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1.
Circulation ; 2019 Sep 23.
Artigo em Inglês | MEDLINE | ID: mdl-31542942

RESUMO

Background: Once-weekly exenatide (EQW) had a neutral effect on hospitalization for heart failure (hHF) in the Exenatide Study of Cardiovascular Event Lowering (EXSCEL), with no differential treatment effect on major adverse cardiac events (MACE) by baseline heart failure (HF) status. EQW's effects on secondary endpoints based on hHF status have not been reported. The objective was to explore the effects of EQW on secondary endpoints in patients with and without baseline HF and test the effects of EQW on recurrent hHF events. Methods: The prespecified analysis of the randomized controlled EXSCEL trial, which enrolled patients with type 2 diabetes with and without additional cardiovascular disease, analyzed EQW effects on all-cause death, each MACE component, first hHF and repeat hHF by baseline HF status (regardless of ejection fraction). A subgroup analysis of the population stratified by preserved or reduced baseline ejection fraction was performed. Results: Of 14,752 EXSCEL participants, 2389 (16.2%) had HF at baseline. Compared with those without HF at baseline, patients with preexisting HF were older, more likely to be male and White, and with a higher burden of other cardiovascular diseases. Overall, those assigned to EQW had a lower incidence of all-cause death (HR 0.86, 95%CI 0.77-0.97) and the composite outcome of all-cause death or hHF (HR 0.89, 95%CI 0.80-0.99). When stratified by presence or absence of baseline HF, there was no observed reduction in all-cause death with EQW with baseline HF (HR 1.05, 95%CI 0.85-1.29), while the risk of mortality was reduced with EQW in the no-HF group (HR 0.79, 95%CI 0.68-0.92) with an interaction p-value of 0.031. Reduction in all-cause death or hHF seen with EQW in patients without baseline HF (HR 0.81, 95%CI 0.71-0.93) was not seen in patients with baseline HF (HR 1.07, 95%CI 0.89-1.29) (interaction p=0.015). First plus recurrent hHF was reduced in the exenatide group versus placebo (HR 0.82, 95%CI 0.68-0.99; p=0.038). Conclusions: In EXSCEL, the use of EQW in patients with or without HF was well tolerated, but benefits of EQW on reduction in all-cause death and first hospitalization for HF were attenuated in patients with baseline HF. Clinical Trial Registration: URL: https://clinicaltrials.gov Unique Identifier: NCT01144338.

2.
Clin Transplant ; : e13710, 2019 Sep 13.
Artigo em Inglês | MEDLINE | ID: mdl-31518448

RESUMO

BACKGROUND: Physical inactivity and depressive symptoms following cardiothoracic transplantation are recognized as potentially modifiable psychosocial factors to improve clinical outcomes. However, few studies have prospectively assessed these in ambulatory, outpatient transplant recipients. METHODS: We conducted a prospective, single-center study examining actigraphy-assessed physical activity (PA) levels over a 1-week period in heart or lung transplant recipients recruited at 6 months (range 4-9) post-transplant. Depressive symptoms (Centers for Epidemiologic Study of Depression [CESD]), quality of life (QoL), and clinical events (transplant-related hospitalization and death) were collected. Clustered Cox proportional hazards models were used to examine the associations between PA, psychological measures, and clinical events. RESULTS: Among 105 potentially eligible participants, 66 (63%) met inclusion criteria and were enrolled between July, 2016 and May, 2017, including 42 lung and 24 heart transplant recipients. The mean age of the population was 53 years, 41% were women and 18% were black. Participants tended to be sedentary, with the majority of activity spent within the "sedentary" level (61%) and an average daily step count of 7188 (SD = 2595). In addition, participants tended to exhibit subclinical depressive symptoms, (mean CESD = 9.4 [SD = 8]) with only a subset exhibiting levels suggestive of clinical depression (22%). Over a median follow-up of 1.4 years (1.14, 1.62), 21 participants (32%) experienced at least one transplant-related hospitalization, including two deaths. In adjusted survival models, greater intensity of PA (HR = 0.45 [0.24, 0.84] per 0.2 METs, P = .012) was associated with a lower risk of clinical events, whereas greater depressive symptoms (HR = 2.11 [1.58, 2.82] per 9 CESD points, P < .001) at 6 months were associated a higher likelihood of subsequent transplant-related hospitalization and/or death. CONCLUSIONS: Physical inactivity and depressive symptoms at 6 months post-transplant were predictive of subsequent adverse clinical events among ambulatory cardiothoracic transplant recipients. Future studies should examine whether improving these potentially modifiable post-transplant risk factors improves clinical outcomes.

5.
Contemp Clin Trials ; 2019 Jun 19.
Artigo em Inglês | MEDLINE | ID: mdl-31228563

RESUMO

Individual-level baseline covariate imbalance could happen more frequently in cluster randomized trials, and may influence the observed treatment effect. Using computer and real-data simulations, this paper quantifies the extent and impact of covariate imbalance on the estimated treatment effect for both continuous and binary outcomes, and relates it to the degree of imbalance for different numbers of clusters, cluster sizes, and covariate intraclass correlation coefficients. We focused on the impact of race as a covariate, given the emphasis of regulatory and funding bodies on understanding the influence of demographic characteristics on treatment effectiveness. We found that bias in the treatment effect is proportional to both the degree of baseline covariate imbalance and the covariate effect size. Larger numbers of clusters result in lower covariate imbalance, and increasing cluster size is less effective in reducing imbalance compared to increasing the number of clusters. Models adjusted for important baseline confounders are superior to unadjusted models for minimizing bias in both model-based simulations and an innovative simulation based on real clinical trial data. Higher outcome intraclass correlation coefficients did not affect bias but resulted in greater variance in treatment estimates.

7.
Artigo em Inglês | MEDLINE | ID: mdl-31147170

RESUMO

OBJECTIVES: We hypothesized that an increased duration of donor brain death may worsen survival following orthotopic heart transplantation. METHODS: The United Network for Organ Sharing Registry was queried for first-time, adult recipients of heart transplant from 2006 to 2018. Cox proportional hazards with penalized smooth splines was used to stratify patients based on donor brain death interval: shorter (<22 hours), reference (22-42 hours), and longer (>42 hours). Overall survival was estimated using Kaplan-Meier and Cox proportional hazards models. RESULTS: A total of 22,960 patients met study criteria (9.2% shorter, 55.0% reference, and 35.8% longer). Longer brain death duration recipients were more likely to have a later year of transplant and have a mechanical bridge to transplant, whereas longer duration donors were more likely to be black and die of anoxia compared with shorter duration and reference donors. Compared with reference, neither shorter (hazard ratio, 1.02; 95% confidence interval, 0.94-1.12) nor longer donor brain death interval (hazard ratio, 1.01; 95% CI, 0.94-1.08) was associated with posttransplant survival in either unadjusted or multivariable analyses (both P values >0.6). CONCLUSIONS: Longer duration of brain death was not associated with worse survival following heart transplantation. Donors with prolonged interval of brain death should not necessarily be excluded based on brain death period alone.

9.
Circulation ; 140(7): e294-e324, 2019 Aug 13.
Artigo em Inglês | MEDLINE | ID: mdl-31167558

RESUMO

Type 2 diabetes mellitus is a risk factor for incident heart failure and increases the risk of morbidity and mortality in patients with established disease. Secular trends in the prevalence of diabetes mellitus and heart failure forecast a growing burden of disease and underscore the need for effective therapeutic strategies. Recent clinical trials have demonstrated the shared pathophysiology between diabetes mellitus and heart failure, the synergistic effect of managing both conditions, and the potential for diabetes mellitus therapies to modulate the risk of heart failure outcomes. This scientific statement on diabetes mellitus and heart failure summarizes the epidemiology, pathophysiology, and impact of diabetes mellitus and its control on outcomes in heart failure; reviews the approach to pharmacological therapy and lifestyle modification in patients with diabetes mellitus and heart failure; highlights the value of multidisciplinary interventions to improve clinical outcomes in this population; and outlines priorities for future research.

10.
J Card Fail ; 25(8): 584-619, 2019 Aug.
Artigo em Inglês | MEDLINE | ID: mdl-31174952

RESUMO

Type 2 diabetes mellitus is a risk factor for incident heart failure and increases the risk of morbidity and mortality in patients with established disease. Secular trends in the prevalence of diabetes mellitus and heart failure forecast a growing burden of disease and underscore the need for effective therapeutic strategies. Recent clinical trials have demonstrated the shared pathophysiology between diabetes mellitus and heart failure, the synergistic effect of managing both conditions, and the potential for diabetes mellitus therapies to modulate the risk of heart failure outcomes. This scientific statement on diabetes mellitus and heart failure summarizes the epidemiology, pathophysiology, and impact of diabetes mellitus and its control on outcomes in heart failure; reviews the approach to pharmacological therapy and lifestyle modification in patients with diabetes mellitus and heart failure; highlights the value of multidisciplinary interventions to improve clinical outcomes in this population; and outlines priorities for future research.

11.
Can J Cardiol ; 35(9): 1097-1105, 2019 Sep.
Artigo em Inglês | MEDLINE | ID: mdl-31230825

RESUMO

BACKGROUND: Acute heart failure (HF) patients with renal insufficiency and risk factors for diuretic resistance may be most likely to derive incremental improvement in congestion with the addition of spironolactone. METHODS: The Aldosterone Targeted Neurohormonal Combined with Natriuresis Therapy in Heart Failure (ATHENA-HF) trial randomized 360 acute HF patients with reduced or preserved ejection fraction to spironolactone 100 mg daily or usual care for 96 hours. The current analysis assessed the effects of study therapy within tertiles of baseline estimated glomerular filtration rate (eGFR) and subgroups at heightened risk for diuretic resistance. RESULTS: Across eGFR tertiles, there was no incremental benefit of high-dose spironolactone on any efficacy endpoint, including changes in log N-terminal pro-B-type natriuretic peptide and signs and symptoms of congestion (all P for interaction ≥ 0.06). High-dose spironolactone had no significant effect on N-terminal pro-B-type natriuretic peptide reduction regardless of blood pressure, diabetes mellitus status, and loop diuretic dose (all P for interaction ≥ 0.38). In-hospital changes in serum potassium and creatinine were similar between treatment groups for all GFR tertiles (all P for interaction ≥ 0.18). Rates of inpatient worsening HF, 30-day worsening HF, and 60-day all-cause mortality were numerically higher among patients with lower baseline eGFR, but relative effects of study treatment did not differ with renal function (all P for interaction ≥ 0.27). CONCLUSIONS: High-dose spironolactone did not improve congestion over usual care among patients with acute HF, irrespective of renal function and risk factors for diuretic resistance. In-hospital initiation or continuation of spironolactone was safe during the inpatient stay, even when administered at high doses to patients with moderate renal dysfunction.

12.
JAMA Netw Open ; 2(5): e192375, 2019 May 03.
Artigo em Inglês | MEDLINE | ID: mdl-31050773

RESUMO

Importance: Use of palliative care (PC) for patients with cardiovascular disease (CVD) has increased recently. However, it is unknown if patients are receiving earlier referrals to PC. Objective: To assess characteristics and trends of patients with CVD referred to PC. Design, Setting, and Participants: Cohort study in which analysis of data from the multicenter Quality Data Collection Tool for Palliative Care registry from January 2, 2015, through December 29, 2017, included patients with CVD 18 years or older referred to initial PC consultation who had a documented palliative performance score (PPS) . Exposures: Patients with CVD who presented for an initial PC visit. Main Outcomes and Measures: The primary outcome was PPS. Secondary outcomes included symptoms and end-of-life documentation. Results: Among 1801 patients (mean [SD] age, 77.7 [13.7] years) from 16 sites in the analysis, 875 (48.6%) were women and 1339 (74.3%) were white. A low PPS score (0%-30%), consistent with bedbound status, was recorded for 521 patients (28.9%), with no change through time. The most common moderate to severe symptoms were poor well-being, tiredness, anorexia, and dyspnea. Year of encounter was associated with improved symptoms of pain (odds ratio, 1.25; 95% CI, 1.05-1.50) and with constipation (odds ratio, 1.32; 95% CI, 1.03-1.69). No change through time was noted in other symptoms or end-of-life documentation. Although the proportion of referrals from general medicine increased from 43.2% (167 of 387) in 2015 to 52.9% (410 of 775) in 2017, the proportion of referrals from cardiologists decreased from 16.5% (64 of 387) in 2015 to 10.5% (81 of 775) in 2017. The proportion of patients referred to PC who were black decreased from 11.9% (46 of 387) in 2015 to 6.3% (49 of 775) in 2017. While 69.5% of all patients with CVD (1252 of 1801) had a primary diagnosis of heart failure, the proportion of non-heart failure CVD diagnoses, such as coronary artery disease and valvular heart disease, increased from 25.6% (99 of 387) in 2015 to 30.1% (233 of 775) in 2017. Conclusions and Relevance: Patients with CVD demonstrated significant symptom burden, and there was no evidence in the registry of change in the PPSs of patients with CVD referred to PC through time. Cardiologists provided comparatively fewer referrals to PC for patients with CVD, and this proportion decreased through time. The proportion of racial and ethnic minorities referred to PC was small and decreased through time. These findings reinforce the need for cardiologists to be more engaged with PC and consider referring appropriate patients with CVD sooner.

13.
JACC Heart Fail ; 7(5): 371-382, 2019 May.
Artigo em Inglês | MEDLINE | ID: mdl-31047016

RESUMO

Large randomized clinical trials (RCT) supporting guidelines for the management of heart failure with reduced ejection fraction (HFrEF) have typically excluded patients with advanced chronic kidney disease (CKD). Patients with concomitant advanced CKD and HFrEF experience poor cardiovascular outcomes and mortality relative to either disease in isolation and have been shown to consistently receive lower rates of HFrEF guideline-directed medical therapy (GDMT). This review evaluated recent evidence for the use of GDMT in patients with HFrEF and advanced CKD approaching dialysis from RCTs and observational cohorts. The authors also discuss the limitations and challenges inherent in the evidence for GDMT in this population, and offer guidance to clinicians for proper clinical use and future research directions.

14.
J Am Coll Cardiol ; 73(19): 2388-2397, 2019 May 21.
Artigo em Inglês | MEDLINE | ID: mdl-31097157

RESUMO

BACKGROUND: Primary prevention strategies to mitigate the burden of heart failure (HF) are urgently needed. However, no validated risk prediction tools are currently in use. OBJECTIVES: This study sought to derive 10-year risk equations of developing incident HF. METHODS: Race- and sex-specific 10-year risk equations for HF were derived and validated from individual-level data from 7 community-based cohorts with at least 12 years of follow-up. Participants who were recruited between 1985 and 2000, between 30 to 79 years, and were free of cardiovascular disease at baseline were included to create a pooled cohort (PC) and were randomly split for derivation and internal validation. Model performance was also assessed in 2 additional cohorts. RESULTS: In the derivation sample of the PC (n = 11,771), 58% were women, 22% were black with a mean age of 52 ± 12 years, and HF occurred in 1,339 participants. Predictors of HF included in the race-sex-specific models were age, blood pressure (treated or untreated), fasting glucose (treated or untreated), body mass index, cholesterol, smoking status, and QRS duration. The PC equations to Prevent HF model had good discrimination and strong calibration in internal and external validation cohorts. A web-based tool was developed to facilitate clinical application of this tool. CONCLUSIONS: The authors present a contemporary analysis from 33,010 men and women demonstrating the utility of the sex- and race-specific 10-year PC equations to Prevent HF risk score, which integrates clinical parameters readily available in primary care settings. This tool can be useful in risk-based decision making to determine who may merit intensive screening and/or targeted prevention strategies.

15.
Am J Ther ; 2019 May 24.
Artigo em Inglês | MEDLINE | ID: mdl-31145139

RESUMO

BACKGROUND: Many patients with heart failure (HF) are treated with warfarin or non-vitamin K oral anticoagulants (NOACs). Randomized outcome-driven comparisons of different anticoagulant strategies in HF are lacking. Data from international, government-mandated registries may be useful in understanding the real-life use of various anticoagulants and how they are linked to outcomes. STUDY QUESTION: To assess 2015 annual all-cause mortality, myocardial infarction, and stroke rates co-reported for warfarin and NOACs in subjects with and without HF in the US Food and Drug Administration Adverse Event Reporting System (FAERS) database. STUDY DESIGN: We extracted and examined outcome cases in subjects with HF and on warfarin, dabigatran, rivaroxaban, apixaban, or edoxaban and stratified these according to anticoagulants. MEASURES AND OUTCOMES: Annual all-cause mortality, myocardial infarction, and stroke in FAERS. ANALYSIS METHOD: Odds ratio (OR) and χχ for oral anticoagulants from FAERS with and without HF among complete primary reports issued in 2015. RESULTS: FAERS reported 137,026 HF cases, with death co-reported in 42,942 (31.3%). In total, 11,278 (8.2%) HF patients were treated with anticoagulants, with more prescribed warfarin (n = 8260) than all NOACs combined (n = 3018). Very few reports for edoxaban were available. Warfarin consistently displayed a signal for excess adverse events compared to NOACs: OR (95% confidence interval) for the composite of mortality, myocardial infarction, and stroke were 1.91 (1.76-2.07) versus apixaban, 1.92 (1.81-2.03) versus dabigatran, 4.09 (3.38-4.37) versus rivaroxaban, and 2.64 (2.53-2.76) versus all NOACs combined (all P < 0.001). Warfarin, compared to all NOACs combined, demonstrated higher rates of all-cause mortality [OR = 2.69 (95% confidence interval, 2.49-2.90)], myocardial infarction [5.30 (4.17-6.74)], stroke [OR = 8.85 (6.61-11.84)], and ischemic stroke [OR = 12.73 (8.87-18.27); all P < 0.001]. CONCLUSIONS: Annual 2015 FAERS profiles in HF patients reveal that warfarin was numerically dominant. Warfarin was associated with higher risk of death, myocardial infarction, and stroke compared to NOACs. These observational data provide real-world insight into a potential safety benefit of NOACs over warfarin in the setting of HF.

16.
Eur Heart J ; 40(26): 2155-2163, 2019 Jul 01.
Artigo em Inglês | MEDLINE | ID: mdl-30957868

RESUMO

Randomized clinical trials initially used heart failure (HF) patients with low left ventricular ejection fraction (LVEF) to select study populations with high risk to enhance statistical power. However, this use of LVEF in clinical trials has led to oversimplification of the scientific view of a complex syndrome. Descriptive terms such as 'HFrEF' (HF with reduced LVEF), 'HFpEF' (HF with preserved LVEF), and more recently 'HFmrEF' (HF with mid-range LVEF), assigned on arbitrary LVEF cut-off points, have gradually arisen as separate diseases, implying distinct pathophysiologies. In this article, based on pathophysiological reasoning, we challenge the paradigm of classifying HF according to LVEF. Instead, we propose that HF is a heterogeneous syndrome in which disease progression is associated with a dynamic evolution of functional and structural changes leading to unique disease trajectories creating a spectrum of phenotypes with overlapping and distinct characteristics. Moreover, we argue that by recognizing the spectral nature of the disease a novel stratification will arise from new technologies and scientific insights that will shape the design of future trials based on deeper understanding beyond the LVEF construct alone.

17.
Am Heart J ; 212: 72-79, 2019 Jun.
Artigo em Inglês | MEDLINE | ID: mdl-30954832

RESUMO

BACKGROUND: Emerging data suggest that neck circumference (NC) is associated with cardiometabolic risk factors. Limited research is available regarding the association between NC and cardiovascular outcomes in African Americans. METHODS: Using data from the Jackson Heart Study, we included participants with recorded NC measurements at baseline (2000-2004). Baseline characteristics for the included population were summarized by tertiles of NC. We then calculated age- and sex-adjusted cumulative incidence of clinical cardiovascular outcomes and performed Cox proportional-hazards with stepwise models. RESULTS: Overall, 5,290 participants were categorized into tertiles of baseline NC defined as ≤37 cm (n = 2179), 38-40 cm (n = 1552), and >40 cm (n = 1559). After adjusting for age and sex, increasing NC was associated with increased risk of heart failure (HF) hospitalization (cumulative incidence = 13.4% [99% CI, 10.7-16.7] in the largest NC tertile vs 6.5% [99% CI, 4.7-8.8] in the smallest NC tertile), but not mortality, stroke, myocardial infarction, or coronary heart disease (all P ≥ .1). Following full risk adjustment, there was a nominal increase in the risk of HF hospitalization with increasing NC, but this was not statistically significant (hazard ratio per 1-cm increase, 1.04 [99% CI, 0.99-1.10], P = .06). CONCLUSIONS: In this large cohort of African American individuals, a larger NC was associated with increased risk for HF hospitalization following adjustment for age and sex, but this risk was not statistically significant after adjusting for other clinical variables. Although NC is not independently associated with increased risk for cardiovascular events, it may offer prognostic information particularly related to HF hospitalization.

18.
ESC Heart Fail ; 6(3): 464-474, 2019 06.
Artigo em Inglês | MEDLINE | ID: mdl-31021532

RESUMO

Acute heart failure (HF) is a major public health concern, responsible for >26 million hospitalizations per year worldwide. Many trials have investigated new therapeutic options for acute HF, with most revealing equivocal results. Successful innovations in therapy for acute HF have remained limited, and standard of care has remained largely unchanged over the past decade, suggesting the need for a new approach for therapeutic decision making and clinical trial design in acute HF. This manuscript focuses on one approach that could prove useful in the development and application of novel therapies: classification of patients based on clinical profiles. While previous attempts at developing clinical profiles were successful in stratifying patients based on clinical and laboratory variables, they have not been utilized for personalized treatment strategies that improve patient outcomes. We suggest a new approach to the creation of clinical profiles that could stratify patients based on their underlying aetiology and their response to novel interventions. We also investigate novel analytic approaches to the creation of new clinical profiles that both investigators and clinicians alike could utilize to inform clinical trial design and the application of new therapies. Despite a large number of clinical trials for new therapeutic options, the treatment of acute HF has seen few advances over the past decades. Innovative approaches to patient selection through the use of clinical profiles could help to identify patients most likely to benefit from novel interventions and lead to the discovery of new therapeutic options.

19.
JAMA ; 321(11): 1081-1095, 2019 03 19.
Artigo em Inglês | MEDLINE | ID: mdl-30874756

RESUMO

Importance: Cholesterol is a common nutrient in the human diet and eggs are a major source of dietary cholesterol. Whether dietary cholesterol or egg consumption is associated with cardiovascular disease (CVD) and mortality remains controversial. Objective: To determine the associations of dietary cholesterol or egg consumption with incident CVD and all-cause mortality. Design, Setting, and Participants: Individual participant data were pooled from 6 prospective US cohorts using data collected between March 25, 1985, and August 31, 2016. Self-reported diet data were harmonized using a standardized protocol. Exposures: Dietary cholesterol (mg/day) or egg consumption (number/day). Main Outcomes and Measures: Hazard ratio (HR) and absolute risk difference (ARD) over the entire follow-up for incident CVD (composite of fatal and nonfatal coronary heart disease, stroke, heart failure, and other CVD deaths) and all-cause mortality, adjusting for demographic, socioeconomic, and behavioral factors. Results: This analysis included 29 615 participants (mean [SD] age, 51.6 [13.5] years at baseline) of whom 13 299 (44.9%) were men and 9204 (31.1%) were black. During a median follow-up of 17.5 years (interquartile range, 13.0-21.7; maximum, 31.3), there were 5400 incident CVD events and 6132 all-cause deaths. The associations of dietary cholesterol or egg consumption with incident CVD and all-cause mortality were monotonic (all P values for nonlinear terms, .19-.83). Each additional 300 mg of dietary cholesterol consumed per day was significantly associated with higher risk of incident CVD (adjusted HR, 1.17 [95% CI, 1.09-1.26]; adjusted ARD, 3.24% [95% CI, 1.39%-5.08%]) and all-cause mortality (adjusted HR, 1.18 [95% CI, 1.10-1.26]; adjusted ARD, 4.43% [95% CI, 2.51%-6.36%]). Each additional half an egg consumed per day was significantly associated with higher risk of incident CVD (adjusted HR, 1.06 [95% CI, 1.03-1.10]; adjusted ARD, 1.11% [95% CI, 0.32%-1.89%]) and all-cause mortality (adjusted HR, 1.08 [95% CI, 1.04-1.11]; adjusted ARD, 1.93% [95% CI, 1.10%-2.76%]). The associations between egg consumption and incident CVD (adjusted HR, 0.99 [95% CI, 0.93-1.05]; adjusted ARD, -0.47% [95% CI, -1.83% to 0.88%]) and all-cause mortality (adjusted HR, 1.03 [95% CI, 0.97-1.09]; adjusted ARD, 0.71% [95% CI, -0.85% to 2.28%]) were no longer significant after adjusting for dietary cholesterol consumption. Conclusions and Relevance: Among US adults, higher consumption of dietary cholesterol or eggs was significantly associated with higher risk of incident CVD and all-cause mortality in a dose-response manner. These results should be considered in the development of dietary guidelines and updates.


Assuntos
Doenças Cardiovasculares/etiologia , Colesterol na Dieta/efeitos adversos , Ovos/efeitos adversos , Mortalidade , Adulto , Idoso , Dieta , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Inquéritos Nutricionais , Estudos Prospectivos , Fatores de Risco , Autorrelato
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