High Risk For Vascular Events Research Articles

Increased risk for vascular complications due to GP IIb/IIIa-antagonists in patients with cardiogenic shock supported by intraaortic balloon pump (IABP)

BackgroundIABP is routinely used to support coronary blood flow and systemic circulation in patients with cardiogenic shock. Our aim was to explore the incidence of vascular complications associated with the use of IABP in this scenario and their influence on mortality. MethodsTherefor we analysed 204 consecutive patients between 2002 and 2013 treated with IAPB in cardiogenic shock for vascular complications and mortality within 30days after implantation of IAPB. Primary endpoints were severe bleeding (TIMI-definition: intracranial bleeding, loss of haemoglobin (Hb) >5g/dl or haematocrit (PCV) >15%), vascular complications with therapeutic consequence (venous thrombosis, arterial embolism) and stroke. Results80 (39%) patients died within 30days after implantation of IABP. In 42 (21%) patients, vascular complications occurred: severe bleeding was present in 26 patients (62% of all complications), 13 (31%) patients suffered from venous thrombosis or arterial embolism and 3 (7%) patients from stroke. 25% of the patients who died had a vascular complication. The rate in patients who overcame cardiogenic shock was 17.7% (p=0.22). Multivariate analyses showed treatment with Glycoprotein (GP) IIb/IIIa- inhibitors to be an independent risk factor for the occurrence of vascular complications (p=0.04). ConclusionVascular events with the use of IABP are common but in our study, not significantly associated with a higher mortality. Treatment with GP IIb/IIIa-antagonists is associated with a higher risk of vascular events.

The ARTICO study: identification of patients at high risk of vascular recurrence after a first non-cardioembolic stroke.

BackgroundAbout 20% of patients with a first ischaemic stroke will experience a new vascular event within the first year. The atherosclerotic burden, an indicator of the extension of atherosclerosis in a patient, has been associated with the risk of new cardiovascular events in the general population. However, no predictive models reliably identify groups at a high risk of recurrence. The ARTICO study prospectively analysed the predictive value for the risk of recurrence of specific atherosclerotic markers.MethodsThe multicentre ARTICO study included 620 consecutive independent patients older than 60 years suffering from a first non-cardioembolic stroke. We analysed classical stroke risk factors; duplex study of supraaortic trunk including intima-media thickness (IMT) measurement; quantification of internal carotid (ICA) stenosis; number, morphology and surface characteristics of carotid plaques; ankle brachial index (ABI); and the presence of microalbuminuria. Patients were followed up at 6 and 12 months after inclusion. The primary end-point was death or major cardiovascular events.ResultsAny vascular event or death at 12 months occurred in 78 (13.8%) patients. In 40 (7.1%) of these the vascular event was a stroke recurrence. Weight, history of diabetes mellitus, history of symptomatic PAD, ABI <0.9 and significant ICA stenosis (>50%) were associated with a higher risk of vascular events on follow-up in the bivariate analysis.In the final Cox regression analysis, body mass index (BMI), systolic blood pressure, history of diabetes mellitus, symptomatic PAD (HR, 2.76; 95% CI, 1.10–6.95; p=0.03), and particularly patients with both ICA stenosis >50% and PAD (HR 4.52; 95% CI, 2.14-9.53; p<0.001) were independently associated with an increased risk of vascular events. Neither isolated ICA stenosis >50% nor isolated abnormal ABI remained associated with an increased risk of recurrence in comparison with the whole population.ConclusionsSymptomatic PAD identifies a high risk group of vascular recurrence after a first non-cardioembolic stroke. The associated increased risk was particularly high in patients with both ICA stenosis and either symptomatic or asymptomatic PAD. Neither asymptomatic PAD alone nor isolated ICA stenosis >50% were associated with an increased risk of recurrence in this particularly high-risk group of non-cardioembolic stroke.Electronic supplementary materialThe online version of this article (doi:10.1186/s12883-015-0278-4) contains supplementary material, which is available to authorized users.

Microvascular Disease After Renal Transplantation

Background/Aims: Individuals who reach end-stage kidney disease (CKD5) have a high risk of vascular events that persists even after renal transplantation. This study compared the prevalence and severity of microvascular disease in transplant recipients and patients with CKD5. Methods: Individuals with a renal transplant or CKD5 were recruited consecutively from renal clinics, and underwent bilateral retinal photography (Canon CR5-45, Canon). Their retinal images were deidentified and reviewed for hypertensive/microvascular signs by an ophthalmologist and a trained grader (Wong and Mitchell classification), and for vessel caliber at a grading centre using a computer-assisted method and Knudtson's modification of the Parr-Hubbard formula. Results: Ninety-two transplant recipients (median duration 6.4 years, range 0.8 to 28.8) and 70 subjects with CKD5 were studied. Transplant recipients were younger (p<0.001), with a higher eGFR (p< 0.001), but were just as likely to have a moderate-severe hypertensive/microvascular retinopathy (46/92, 50%) as subjects with CKD5 (38/70, 54%; OR 0.84, CI 0.45 to 1.57, p=0.64), and had similar mean arteriole and venular calibres (135.1 ± 7.5 µm and 137.9 ± 14.9 µm, p=0.12; and 199.1 ± 17.8 µm and 202.4 ± 27.8 µm, p=0.36, respectively). Arteriole and venular caliber were not different in nine patients examined before and after transplantation (p=0.62 and p=0.11, respectively). Conclusions: Hypertensive/microvascular disease occurred just as often and was generally as severe in transplant recipients and subjects with CKD5. Microvascular disease potentially contributes to increased cardiac events post- transplantation.

VEGFA SNP rs2010963 is associated with vascular toxicity in recurrent glioblastomas and longer response to bevacizumab.

Although anti-VEGF therapy is widely used in high-grade gliomas, no predictor of response or toxicity has been reported yet. We investigated here the association of the functional single nucleotide polymorphism (SNP) rs2010963, located in the 5' untranslated terminal region of the VEGFA gene, with survival, response to bevacizumab (BVZ) and vascular toxicity. The rs2010963 was genotyped by Taqman assay in blood DNA from 954 glioma patients with available survival data, including 225 glioblastoma (GBM) patients treated with BVZ. VEGFA plasma levels were assessed by ELISA in 87 patients before treatment. Thrombo-hemorragic adverse events were recorded during BVZ treatment or not, and in an independent population of 92 GBM patients treated with temozolomide. The CC genotype was associated with the occurrence of thrombo-hemorragic events (CC 25 versus CG 13.5 and GG 5.2 %; P = 0.0044) during BVZ. A similar but weaker and non significant trend was observed in patients not receiving BVZ. A CC genotype was associated with higher levels of plasma VEGFA at baseline (107.6 versus 57.50 pg/mL in heterozygotes (CG) and 52.75 pg/mL in GG patients, P = 0.035 and P = 0.028 respectively). The CC genotype tended to be associated to longer PFS when treated with BVZ (P = 0.05), but not when treated with the temozolomide treatment. Our data suggest that the rs2010963 genotype is associated with longer PFS, higher risk of vascular events in recurrent GBM especially treated with BVZ, and higher plasma VEGFA concentration. It may help to identify patients at risk of vascular adverse events during BVZ treatment.

Incidence and Characteristics of Polycythemia Vera, Essential Thrombocythemia and Primary Myelofibrosis in Thailand: A 5-Year Retrospective Study

Background: Polycythemia vera (PV), essential thrombocythemia (ET) and primary myelofibrosis (PMF) are members of myeloproliferative neoplasm group. They shared common features such as JAK2 V617F+ mutation, thrombosisor hemorrhage, progression to marrow fibrosis or acute leukemia.Objective: To study incidence and clinical characteristics of PV, ET and PMF with complications and treatment modalities in Thailand.Study Designs: Retrospective chart reviewMethods: All JAK2 V617F+ and V617F- mutation patients during 2008-2012 were reviewed for demographic data, diagnosis of PV, ET and PMF according to WHO 2008 criteria, complications and treatment.Results: 363 of 735 patients were 140 PV, 172 ET, 47 PMF and 4 MPN-U. 372 patients were excluded due to routine thrombotic workup (98), secondary erythrocytosis (97), reactive thrombocytosis (55), CML (26), HES/eosinophilia (24), MPN/MDS (3), others (69). In PV, JAK2 V617F+ and JAK2 exon 12 mutation patients were 106 and 2. PV showed male:female ratio of 85:55, mean age 57.7 year (11-86), mean hemoglobin 17.6 g/dl (6.7-24.6), and received aspirin (125), hydroxyurea (116), phlebotomy (84), clopidogrel (10), warfarin (7), anagrelide (6), busulfan (5) and each for interferon, oxymethalone, corticosteroid, and JAK inhibitor. Thrombosis:hemorrhage was 34:16. Myelofibrosis and AML transformation were 7 and 2. In ET, JAK2 V617F+ patients were 121. ET showed male:female ratio of 83:89, mean age 59.45 year (14-91), mean platelet count 924,168/mm3 (283,000-2,235,000), and received aspirin (140), hydroxyurea (139), anagrelide (47), warfarin (11), clopidogrel (7), erythropoietin (6), oxymethalone (3), busulfan (3), corticosteroid (2), interferon (1) and splenectomy (1). Thrombosis:hemorrhage was 52:16. Myelofibrosis and AML transformation were 4 and 1. In PMF, JAK2 V617F+ patients were 32. PMF showed male:female ratio of 21:26, mean age 62.2 year (23-81), mean hemoglobin 8.6 g/dl (3.7-15.5), mean subcostal splenic size 10 cm (1-26) and received hydroxyurea (26), erythropoietin (16), corticosteroid (10), oxymethalone (8), JAK inhibitor (7), transfusion dependency (6), aspirin (3), warfarin (2) and each for anagrelide, thalidomide, splenectomy and allogeneic transplantation. Thrombosis:hemorrhage was 4:5. AML transformation was 4. In multivariate analysis, previous thrombosis, clopidogrel use, splenomegaly, alcohol use and JAK2 V617F+ were independent risk factors for thrombosis.Conclusion: PV, ET and PMF carry high risk for vascular events. DisclosuresKhuhapinant:Roche: Honoraria, Membership on an entity’s Board of Directors or advisory committees; Janssen: Honoraria, Membership on an entity’s Board of Directors or advisory committees; Novartis: Honoraria, Membership on an entity’s Board of Directors or advisory committees; Celgene: Honoraria. Phikulsod:Novartis: Honoraria. Siritanaratkul:Novartis: Research Funding; Roche: Research Funding; Janssen: Research Funding.

Reducing Clinical Inertia in Diabetes Management: An observational study

BackgroundPatients with diabetes are at high risk of vascular events. Aggressive treatment of hyperglycemia, hyperlipidemia and hypertension are cornerstones of diabetes management in an effort to reduce risk of vascular disease. Our aim was to get a snapshot of diabetes management in the community in terms of the above three risk factors, so that deficient areas can be targeted to educate physicians and diabetologists. MethodsAll consecutive patients with known history of diabetes managed in the community who had enrolled for a diabetes master health check over a one year period from Jan 2013 to December 2013 at Apollo Speciality Hospital, Madurai were included in this study. Local Ethics Committee approval was obtained. Variables were collected and analyzed using Microsoft Excel 2007. ResultsData from one hundred and one patients were analyzed. Mean age of patients was 53.8 years with an average duration of diabetes of 3.5 years. Mean glycosylated hemoglobin was 8.6%. About 90% of patients had a blood pressure within the target range. Nearly two-thirds of patients were not on a statin. The rates of newly detected neuropathy, retinopathy and microalbuminuria were 40%, 30% and 35% respectively. ConclusionPhysicians should adopt a more holistic approach to microvascular and cardiovascular risk factors in patients with diabetes, adhering to evidence based guidelines with personalized targets.

Thrombotic Risk Assessment in Systemic Lupus Erythematosus: Validation of the Global Antiphospholipid Syndrome Score in a Prospective Cohort

This study was performed to prospectively and independently validate the Global Antiphospholipid Syndrome Score (GAPSS), a system derived from the combination of independent risk factors for thrombosis, including antiphospholipid antibodies (aPL) and conventional cardiovascular risk factors. The GAPSS was applied to 51 consecutive systemic lupus erythematosus patients, all positive for aPL and prospectively followed up for mean ± SD 32.94 ± 12.06 months. Of them, 48 were women with a mean ± SD age of 37.35 ± 12.15 years at entry. The GAPSS was calculated yearly for each patient by adding together the points corresponding to the risk factors. An increase in the GAPSS (entry versus last visit) was seen in patients who experienced vascular events (n = 4, mean ± SD 7.5 ± 4.36 versus 10.0 ± 5.4; P = 0.032). No changes were observed in those without thrombosis (n = 47, mean ± SD 8.28 ± 4.88 versus 7.13 ± 5.75; P = 0.24). An increase in the GAPSS during the followup was associated with a higher risk of vascular events (relative risk 12.30 [95% confidence interval (95% CI) 1.43-106.13], P = 0.004), and an increase of more than 3 points showed the best risk accuracy for vascular events (hazard ratio 48 [95% CI 6.90-333.85], P = 0.0001). The cumulative proportion of thrombosis-free individuals was lower in patients whose GAPSS was increased by 3 or more points (P = 0.0027). We have prospectively demonstrated that GAPSS is a valid tool for accurate prediction of vascular events in SLE patients with aPL.

ICEBERG: Intimal Carotid Evaluation Before Echocardiography Reveals Global Vascular Risk

BackgroundThere is growing evidence that carotid ultrasonography provides important prognostic information about cardiovascular risk assessment. Our objective was to determine whether abbreviated rapid carotid ultrasonographic screening would reveal important global vascular risk information in statin-naive patients referred for routine transthoracic echocardiography (TTE). MethodsAbbreviated carotid ultrasonographic imaging was performed in 560 consecutive patients undergoing TTE. The common carotid artery (CCA), the carotid bulb, and the internal carotid artery (ICA) were scanned. Maximal CCA intima-media thickness (IMT) was measured in the far wall. Carotid plaque was defined using the Atherosclerosis Risk in Communities (ARIC) study criteria. ResultsOf the 2283 patients who underwent TTE during a 1-year period, a total of 560 patients met inclusion criteria. There were 241 men, with a mean age of 63.2 ± 12.8 years and a mean CCA IMT of 1.11 ± 0.48 mm; 61% (147) had carotid plaque. The 319 women had a mean age of 66.3 ± 10.8 years and a mean CCA IMT of 1.03 ± 0.36 mm; 62.4% (199) had carotid plaque. All patients with plaque were considered to be at high risk. ConclusionsOf the 560 consecutive statin-naive patients referred for TTE with no history of vascular disease, a large proportion of both men (61%) and women (62.4%) had carotid plaque, indicating a high risk for vascular events according to the Canadian lipid guidelines. Although such patients are seen in the echocardiography laboratory, the addition of an abbreviated carotid ultrasonographic screening provides important information regarding risk stratification and the implementation of preventive therapy.

Is the Long-Term Prognosis of Transient Ischemic Attack or Minor Ischemic Stroke Affected by the Occurrence of Nonfocal Symptoms?

In patients with a transient ischemic attack or ischemic stroke, nonfocal neurological symptoms, such as confusion and nonrotatory dizziness, may be associated with a higher risk of vascular events. We assessed the relationship between nonfocal symptoms and the long-term risk of vascular events or death in patients with a transient ischemic attack or minor ischemic stroke. We related initial symptoms with outcome events in 2409 patients with a transient ischemic attack (n=723) or minor ischemic stroke (n=1686), included in the Life Long After Cerebral ischemia cohort. All patients underwent a standardized interview on the occurrence of focal and nonfocal neurological symptoms during the qualifying event. The primary outcome was the composite of any stroke, myocardial infarction, or vascular death. Secondary outcomes were all-cause death, vascular death, cardiac death, myocardial infarction, and stroke. Hazard ratios were calculated with Cox regression. Focal symptoms were accompanied by nonfocal symptoms in 739 (31%) patients. During a mean follow-up of 10.1 years, the primary outcome occurred in 1313 (55%) patients. There was no difference in the risk of the primary outcome between patients with both focal and nonfocal symptoms and patients with focal symptoms alone (adjusted hazard ratio, 0.97; 95% confidence interval, 0.86-1.09; P=0.60). The risk of each of the secondary outcomes was also similar in both groups. About one third of the patients with a transient ischemic attack or minor ischemic stroke has both focal and nonfocal neurological symptoms. Nonfocal symptoms are not associated with an increased long-term risk of vascular events or death. This trial was not registered because enrollment began before July 1, 2005.

Long-term efficacy and safety of statin treatment beyond six years: A meta-analysis of randomized controlled trials with extended follow-up

Large-scale randomized controlled trials (RCTs) have well demonstrated the beneficial effects of cholesterol-lowering treatment with statins in patients at high risk of vascular disease. However, large statin RCTs were usually restricted to the typical 5–6 years. Moreover, non-cardiovascular events, especially the risk of cancer, probably failed to emerge within a restricted period of 6 years. The aim of this study was to evaluate the long-term efficacy and safety of statin treatment by performing a meta-analysis of statin RCTs with extended follow-up beyond 6 years. Six RCTs with post-trial follow-up were eligible for inclusion, involving 47,296 patients with total follow-up ranging from 6.7 to 14.7 years. During the post-trial period, all the surviving participants were advised to take a statin and the cholesterol level were almost identical between the original statin group and the original placebo group. Over the entire 6.7–14.7 years of follow-up, a significant reduction in the rates of all-cause mortality (relative risk 0.90, 95% confidence interval 0.85–0.96; P=0.0009), cardiovascular mortality (0.87, 0.81–0.93; P<0.0001) and major coronary events (0.79, 0.72–0.86; P<0.00001) was observed in favour of the original statin group. During 2-year post-trial period, further reduction in all-cause mortality (0.83, 0.74–0.93; P=0.001), cardiovascular mortality (0.81, 0.69–0.95; P=0.01) and major coronary events (0.77, 0.63–0.95; P=0.01) was observed among initially statin-treated patients. Over the entire follow-up period, statin treatment did not increase the incidence of cancers (0.99, 0.95–1.04; P=0.79), deaths from cancers (1.00, 0.93–1.07; P=0.98) and non-cardiovascular mortality (0.95, 0.90–1.00; P=0.07). In conclusion, statin treatment beyond 6 years is effective and safe in patients at high risk of vascular events. Moreover, earlier treatment with statin may not only preserve the initial benefit but also have further survival benefit for additional 2 years. Further studies are called for to explore the underlying mechanisms.

ASA failure

To assess whether adding clopidogrel to acetylsalicylic acid (ASA) has a long-term protective vascular effect in patients with lacunar stroke while taking ASA. Post hoc analysis of 838 patients with ASA failure and recent lacunar stroke from the Secondary Prevention of Small Subcortical Strokes Trial (SPS3) cohort randomly allocated to aspirin (325 mg/day) and clopidogrel (75 mg/day) or placebo. Primary efficacy outcome was stroke recurrence (ischemic and intracranial hemorrhage) and main safety outcome was major extracranial hemorrhage. Patients were followed for a mean period of 3.5 years. The ASA failure group had a significantly higher risk of vascular events including ischemic stroke when compared with the non-ASA failure group (n = 2,151) in SPS3 (p = 0.03). Mean age was 65.6 years and 65% were men. The risk of recurrent stroke was not reduced in the dual antiplatelet group, 3.1% per year, compared to the aspirin-only group, 3.3% per year (hazard ratio [HR] 0.91; 95% confidence interval [CI] 0.61-1.37). There was also no difference between groups for ischemic stroke (HR 0.90; 95% CI 0.59-1.38). The risk of gastrointestinal bleeding was higher in the dual antiplatelet group (HR 2.7; 95% CI 1.1-6.9); however, the risk of intracranial hemorrhage was not different. In patients with a recent lacunar stroke while taking ASA, the addition of clopidogrel did not result in reduction of vascular events vs continuing ASA only. This study provides Class I evidence that for patients with recent lacunar stroke while taking ASA, adding clopidogrel as compared to continuing ASA alone does not reduce the risk of recurrent stroke.

CHADS 2 Scores in the Prediction of Major Adverse Cardiovascular Events in Patients with Cushing's Syndrome.

Vascular events are one of the major causes of death in case of Cushing's syndrome (CS). However, due to the relative low frequency of CS, it is hard to perform a risk assessment for these events. As represented congestive heart failure (C), hypertension (H), age (A), diabetes (D), and stroke (S), the CHADS2 score is now accepted to classify the risk of major adverse cardiovascular events (MACEs) in patients with atrial fibrillation. In this study, participants were enrolled from the National Health Research Institute Database (NHIRD) of Taiwan, and we reviewed 551 patients with their sequential clinically diagnosed CS data between 2002 and 2009 in relation to MACEs risk using CHADS2 score. Good correlation could be identified between the CS and CHADS2 score (AUC = 0.795). Our results show that patients with CS show significantly higher risk of vascular events and the CHADS2 score could be applied for MACEs evaluation. Adequate lifestyle modifications and aggressive cardiovascular risks treatment are suggested for CS patients with higher CHADS2 score.

Effect of an intervention to improve the cardiovascular health of family members of patients with coronary artery disease: a randomized trial.

Family members of patients with coronary artery disease (CAD) have higher risk of vascular events. We conducted a trial to determine if a family heart-health intervention could reduce their risk of CAD. We assessed coronary risk factors and randomized 426 family members of patients with CAD to a family heart-health intervention (n = 211) or control (n = 215). The intervention included feedback about risk factors, assistance with goal setting and counselling from health educators for 12 months. Reports were sent to the primary care physicians of patients whose lipid levels and blood pressure exceeded threshold values. All participants received printed materials about smoking cessation, healthy eating, weight management and physical activity; the control group received only these materials. The main outcomes (ratio of total cholesterol to high-density lipoprotein [HDL] cholesterol; physical activity; fruit and vegetable consumption) were assessed at 3 and 12 months. We examined group and time effects using mixed models analyses with the baseline values as covariates. The secondary outcomes were plasma lipid levels (total cholesterol, low-density lipoprotein cholesterol, HDL cholesterol and triglycerides); glucose level; blood pressure; smoking status; waist circumference; body mass index; and the use of blood pressure, lipid-lowering and smoking cessation medications. We found no effect of the intervention on the ratio of total cholesterol to HDL cholesterol. However, participants in the intervention group reported consuming more fruit and vegetables (1.2 servings per day more after 3 mo and 0.8 servings at 12 mo; p < 0.001). There was a significant group by time interaction for physical activity (p = 0.03). At 3 months, those in the intervention group reported 65.8 more minutes of physical activity per week (95% confidence interval [CI] 47.0-84.7 min). At 12 months, participants in the intervention group reported 23.9 more minutes each week (95% CI 3.9-44.0 min). A health educator-led heart-health intervention did not improve the ratio of total cholesterol to HDL cholesterol but did increase reported physical activity and fruit and vegetable consumption among family members of patients with CAD. Hospitalization of a spouse, sibling or parent is an opportunity to improve cardiovascular health among other family members. clinicaltrials.gov, no NCT00552591.

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HPS2-THRIVE: Niacin Fails to Show Benefit in Patients at High Risk of Vascular Events

The results of this large randomized controlled trial in patients with well-controlled lipid levels but who are at a high risk of cardiovascular events once again call into question the the clinical benefits of niacin despite an increase in high-density lipoprotein cholesterol (HDL-C), and reductions in triglyceride levels and low density lipoprotein cholesterol levels. This article presents the results of the Treatment of HDL to Reduce the Incidence of Vascular Events trial [HPS2-THRIVE Collaborative Group. Eur Heart J 2013].

Screening for the Presence of Coronary Artery Disease

Screening for the Presence of Coronary Artery Disease

Aliskiren increased adverse events in patients with diabetes and kidney disease who were receiving ACE inhibitors or ARBs

ACP Journal Club19 March 2013Aliskiren increased adverse events in patients with diabetes and kidney disease who were receiving ACE inhibitors or ARBsPeter W. de Leeuw, MDPeter W. de Leeuw, MDMaastricht University Medical Centre and, Cardiovascular Research Institute Maastricht (CARIM), Maastricht, The Netherlands (P.W.D.)Search for more papers by this authorAuthor, Article, and Disclosure Informationhttps://doi.org/10.7326/0003-4819-158-6-201303190-02007 SectionsAboutFull TextPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissions ShareFacebookTwitterLinkedInRedditEmail Source CitationParving HH, Brenner BM, McMurray JJ, et al; ALTITUDE Investigators. Cardiorenal end points in a trial of aliskiren for type 2 diabetes. N Engl J Med. 2012;367:2204-13. https://pubmed.ncbi.nlm.nih.gov/23121378Clinical Impact RatingsCardiology: Endocrinology: Nephrology: References1 Pogue J, Devereaux PJ, Thabane L, Yusuf S. Designing and analyzing clinical trials with composite outcomes: consideration of possible treatment differences between the individual outcomes. PLoS One. 2012;7:e34785. [PMID: 22529934] Google Scholar2 ONTARGET Investigators, Yusuf S, Teo KK, et al. Telmisartan, ramipril, or both in patients at high risk for vascular events. N Engl J Med. 2008;358:1547-59. [PMID: 18378520] Google Scholar3 Harel Z, Gilbert C, Wald R, et al. The effect of combination treatment with aliskiren and blockers of the renin-angiotensin system on hyperkalaemia and acute kidney injury: systematic review and meta-analysis. BMJ. 2012;344:e42. [PMID: 22232539] Google Scholar4 Pfeffer MA, McMurray JJ, Velazquez EJ, et al. Valsartan, captopril, or both in myocardial infarction complicated by heart failure, left ventricular dysfunction, or both. N Engl J Med. 2003;349:1893-906. [PMID: 14610160] Google Scholar Author, Article, and Disclosure InformationAffiliations: Maastricht University Medical Centre and, Cardiovascular Research Institute Maastricht (CARIM), Maastricht, The Netherlands (P.W.D.)This article was published at Annals.org on 5 March 2013. PreviousarticleNextarticle Advertisement FiguresReferencesRelatedDetails Metrics Cited ByKidney Disease End Points in a Pooled Analysis of Individual Patient–Level Data From a Large Clinical Trials Program of the Dipeptidyl Peptidase 4 Inhibitor Linagliptin in Type 2 DiabetesAliskiren, the first direct renin inhibitor: assessing a role in pediatric hypertension and kidney diseasesRenoprotective effect of renal liver-type fatty acid binding protein and angiotensin II type 1a receptor loss in renal injury caused by RAS activationScreening, Early Diagnosis, Genetic Markers, and Predictors of Diabetic Nephropathy 19 March 2013Volume 158, Issue 6Page: JC7KeywordsACE inhibitorsAdverse eventsCardiovascular therapyChronic kidney diseaseHeartHeart failureHypotensionLongitudinal studiesRenal diseasesType 2 diabetes ePublished: 19 March 2013 Issue Published: 19 March 2013 CopyrightCopyright © 2013 by American College of Physicians. All Rights Reserved.PDF DownloadLoading ...

Protocol for a systematic review of the diagnostic and prognostic utility of tests currently available for the detection of aspirin resistance in patients with established cardiovascular or cerebrovascular disease

BackgroundThe benefits of aspirin as an anti-platelet agent are well established; however, there has been much debate about the lack of uniformity in the efficacy of aspirin to inhibit platelet function. In some patients, aspirin fails to inhibit platelets even where compliance has been verified, a phenomenon which has been termed “aspirin resistance”. These patients may in turn be at a higher risk of future vascular events. The proportion of “resistant” patients identified depends on the type of platelet function test. Therefore, the aim of this systematic review is to determine which, if any, platelet function test has utility in terms of identifying patients with a high risk of vascular events. The review has been registered with PROSPERO (CRD42012002151).MethodsRelevant studies will be sought from bibliographic databases. Trials registers will be searched for ongoing studies. Reference lists will be checked and subject experts contacted. There will be no date or language restrictions. Standard reviewing methodology to minimise bias will be employed. Any prospective studies in patients on aspirin therapy and assessing platelet function in relation to relevant clinical outcomes will be included, as will studies reporting prognostic models. Risk of bias assessment will be based on the Quality Assessment of Diagnostic Accuracy Studies guidelines, and suitable criteria for assessing quality of prognostic studies. Data on test accuracy measures, relative risks, odds or hazard ratios will be extracted and meta-analysed, where possible, using a random-effects model to account for between-study heterogeneity. Where appropriate, the causes of heterogeneity will be explored through meta-regression and sub-group or sensitivity analyses. If platelet function testing is demonstrated to have diagnostic/predictive utility in a specific population, the potential for a cost-effectiveness analysis will be considered and, if possible, an economic model constructed. This will be supported by a systematic review of existing economic evaluation studies.DiscussionThe results of the review could indicate if platelet function test(s) could lead to a reliable prediction of the risk of clinically important events in a defined population, and thus support investigations into adjustments to therapy in order to compensate for a predicted poor response to standard aspirin.

One-Year Progression of Moderate Asymptomatic Carotid Stenosis Predicts the Risk of Vascular Events

This study aimed at evaluating whether ultrasound monitoring of moderate asymptomatic carotid stenosis may help in identifying subjects at high risk for vascular events. We included 523 subjects with unilateral asymptomatic carotid stenosis of 50% to 69%. Follow-up carotid ultrasound was performed within 12 months from inclusion to detect the frequency and degree of stenosis progression. Subjects were prospectively evaluated for a median period of 42 months (interquartile range, 38-45) after a second ultrasound evaluation. Outcome measures were any stroke and transient ischemic attack, myocardial infarction, and death. Carotid stenosis progression was associated with the occurrence of vascular events (hazard ratio, 21.57; 95% confidence interval, 11.81-39.39; P<0.001). During follow-up, 96.7% of subjects without progressive carotid stenosis remained free from vascular events. Among patients with progressive stenosis, 53.7% experienced a vascular event and 27.1% experienced an ipsilateral stroke. One-year moderate asymptomatic carotid stenosis progression is related to higher risk of vascular events, including ipsilateral stroke.