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1.
JACC Heart Fail ; 2020 Jan 31.
Artigo em Inglês | MEDLINE | ID: mdl-32035890

RESUMO

OBJECTIVES: The aims of this study were to compare the characteristics of patients with and without diabetes and to use network analyses to compare biomarker profiles and associated pathways in patients with diabetes compared with those without diabetes, which might offer new avenues for potential therapeutic targets. BACKGROUND: Diabetes adversely affects clinical outcomes and complicates treatment in patients with heart failure (HF). A clear understanding of the pathophysiological processes associated with type 2 diabetes in HF is lacking. METHODS: Network and pathway over-representation analyses were performed to identify unique pathological pathways in patients with and without diabetes using 92 biomarkers from different pathophysiological domains measured in plasma samples from 1,572 patients with HF (31% with diabetes) with reduced ejection fraction (left ventricular ejection fraction <40%). The results were validated in an independent cohort of 729 patients (30% with diabetes). RESULTS: Biomarker profiles were first compared between patients with HF with and without diabetes. Patients with diabetes showed higher levels of galectin-4, growth differentiation factor 15, and fatty acid binding protein 4 and lower levels of paraoxonase 3. Network analyses were then performed, revealing that epidermal growth factor receptor and galectin-3 were the most prominent connecting proteins. Translation of these networks to biologic pathways revealed that diabetes was associated with inflammatory response and neutrophil degranulation. Diabetes conferred worse outcomes after correction for an established risk model (hazard ratio: 1.20; 95% confidence interval: 1.01 to 1.42). CONCLUSIONS: Concomitant diabetes in patients with HF with reduced ejection fraction is associated with distinct pathophysiological pathways related to inflammation, protein phosphorylation, and neutrophil degranulation. These data support the evaluation of anti-inflammatory therapeutic approaches, epidermal growth factor receptor in particular, for patients with HF and diabetes.

2.
J Am Heart Assoc ; 9(1): e012797, 2020 Jan 07.
Artigo em Inglês | MEDLINE | ID: mdl-31902327

RESUMO

Background Improved heart failure (HF) risk stratification after a recent acute coronary syndrome may identify those who can benefit from therapies that reduce HF risk. We aimed to identify clinical and biomarker predictors for expanded HF outcomes in patients with type 2 diabetes mellitus after recent acute coronary syndrome. Methods and Results The EXAMINE (Examination of Cardiovascular Outcomes with Alogliptin versus Standard of Care) trial was a multicenter, non-inferiority, double-masked, placebo-controlled study which randomized 5380 patients with type 2 diabetes mellitus after recent acute coronary syndrome to alogliptin or placebo. Baseline biomarkers were measured in 5154 patients: NT-proBNP (N-terminal pro-B-type natriuretic peptide), high-sensitivity troponin I, adiponectin, growth-differentiation-factor-15, and galectin-3. Our primary outcome was cardiovascular) death, HF hospitalization, elevated NT-proBNP during follow-up, or loop diuretics initiation. The association between clinical variables, biomarkers, and outcomes were assessed using Cox regression models. In the study population, the median age was 61.0 years, 67.7% were men, and 28.0% had baseline HF (median follow-up was 18 months). In multivariable analyses, NT-proBNP had the strongest association with the primary outcome (per log2, hazard ratio 1.24; Wald χ2 67.4; P<0.0001) followed by a prior HF history (hazard ratio 1.42; Wald χ2 20.8; P<0.0001). A model with clinical variables and biomarkers allowed for risk prediction for expanded HF outcomes (C-statistic=0.72). Discrimination results were similar for cardiovascular death or HF hospitalization. Conclusions Among patients with type 2 diabetes mellitus after recent acute coronary syndrome, the use biomarkers such as N-terminal pro-B-type natriuretic peptide and clinical variables enables risk stratification for expanded HF outcomes. Clinical Trial Registration URL: https://www.clinicaltrials.gov/. Unique identifier: NCT00968708.

3.
Mater Sci Eng C Mater Biol Appl ; 108: 110465, 2020 Mar.
Artigo em Inglês | MEDLINE | ID: mdl-31924022

RESUMO

A biocompatible, cost-effective, and scalable reduced graphene oxide (rGO) film was obtained from shellac using thermal treatment and its structural, chemical, and electrical properties were investigated. This thermally-decomposed rGO (TrGO) film exhibited good crystallinity, low sheet resistance, and high carbon content. TrGO flakes obtained from the film were dispersed and drop cast onto indium tin oxide/glass electrodes to fabricate label-free electrochemical immunosensors for the quantitative detection of the influenza virus H1N1 via electrochemical impedance spectroscopy. These sensors exhibited high stability and reproducibility, both possibly ascribable to the high adhesion of TrGO due to its phenolic-OH moiety; the limits of detection were 26 and 33 plaque-forming units, respectively, in phosphate-buffered saline and diluted saliva. These cost-effective TrGO-based sensors showed great potential as reliable and robust nanomaterial-based biosensors for widespread clinical applications.

4.
Circulation ; 2020 Jan 29.
Artigo em Inglês | MEDLINE | ID: mdl-31992065

RESUMO

Responding to concerns about the potential for increased risk of adverse cardiovascular (CV) outcomes, specifically myocardial infarction, associated with certain glucose-lowering therapies, the U.S. Food and Drug Administration and the Committee for Medicinal Products for Human Use of the European Medicines Agency issued guidance to the pharmaceutical industry in 2008. Glucose-lowering therapies were primarily granted regulatory approval from smaller studies that have demonstrated reductions in glycated hemoglobin concentration. Such studies were overall underpowered and of insufficient duration to show any effect on CV outcomes. The 2008 guidance aimed to ensure CV safety of new glucose-lowering therapies to treat patients with type 2 diabetes mellitus. This resulted in a plethora of new CV outcome trials, most designed primarily as placebo-controlled noninferiority trials, but with many also powered for superiority. Several of these outcome trials demonstrated CV benefits of the newer agents, resulting in the first-ever CV protection indications for glucose-lowering therapies. Determining whether the guidance continues to have value in its current form is critically important as we move forward after the first decade of implementation. In February 2018, a think tank comprising representatives from academia, industry, and regulatory agencies convened to consider the guidance in light of the findings of the completed CV outcome trials. The group made several recommendations for future regulatory guidance and for CV outcome trials regarding glucose-lowering therapies. These recommendations include requiring only the 1.3 noninferiority margin for regulatory approval, conducting trials for longer durations, considering studying glucose-lowering therapies as first-line management of type 2 diabetes, considering heart failure or kidney outcomes within the primary outcome, considering head-to-head active comparator trials, increasing the diversity of patients enrolled, evaluating strategies to streamline registries and the study of unselected populations, and identifying ways to improve translation of trial results to general practice.

5.
Eur J Heart Fail ; 2020 Jan 16.
Artigo em Inglês | MEDLINE | ID: mdl-31944496

RESUMO

AIMS: To develop a risk model for sudden cardiac death (SCD) in high-risk acute myocardial infarction (AMI) survivors. METHODS AND RESULTS: Data from the Effect of Carvedilol on Outcome After Myocardial Infarction in Patients With Left Ventricular Dysfunction trial (CAPRICORN) and the Valsartan in Acute Myocardial Infarction Trial (VALIANT) were used to create a SCD risk model (with non-SCD as a competing risk) in 13 202 patients. The risk model was validated in the Eplerenone Post-AMI Heart Failure Efficacy and Survival Study (EPHESUS). The rate of SCD was 3.3 (95% confidence interval 3.0-3.5) per 100 person-years over a median follow-up of 2.0 years. Independent predictors of SCD included age > 70 years; heart rate ≥ 70 bpm; smoking; Killip class III/IV; left ventricular ejection fraction ≤30%; atrial fibrillation; history of prior myocardial infarction, heart failure or diabetes; estimated glomerular filtration rate < 60 mL/min/1.73 m2 ; and no coronary reperfusion or revascularisation therapy for index AMI. The model was well calibrated and showed good discrimination (C-statistic = 0.72), including in the early period after AMI. The observed 2-year event rates increased steeply with each quintile of risk score (1.9%, 3.6%, 6.2%, 9.0%, 13.4%, respectively). CONCLUSION: An easy to use SCD risk score developed from routinely collected clinical variables in patients with heart failure, left ventricular systolic dysfunction or both, early after AMI was superior to left ventricular ejection fraction. This score might be useful in identifying patients for future trials testing treatments to prevent SCD early after AMI.

6.
J Orthop Res ; 38(2): 320-328, 2020 Feb.
Artigo em Inglês | MEDLINE | ID: mdl-31517395

RESUMO

Massive tears of the rotator cuff (RC) are often associated with progressive and irreversible muscle degeneration due to fibrosis, fatty infiltration, and muscle atrophy. RC tears are common in individuals older than 60 years and the repair of these tears is amongst the most prevalent of orthopedic procedures. However, most current models of this injury are established in young animals, which may not accurately recapitulate the clinical condition. In this study, we used a murine model of massive RC tears to evaluate age-related muscle degeneration following chronic injury. The expression of the fibro-adipogenic genes encoding collagen type III and leptin was higher in aged RC compared with matched injured young tissue at 2 weeks post-injury, and development of fibrosis was accelerated in aged mice within 5 days post-injury. Furthermore, the synthesis of collagens type I and III and fat tissue accumulation were significantly higher in injured RCs of aged mice. Similar frequency of fibro-adipogenic PDGFRß+ PDGFRα+ progenitor cells was measured in non-injured RC of aged and young mice, but PDGFRß+ PDGFRα+ cells contributed to significantly larger fibrotic lesions in aged RCs within 2 weeks post-injury, implying a more robust fibrotic environment in the aged injured muscle. Altogether, these findings demonstrate age-dependent differences in RC response to chronic injury with a more profound fibro-adipogenic change in aged muscles. Clinically, cell therapies for muscular pathologies should not only consider the cell type being transplanted but also the recipient milieu into which these cells are seeded. © 2019 Orthopaedic Research Society. Published by Wiley Periodicals, Inc. J Orthop Res 38:320-328, 2020.

7.
Can J Diabetes ; 44(1): 93-102, 2020 Feb.
Artigo em Inglês | MEDLINE | ID: mdl-31882322

RESUMO

The growing global burden of type 2 diabetes mellitus confers significant morbidity and mortality in addition to significant cost to local health-care systems. In recent years, 2 classes of therapies have shown some promise in reducing the risk of adverse cardiovascular (CV) events: 1) glucagon-like-peptide-1 (GLP-1) receptor agonists and 2) sodium-glucose cotransporter-2 (SGLT-2) inhibitors. The mechanisms whereby these therapies reduce the risk of adverse CV outcomes are emerging. Both classes of therapies have overlapping yet distinct mechanisms of action. GLP-1 receptor agonists appear to target the incretin axis, inhibit gastric mobility pathways, modify CV risk factors through weight reduction, induce protection of ischemia/reperfusion injury and improve endothelial dysfunction. In comparison, SGLT-2 inhibitors appear to improve ventricular loading conditions, reduce sympathetic nervous system activation, reduce cardiac fibrosis, reduce renal hypoxia and renal-cardiac signalling, reduce left ventricular mass and improve cardiac energetics. In this review, we summarize the potential mechanisms whereby GLP-1 receptor agonists and SGLT-2 inhibitors improve CV outcomes in patients with type 2 diabetes and highlight evidence for their use in populations without diabetes.

8.
J Am Heart Assoc ; 8(24): e011560, 2019 Dec 17.
Artigo em Inglês | MEDLINE | ID: mdl-31818219

RESUMO

Background Limited data exist to guide treatment for patients with heart failure with preserved ejection fraction and atrial fibrillation, including the important decision regarding rate versus rhythm control. Methods and Results We analyzed the Get With The Guidelines-Heart Failure (GWTG-HF) registry linked to Medicare claims data from 2008 to 2014 to describe current treatments for rate versus rhythm control and subsequent outcomes in patients with heart failure with preserved ejection fraction and atrial fibrillation using inverse probability weighted analysis. Rhythm control was defined as use of an antiarrhythmic medication, cardioversion, or AF ablation or surgery. Rate control was defined as use of any combination of ß-blocker, calcium channel blocker, and digoxin without evidence of rhythm control. Among 15 682 fee-for-service Medicare patients, at the time of discharge, 1857 were treated with rhythm control and 13 825 with rate control, with minimal differences in baseline characteristics between groups. There was higher all-cause death at 1 year in the rate control compared with the rhythm control group (37.5% and 30.8%, respectively, P<0.01). The lower 1-year all-cause death in the rhythm control group remained after risk adjustment (adjusted hazard ratio, 0.86; 95% CI, 0.75-0.98; P=0.02). Conclusions Rhythm control in patients aged 65 and older with heart failure with preserved ejection fraction and AF was associated with a lower risk of 1 year all-cause mortality. Future prospective randomized studies are needed to explore this potential benefit.

9.
Syst Rev ; 8(1): 317, 2019 Dec 06.
Artigo em Inglês | MEDLINE | ID: mdl-31810495

RESUMO

BACKGROUND: The growing number of medical literature and textual data in online repositories led to an exponential increase in the workload of researchers involved in citation screening for systematic reviews. This work aims to combine machine learning techniques and data preprocessing for class imbalance to identify the outperforming strategy to screen articles in PubMed for inclusion in systematic reviews. METHODS: We trained four binary text classifiers (support vector machines, k-nearest neighbor, random forest, and elastic-net regularized generalized linear models) in combination with four techniques for class imbalance: random undersampling and oversampling with 50:50 and 35:65 positive to negative class ratios and none as a benchmark. We used textual data of 14 systematic reviews as case studies. Difference between cross-validated area under the receiver operating characteristic curve (AUC-ROC) for machine learning techniques with and without preprocessing (delta AUC) was estimated within each systematic review, separately for each classifier. Meta-analytic fixed-effect models were used to pool delta AUCs separately by classifier and strategy. RESULTS: Cross-validated AUC-ROC for machine learning techniques (excluding k-nearest neighbor) without preprocessing was prevalently above 90%. Except for k-nearest neighbor, machine learning techniques achieved the best improvement in conjunction with random oversampling 50:50 and random undersampling 35:65. CONCLUSIONS: Resampling techniques slightly improved the performance of the investigated machine learning techniques. From a computational perspective, random undersampling 35:65 may be preferred.

10.
J Biomed Inform ; 102: 103354, 2019 Dec 12.
Artigo em Inglês | MEDLINE | ID: mdl-31838210

RESUMO

INTRODUCTION: Machine learning (ML) and natural language processing have great potential to improve information extraction (IE) within electronic medical records (EMRs) for a wide variety of clinical search and summarization tools. Despite ML advancements, clinical adoption of real time IE tools for patient care remains low. Clinically motivated IE task definitions, publicly available annotated clinical datasets, and inclusion of subtasks such as coreference resolution and named entity normalization are critical for the development of useful clinical tools. MATERIALS AND METHODS: We provide a task definition and comprehensive annotation requirements for a clinically motivated symptom extraction task. Four annotators labeled symptom mentions within 1108 discharge summaries from two public clinical note datasets for the tasks of named entity recognition, coreference resolution, and named entity normalization; these annotations will be released to the public. Baseline human performance was assessed and two ML models were evaluated on the symptom extraction task. RESULTS: 16,922 symptom mentions were identified within the discharge summaries, with 11,944 symptom instances after coreference resolution and 1255 unique normalized answer forms. Human annotator performance averaged 92.2% F1. Recurrent network model performance was 85.6% F1 (recall 85.8%, precision 85.4%), and Transformer-based model performance was 86.3% F1 (recall 86.6%, precision 86.1%). Our models extracted vague symptoms, acronyms, typographical errors, and grouping statements. The models generalized effectively to a separate clinical note corpus and can run in real time. CONCLUSION: To our knowledge, this dataset will be the largest and most comprehensive publicly released, annotated dataset for clinically motivated symptom extraction, as it includes annotations for named entity recognition, coreference, and normalization for more than 1000 clinical documents. Our neural network models extracted symptoms from unstructured clinical free text at near human performance in real time. In this paper, we present a clinically motivated task definition, dataset, and simple supervised natural language processing models to demonstrate the feasibility of building clinically applicable information extraction tools.

11.
Orthopedics ; : 1-5, 2019 Dec 16.
Artigo em Inglês | MEDLINE | ID: mdl-31841606

RESUMO

The purpose of this study was to assess trends in the use of perioperative single and continuous peripheral nerve blocks (PNBs) and their associations with emergency department (ED) visits after arthroscopic rotator cuff repair (RCR) surgery. The authors used a large database from a private insurer to identify patients who received perioperative PNBs for arthroscopic RCR surgeries from 2007 to 2015. They analyzed patient demographics as well as trends in perioperative PNB use. They also assessed rates of single shot vs continuous PNB use and compared rates of postoperative ED visits according to PNB type. The rate of perioperative PNB for arthroscopic RCR was higher than previously reported (65.9%) and increased over time (52.8% in 2007 to 64.6% in 2015; P=.029). Single shot PNBs were more common than continuous, catheter-mediated PNBs (60.0% vs 6.6%; P<.001), although the use of continuous blocks increased at a greater rate during the study period. Patients who received a perioperative continuous PNB were significantly more likely to visit an ED within 7 days of their surgery than those who received a single shot PNB or no PNB (6.71% vs 4.78% vs 4.74%; P<.02). The rates of ED visits within each group did not change significantly over time. Continuous PNBs are increasingly common for patients undergoing arthroscopic RCR surgery but are associated with increased rates of postoperative ED visits. Studies are needed to identify the reasons for this increased rate of ED visits and strategies to decrease ED use. [Orthopedics. 2020; xx(x): xx-xx.].

13.
Opt Express ; 27(24): 34496-34504, 2019 Nov 25.
Artigo em Inglês | MEDLINE | ID: mdl-31878638

RESUMO

Efficient monitoring of airborne particulate matter (PM), especially particles with aerodynamic diameter less than 2.5 µm (PM2.5), is crucial for improving public health. Reliable information on the concentration, size distribution and chemical characteristics of PMs is key to evaluating air pollution and identifying its sources. Standard methods for PM2.5 characterization require sample collection from the atmosphere and post-analysis using sophisticated equipment in a laboratory environment, and are normally very time-consuming. Although optical methods based on analysis of scattering of free-space laser beams or evanescent fields are in principle suitable for real-time particle counting and sizing, lack of knowledge of the refractive index in these methods not only leads to inevitable sizing ambiguity but also prevents identification of the particle material. In the case of evanescent wave detection, the system lifetime is strongly limited by adhesion of particles to the surfaces. Here we report a novel technique for airborne particle metrology based on hollow-core photonic crystal fibre. It offers in situ particle counting, sizing and refractive index measurement with effectively unlimited device lifetime, and relies on optical forces that automatically capture airborne particles in front of the hollow core and propel them into the fibre. The resulting transmission drop, together with the time-of-flight of the particles passing through the fibre, provide unambiguous mapping of particle size and refractive index with high accuracy. The technique offers unique advantages over currently available real-time particle metrology systems, and can be directly applied to monitoring air pollution in the open atmosphere as well as precise particle characterization in a local environment such as a closed room or a reaction vessel.

14.
JCI Insight ; 4(24)2019 12 19.
Artigo em Inglês | MEDLINE | ID: mdl-31852842

RESUMO

Massive tears of the rotator cuff (RC) are associated with chronic muscle degeneration due to fibrosis, fatty infiltration, and muscle atrophy. The microenvironment of diseased muscle often impairs efficient engraftment and regenerative activity of transplanted myogenic precursors. Accumulating myofibroblasts and fat cells disrupt the muscle stem cell niche and myogenic cell signaling and deposit excess disorganized connective tissue. Therefore, restoration of the damaged stromal niche with non-fibro-adipogenic cells is a prerequisite to successful repair of an injured RC. We generated from human embryonic stem cells (hES) a potentially novel subset of PDGFR-ß+CD146+CD34-CD56- pericytes that lack expression of the fibro-adipogenic cell marker PDGFR-α. Accordingly, the PDGFR-ß+PDGFR-α- phenotype typified non-fibro-adipogenic, non-myogenic, pericyte-like derivatives that maintained non-fibro-adipogenic properties when transplanted into chronically injured murine RCs. Although administered hES pericytes inhibited developing fibrosis at early and late stages of progressive muscle degeneration, transplanted PDGFR-ß+PDGFR-α+ human muscle-derived fibro-adipogenic progenitors contributed to adipogenesis and greater fibrosis. Additionally, transplanted hES pericytes substantially attenuated muscle atrophy at all tested injection time points after injury. Coinciding with this observation, conditioned medium from cultured hES pericytes rescued atrophic myotubes in vitro. These findings imply that non-fibro-adipogenic hES pericytes recapitulate the myogenic stromal niche and may be used to improve cell-based treatments for chronic muscle disorders.

15.
ESC Heart Fail ; 2019 Nov 20.
Artigo em Inglês | MEDLINE | ID: mdl-31747132

RESUMO

AIMS: Sodium-glucose co-transporter (SGLT)-2 inhibitors have been shown to reduce the risk of cardiovascular death and heart failure (HF) hospitalization in patients with type 2 diabetes mellitus (DM) and high cardiovascular risk in two large clinical outcome trials: empagliflozin in EMPA-REG OUTCOME and canagliflozin in CANVAS. The scope of eligibility for SGLT-2 inhibitors (empagliflozin and canagliflozin) among patients with type 2 DM and HF, based on clinical trial criteria and current US Food and Drug Administration (FDA) labelling criteria, remains unknown. METHODS AND RESULTS: Using data from the US Get With The Guidelines (GWTG)-Heart Failure registry, we evaluated the proportion of patients with DM and HF eligible for SGLT-2 inhibitor therapy based on the clinical trial criteria and the US FDA labelling criteria. The GWTG-HF registry is a quality improvement registry of patients admitted in hospital with HF in the USA. We included GWTG-HF registry participants meeting eligibility criteria hospitalized between August 2014 and 30 June 2017 from sites fully participating in the registry. The initial inclusion time point reflects when both drugs had FDA approval. Among the 139 317 patients (out of 407 317) with DM hospitalized with HF (in 460 hospitals; 2014 to 2017), the median age was 71 years, 47% (n = 65 685) were female, and 43% (n = 59 973) had HF with reduced ejection fraction. Overall, 43% (n = 59 943) were eligible for the EMPA-REG OUTCOME trial, 45% (n = 62 818) were eligible for the CANVAS trial, and 34% (n = 47 747) of patients were eligible for either SGLT-2 inhibitors based on the FDA labelling criteria. Among the FDA-eligible patients, 91.5% (n = 43 708) were eligible for either the EMPA-REG OUTCOME trial or the CANVAS trial. Patients who were FDA eligible, compared with those who were not, were younger (70.0 vs. 72.0 years of age), more likely to be male (57.7 vs. 50.3%), and had less burden of co-morbidities. CONCLUSIONS: The majority of patients with DM who are hospitalized with HF are not eligible for SGLT-2 inhibitor therapies. Ongoing studies evaluating the safety and efficacy of SGLT-2 inhibitors among patients with HF may potentially broaden the population that may benefit from these therapies.

16.
Circulation ; 140(17): 1426-1436, 2019 Oct 22.
Artigo em Inglês | MEDLINE | ID: mdl-31634011

RESUMO

The complexity and costs associated with traditional randomized, controlled trials have increased exponentially over time, and now threaten to stifle the development of new drugs and devices. Nevertheless, the growing use of electronic health records, mobile applications, and wearable devices offers significant promise for transforming clinical trials, making them more pragmatic and efficient. However, many challenges must be overcome before these innovations can be implemented routinely in randomized, controlled trial operations. In October of 2018, a diverse stakeholder group convened in Washington, DC, to examine how electronic health record, mobile, and wearable technologies could be applied to clinical trials. The group specifically examined how these technologies might streamline the execution of clinical trial components, delineated innovative trial designs facilitated by technological developments, identified barriers to implementation, and determined the optimal frameworks needed for regulatory oversight. The group concluded that the application of novel technologies to clinical trials provided enormous potential, yet these changes needed to be iterative and facilitated by continuous learning and pilot studies.

17.
Curr Probl Cardiol ; : 100471, 2019 Sep 20.
Artigo em Inglês | MEDLINE | ID: mdl-31635841

RESUMO

Tortuous brachiocephalic artery may lead to procedural difficulties among patients undergoing right transradial cardiac catheterization. By prospectively identifying patients with this anatomic barrier, operators may choose an alternate catheterization site to avoid complications from switching midway. To assess brachiocephalic artery tortuosity, 23 patients who underwent challenging diagnostic coronary angiography by right transradial access were compared to a control group of 29 patients who lacked brachiocephalic artery tortuosity. Preprocedural, plain chest x-rays were analyzed for measurable anatomic parameters and assessed for statistical significance between groups. The vertebrocarinal distance-the distance in centimeters between the spinous process of the first thoracic vertebra (T1) and the most caudal point of tracheal bifurcation, measured at and parallel to the midline-was the most reliable and statistically significant radiographic predictor of brachiocephalic artery tortuosity. Using this novel concept reduces procedure duration and radiation exposure by decreasing transradial cardiac catheterization failure rates.

18.
Can J Diabetes ; 2019 Aug 23.
Artigo em Inglês | MEDLINE | ID: mdl-31630988

RESUMO

Diabetes and heart failure (HF) independently contribute to significant cardiovascular (CV) morbidity and mortality. Both are tremendous burdens to health-care systems. Among patients with established HF, diabetes mellitus is one of the most common comorbidities, present in up to 45% of all patients. Although atherosclerotic CV disease outcomes are thought to be the major cause of morbidity and mortality among patients with diabetes, HF death and hospitalization has been recognized as being just as common. However, despite this evidence, HF as an outcome among trials of glucose-lowering therapies has been largely ignored. Now, there are 3 noninferiority CV outcome trials that have demonstrated the efficacy of sodium-glucose cotransporter-2 (SGLT-2) inhibitors to reduce the risk of HF hospitalizations in patients with type 2 diabetes with CV risk factors and/or established atherosclerotic CV disease. The demonstration of a reduction in HF outcomes seen in these CV outcome trials represents a paradigm shift in the management of patients with type 2 diabetes mellitus and atherosclerotic CV disease or CV risk factors. Whether SGLT-2 inhibitors represent a therapeutic strategy to reduce the risk of CV events among patients with established HF remains to be explored. Furthermore, the benefit of SGLT-2 inhibitors in a population of patients with HF yet without diabetes remains to be demonstrated across multiple trials. This review aims to highlight the clinical trial and real-world evidence regarding the safety and efficacy of SGLT-2 inhibitors among patients with type 2 diabetes mellitus and established HF.

19.
Eur J Heart Fail ; 21(10): 1248-1258, 2019 Oct.
Artigo em Inglês | MEDLINE | ID: mdl-31476097

RESUMO

AIMS: An implantable cardioverter-defibrillator (ICD) is recommended for reducing the risk of sudden cardiac death (SCD) in myocardial infarction (MI) patients with a left ventricular ejection fraction (LVEF) ≤ 30%, as well as patients with a LVEF ≤ 35% and heart failure symptoms. Diabetes and/or impaired kidney function may confer additional SCD risk. We assessed the association between these two risk factors with SCD and non-SCD among MI survivors taking account of age and LVEF. METHODS AND RESULTS: A total of 17 773 patients from the High-Risk MI Database were evaluated. Overall, diabetes and estimated glomerular filtration rate < 60 mL/min/1.73 m2 , individually and together, conferred a higher risk of SCD [adjusted competing risk: hazard ratio (HR) 1.23, 1.23, and 1.32, respectively; all P < 0.03] and non-SCD (HR 1.34, 1.52, and 2.13, respectively; all P < 0.0001). Annual SCD rates in patients with LVEF > 35% and with diabetes, impaired kidney function, or both (2.0%, 2.5% and 2.7%, respectively) were comparable to rates observed in patients with LVEF 30-35% but no such risk factors (1.7%). However, these patients had also similarly higher non-SCD rates, such that the ratio of SCD to non-SCD was not increased. Importantly, this ratio was mostly dependent on age, with higher overall ratios in youngest subgroups (0.89 in patients < 55 years vs. 0.38 in patients ≥ 75 years), regardless of risk factors. CONCLUSION: Although MI survivors with LVEF > 35% with diabetes, impaired kidney function, or both are at increased risk of SCD, the risk of non-SCD risk is even higher, suggesting an extension of the current indication for an ICD to them is unlikely to be worthwhile. MI survivors with low LVEF and aged < 55 years are likely to have the greatest potential benefit from ICD implantation.

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