDs in Kazakh and Han people, a study population totaling more than 400,000. The populations were compared for SCD incidence.The average age of the Han population was significantly higher than that of the Kazakh. During the year 2015, there were 135 SCDs, specifically 67 and 68 in the Han and Kazakh populations, respectively, incidences of 37.94 and 36.2 per 100,000. After standardizing for age, the incidence in these populations was 29.36 and 51.85 per 100,000. Among those who experienced SCD, the prevalence of hypertension was higher in the Kazakh group than in the Han. The multivariate analysis of populations with SCD showed that, among the patients with coronary heart disease, the Kazakh were more likely to have SCD than the Han (odds ratio: 3.58, confidence interval: 1.18-10.95).Among the elderly, the incidence of SCD was much higher in the Kazakh population than in the Han population. Basic medical services and health education should be strengthened in the Kazakh pastoral areas.


Asunto(s)
Enfermedades Cardiovasculares/mortalidad , Muerte Súbita Cardíaca/etnología , Grupos Étnicos , Adolescente , Adulto , Anciano , Enfermedades Cardiovasculares/complicaciones , China/epidemiología , Estudios Transversales , Muerte Súbita Cardíaca/etiología , Femenino , Humanos , Incidencia , Masculino , Persona de Mediana Edad , Prevalencia , Estudios Retrospectivos , Factores de Riesgo , Adulto Joven
20.
PLoS Med ; 16(12): e1002999, 2019 12.
Artículo en Inglés | MEDLINE | ID: mdl-31877127

RESUMEN

BACKGROUND: Although patients with type 2 diabetes mellitus (T2DM) may fail to achieve adequate hemoglobin A1c (HbA1c) control despite metformin-sulfonylurea (Met-SU) dual therapy, a third-line glucose-lowering medication-including dipeptidyl peptidase-4 inhibitor (DPP4i), insulin, or thiazolidinedione (TZD)-can be added to achieve this. However, treatment effects of intensification with the medications on the risk of severe hypoglycemia (SH), cardiovascular disease (CVD), and all-cause mortality are uncertain. Study aim was to compare the risks of all-cause mortality, CVD, and SH among patients with T2DM on Met-SU dual therapy intensified with DPP4i, insulin, or TZD. METHODS AND FINDINGS: We analyzed a retrospective cohort data of 17,293 patients with T2DM who were free from CVD and on Met-SU dual therapy and who were intensified with DPP4i (n = 8,248), insulin (n = 6,395), or TZD (n = 2,650) from 2006 to 2017. Propensity-score weighting was used to balance out baseline covariates across groups. Hazard ratios (HRs) for all-cause mortality, CVD, and SH were assessed using Cox proportional hazard models. Mean age of all patients was 58.56 ± 11.41 years. All baseline covariates achieved a balance across the 3 groups. Over a mean follow-up period of 34 months with 49,299 person-years, cumulative incidences of all-cause mortality, SH, and CVD were 0.061, 0.119, and 0.074, respectively. Patients intensified with insulin had higher risk of all-cause mortality (HR = 2.648, 95% confidence interval [CI] 2.367-2.963, p < 0.001; 2.352, 95% CI 2.123-2.605, p < 0.001) than those intensified with TZD and DPP4i, respectively. Insulin users had the greatest risk of SH (HR = 1.198, 95% CI 1.071-1.340, p = 0.002; 1.496, 95% CI 1.342-1.668, p < 0.001) compared with TZD and DPP4i users, respectively. Comparing between TZDs and DPP4i, TZDs were associated with a higher risk of SH (HR = 1.249, 95% CI 1.099-1.419, p < 0.001) but not all-cause mortality (HR = 0.888, 95% CI 0.776-1.016, p = 0.084) or CVD (HR = 1.005, 95% CI 0.915-1.104, p = 0.925). Limitations of this study included the lack of data regarding lifestyle, drug adherence, time-varying factors, patients' motivation, and cost considerations. A limited duration of patients intensifying with TZD might also weaken the strength of study results. CONCLUSIONS: Our results indicated that, for patients with T2DM who are on Met-SU dual therapy, the addition of DPP4i was a preferred third-line medication among 3 options, with the lowest risks of mortality and SH and posing no increased risk for CVD events when compared to insulin and TZD. Intensification with insulin had the greatest risk of mortality and SH events.


Asunto(s)
Enfermedades Cardiovasculares/epidemiología , Diabetes Mellitus Tipo 2/epidemiología , Hipoglucemia/mortalidad , Insulina/efectos adversos , Metformina/efectos adversos , Adulto , Anciano , Enfermedades Cardiovasculares/mortalidad , Estudios de Cohortes , Diabetes Mellitus Tipo 2/mortalidad , Inhibidores de la Dipeptidil-Peptidasa IV/uso terapéutico , Quimioterapia Combinada/efectos adversos , Femenino , Humanos , Hipoglucemia/complicaciones , Hipoglucemiantes/efectos adversos , Incidencia , Insulina/uso terapéutico , Masculino , Metformina/uso terapéutico , Persona de Mediana Edad , Estudios Retrospectivos , Compuestos de Sulfonilurea/efectos adversos , Tiazolidinedionas/uso terapéutico , Resultado del Tratamiento
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