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PLoS One ; 15(3): e0230734, 2020.
Artigo em Inglês | MEDLINE | ID: mdl-32214363


BACKGROUND: Concern has been raised about consequences of including patients with left ventricular assist device (LVAD) or heart transplantation in readmission and mortality measures. METHODS: We calculated unadjusted and hospital-specific 30-day risk-standardized mortality (RSMR) and readmission (RSRR) rates for all Medicare fee-for-service beneficiaries with a primary diagnosis of AMI or HF discharged between July 2010 and June 2013. Hospitals were compared before and after excluding LVAD and heart transplantation patients. LVAD indication was measured. RESULTS: In the AMI mortality (n = 506,543) and readmission (n = 526,309) cohorts, 1,166 and 1,016 patients received an LVAD while 3 and 2 had a heart transplantation, respectively. In the HF mortality (n = 1,015,335) and readmission (n = 1,254,124) cohorts, 789 and 931 received an LVAD, while 212 and 202 received a heart transplantation, respectively. Less than 2% of hospitals had either ≥6 patients who received an LVAD or, independently, had ≥1 heart transplantation. The AMI mortality and readmission cohorts used 1.8% and 2.8% of LVADs for semi-permanent/permanent indications, versus 73.8% and 78.0% for HF patients, respectively. The rest were for temporary/external indications. In the AMI cohort, RSMR for hospitals without LVAD patients versus hospitals with ≥6 LVADs was 14.8% and 14.3%, and RSRR was 17.8% and 18.3%, respectively; the HF cohort RSMR was 11.9% and 9.7% and RSRR was 22.6% and 23.4%, respectively. In the AMI cohort, RSMR for hospitals without versus with heart transplantation patients was 14.7% and 13.9% and RSRR was 17.8% and 17.7%, respectively; in the HF cohort, RSMR was 11.9% and 11.0%, and RSRR was 22.6% and 22.6%, respectively. Estimations changed ≤0.1% after excluding LVAD or heart transplantation patients. CONCLUSION: Hospitals caring for ≥6 patients with LVAD or ≥1 heart transplantation typically had a trend toward lower RSMRs but higher RSRRs. Rates were insignificantly changed when these patients were excluded. LVADs were primarily for acute-care in the AMI cohort and chronic support in the HF cohort. LVAD and heart transplantation patients are a distinct group with differential care requirements and outcomes, thus should be considered separately from the rest of the HF cohort.

J Cardiovasc Pharmacol Ther ; 24(1): 54-61, 2019 01.
Artigo em Inglês | MEDLINE | ID: mdl-29940784


BACKGROUND: Proprotein convertase subtilisin/kexin type 9 (PCSK9) is expressed in multiple tissues, including the small intestine. The effect of PCSK9 inhibition on cholesterol absorption is not known. OBJECTIVES: Measure serum cholesterol absorption markers before and after initiation of PCSK9 inhibitors. METHODS: Single-center retrospective cohort of patients administered evolocumab and alirocumab between July 2015 and January 2017. Paired t tests were used to compare mean serum cholesterol marker concentrations, and ratios to total cholesterol, before and after PCSK9 inhibitor initiation. Analyses were repeated for those taking and not taking statins and taking or not taking ezetimibe at both initiation and follow-up, for each PCSK9 inhibitor, and based on follow-up time (<60, 60-120, and >120 days). RESULTS: There were 62 possible participants, 34 were excluded for lack of data or unknown PCSK9 inhibitor initiation date. Average follow-up was 92.5 days. Mean campesterol (before 3.14 µg/mL, 95% CI: 2.79-4.38 µg/mL; after 2.09 µg/mL, 95% CI: 1.87-2.31 µg/mL; P < .0001), sitosterol (before 2.46 µg/mL, 95% CI: 2.23-2.70 µg/mL; after 1.62 µg/mL, 95% CI: 1.48-1.75 µg/mL; P < .0001), and cholestanol (before 3.25 µg/mL, 95% CI: 3.04-3.47 µg/mL; after 2.08 µg/mL, 95% CI: 1.96-2.21 µg/mL; P < .0001) all significantly decreased at follow-up. There was no significant change in absorption marker to total cholesterol ratios. Findings were not influenced by statin or ezetimibe use or nonuse, which PCSK9 inhibitor was prescribed, or time to follow-up. CONCLUSION: Proprotein convertase subtilisin/kexin type 9 inhibition was associated with decreased cholesterol absorption markers.

Anticorpos Monoclonais Humanizados/uso terapêutico , Anticolesterolemiantes/uso terapêutico , Dislipidemias/tratamento farmacológico , Absorção Intestinal/efeitos dos fármacos , Intestinos/efeitos dos fármacos , Pró-Proteína Convertase 9/antagonistas & inibidores , Inibidores de Serino Proteinase/uso terapêutico , Esteróis/sangue , Idoso , Anticorpos Monoclonais Humanizados/efeitos adversos , Anticolesterolemiantes/efeitos adversos , Biomarcadores/sangue , Dislipidemias/sangue , Dislipidemias/diagnóstico , Dislipidemias/enzimologia , Feminino , Humanos , Intestinos/enzimologia , Masculino , Pessoa de Meia-Idade , Pró-Proteína Convertase 9/metabolismo , Estudos Retrospectivos , Inibidores de Serino Proteinase/efeitos adversos , Resultado do Tratamento
Curr Cardiol Rep ; 20(12): 138, 2018 10 17.
Artigo em Inglês | MEDLINE | ID: mdl-30328514


PURPOSE OF THE REVIEW: To summarize advances in genomic medicine and anticipated future directions to improve cardiovascular risk reduction. RECENT FINDINGS: Mendelian randomization and genome-wide association studies have given significant insights into the role of genetics in dyslipidemia and cardiovascular disease (CVD), with over 160 gene loci found to be associated with coronary artery disease to date. This has enabled the creation of genetic risk scores that have demonstrated improved risk prediction when added to clinical markers of CVD risk. Incorporation of genomic data into clinical patient care is on the horizon. Genomic medicine is expected to offer improved risk assessment, determination of targeted treatment strategies, and improved detection of lipid disorders causal to CVD development.

Doenças Cardiovasculares/prevenção & controle , Dislipidemias/prevenção & controle , Terapia de Alvo Molecular/tendências , Medicina de Precisão , Prevenção Primária , Doenças Cardiovasculares/genética , Doenças Cardiovasculares/terapia , Dislipidemias/genética , Dislipidemias/terapia , Diagnóstico Precoce , Estudo de Associação Genômica Ampla , Genômica , Humanos , Análise da Randomização Mendeliana , Medicina de Precisão/tendências , Medição de Risco
JAMA Cardiol ; 2(6): 627-634, 2017 06 01.
Artigo em Inglês | MEDLINE | ID: mdl-28403435


Importance: Trans-fatty acids (TFAs) have deleterious cardiovascular effects. Restrictions on their use were initiated in 11 New York State (NYS) counties between 2007 and 2011. The US Food and Drug Administration plans a nationwide restriction in 2018. Public health implications of TFA restrictions are not well understood. Objective: To determine whether TFA restrictions in NYS counties were associated with fewer hospital admissions for myocardial infarction (MI) and stroke compared with NYS counties without restrictions. Design, Setting, and Participants: We conducted a retrospective observational pre-post study of residents in counties with TFA restrictions vs counties without restrictions from 2002 to 2013 using NYS Department of Health's Statewide Planning and Research Cooperative System and census population estimates. In this natural experiment, we included those residents who were hospitalized for MI or stroke. The data analysis was conducted from December 2014 through July 2016. Exposure: Residing in a county where TFAs were restricted. Main Outcomes and Measures: The primary outcome was a composite of MI and stroke events based on primary discharge diagnostic codes from hospital admissions in NYS. Admission rates were calculated by year, age, sex, and county of residence. A difference-in-differences regression design was used to compare admission rates in populations with and without TFA restrictions. Restrictions were only implemented in highly urban counties, based on US Department of Agriculture Economic Research Service Urban Influence Codes. Nonrestriction counties of similar urbanicity were chosen to make a comparison population. Temporal trends and county characteristics were accounted for using fixed effects by county and year, as well as linear time trends by county. We adjusted for age, sex, and commuting between restriction and nonrestriction counties. Results: In 2006, the year before the first restrictions were implemented, there were 8.4 million adults (53.6% female) in highly urban counties with TFA restrictions and 3.3 million adults (52.3% female) in highly urban counties without restrictions. Twenty-five counties were included in the nonrestriction population and 11 in the restriction population. Three or more years after restriction implementation, the population with TFA restrictions experienced significant additional decline beyond temporal trends in MI and stroke events combined (-6.2%; 95% CI, -9.2% to -3.2%; P < .001) and MI (-7.8%; 95% CI, -12.7% to -2.8%; P = .002) and a nonsignificant decline in stroke (-3.6%; 95% CI, -7.6% to 0.4%; P = .08) compared with the nonrestriction populations. Conclusions and Relevance: The NYS populations with TFA restrictions experienced fewer cardiovascular events, beyond temporal trends, compared with those without restrictions.

Hospitalização/estatística & dados numéricos , Legislação sobre Alimentos , Infarto do Miocárdio/epidemiologia , Acidente Vascular Cerebral/epidemiologia , Ácidos Graxos Trans , Idoso , Estudos de Casos e Controles , Bases de Dados Factuais , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , New York/epidemiologia , Análise de Regressão , Estudos Retrospectivos
Clin Lipidol ; 10(4): 305-312, 2015 Aug 01.
Artigo em Inglês | MEDLINE | ID: mdl-26413163


Lipoprotein X (LpX) is an abnormal lipoprotein found in conditions such as lecithin:cholesterol acyltransferase deficiency and cholestatic states (e.g., primary biliary cirrhosis and primary sclerosing cholangitis). Management of severe hypercholesterolemia due to LpX with drugs and physical removal methods is not well established in the literature. A case is discussed of a 51-year-old woman who presented with multiple electrolyte abnormalities, xanthomas and neuropathy found to be secondary to LpX in the setting of primary sclerosing cholangitis. This case highlights that oral medications, including statins, may be insufficient to normalize lipid levels or improve clinical symptoms of LpX and presents therapeutic plasma exchange as a safe and effective therapeutic option to treat the morbid sequela of LpX hyperlipidemia.