Safety of Perioperative Aprotinin Administration During Isolated Coronary Artery Bypass Graft Surgery: Insights From the ART (Arterial Revascularization Trial)

Background There is still uncertainty about the safety of aprotinin for coronary artery bypass graft surgery. The ART (Arterial Revascularization Trial) was designed to compare survival after bilateral versus single internal thoracic artery grafting. Many of the ART patients (≈30%) received perioperative aprotinin. We investigated the association between perioperative aprotinin administration and short‐term (in‐hospital) and long‐term outcomes by performing a post hoc analysis of the ART. Methods and Results Among patients enrolled in the ART (n=3102) from 2004 to 2007, we excluded those who did not undergo surgery (n=18) and those with no information about use of perioperative aprotinin (n=9). Finally, 836 of 3076 patients (27%) received aprotinin. Propensity matching was used to select 536 pairs for final comparison. Aprotinin was also associated with an increased risk of hospital mortality (9 [1.7%] versus 1 [0.2%]; odds ratio, 9.12; 95% confidence interval [CI], 1.15–72.2; P=0.03), intra‐aortic balloon pump insertion (37 [6.9%] versus 17 [3.2%]; odds ratio, 2.26; 95% CI, 1.26–4.07; P=0.006), and acute kidney injury (102 [19.0%] versus 76 [14.2%]; odds ratio, 1.42; 95% CI, 1.03–1.97; P=0.03). Aprotinin was not associated with a lower incidence of transfusion (37 [6.9%] versus 28 [5.2%]; odds ratio, 1.34; 95% CI, 0.81–2.23; P=0.25) and reexploration (26 [4.9%] versus 19 [3.5%]; hazard ratio, 1.39; 95% CI, 0.76–2.53; P=0.28). At 5 years, all‐cause mortality was significantly increased in the aprotinin group (56 [10.6%] versus 38 [7.3%]; hazard ratio, 1.51; 95% CI, 1.0–2.28; P=0.045). Conclusions In the present post hoc ART analysis, aprotinin was associated with a significantly increased risk of early and late mortality

Ten-year outcomes after off-pump versus on-pump coronary artery bypass grafting:Insights from the Arterial Revascularization Trial

Objective We performed a post hoc analysis of the Arterial Revascularization Trial to compare 10-year outcomes after off-pump versus on-pump surgery. Methods Among 3102 patients enrolled, 1252 (40% of total) and 1699 patients received off-pump and on-pump surgery (151 patients were excluded because of other reasons); 2792 patients (95%) completed 10-year follow-up. Propensity matching and mixed-effect Cox model were used to compare long-term outcomes. Interaction term analysis was used to determine whether bilateral internal thoracic artery grafting was a significant effect modifier. Results One thousand seventy-eight matched pairs were selected for comparison. A total of 27 patients (2.5%) in the off-pump group required conversion to on-pump surgery. The off-pump and on-pump groups received a similar number of grafts (3.2 ± 0.89 vs 3.1 ± 0.8; P = .88). At 10 years, when compared with on-pump, there was no significant difference in death (adjusted hazard ratio for off-pump, 1.1; 95% confidence interval, 0.84-1.4; P = .54) or the composite of death, myocardial infarction, stroke, and repeat revascularization (adjusted hazard ratio, 0.92; 95% confidence interval, 0.72-1.2; P = .47). However, off-pump surgery performed by low volume off-pump surgeons was associated with a significantly lower number of grafts, increased conversion rates, and increased cardiovascular death (hazard ratio, 2.39; 95% confidence interval, 1.28-4.47; P = .006) when compared with on-pump surgery performed by on–pump-only surgeons. Conclusions The findings showed that in the Arterial Revascularization Trial, off-pump and on-pump techniques achieved comparable long-term outcomes. However, when off-pump surgery was performed by low-volume surgeons, it was associated with a lower number of grafts, increased conversion, and a higher risk of cardiovascular death.</p

Treatment of Hypertension in the Inpatient Setting: Use of Intravenous Labetalol and Hydralazine

Peer Reviewedhttp://deepblue.lib.umich.edu/bitstream/2027.42/73529/1/j.1751-7176.2009.00196.x.pd

Early Antiretroviral Therapy at High CD4 Counts Does Not Improve Arterial Elasticity: A Substudy of the Strategic Timing of AntiRetroviral Treatment (START) Trial

BACKGROUND: Both human immunodeficiency virus (HIV) infection and antiretroviral therapy (ART) may increase cardiovascular disease (CVD) risk. Vascular function assessments can be used to study CVD pathogenesis. We compared the effect of immediate versus deferred ART initiation at CD4 counts >500 cells/mm(3) on small arterial elasticity (SAE) and large artery elasticity (LAE). METHODS: Radial artery blood pressure waveforms were recorded noninvasively. Small arterial elasticity and LAE were derived from analysis of the diastolic pulse waveform. Randomized treatment groups were compared with linear models at each visit and longitudinal mixed models. RESULTS: Study visits involved 332 participants in 8 countries: mean (standard deviation [SD]) age 35 (10), 70% male, 66% nonwhite, 30% smokers, and median CD4 count 625 cells/mm(3) and 10-year Framingham risk score for CVD 1.7%. Mean (SD) SAE and LAE values at baseline were 7.3 (2.9) mL/mmHg × 100 and 16.6 (4.1) mL/mmHg × 10, respectively. Median time on ART was 47 and 12 months in the immediate and deferred ART groups, respectively. The treatment groups did not demonstrate significant within-person changes in SAE or LAE during the follow-up period, and there was no difference in mean change from baseline between treatment groups. The lack of significant differences persisted after adjustment, when restricted to early or late changes, after censoring participants in deferred group who started ART, and among subgroups defined by CVD and HIV risk factors. CONCLUSIONS: Among a diverse global population of HIV-positive persons with high CD4 counts, these randomized data suggest that ART treatment does not have a substantial influence on vascular function among younger HIV-positive individuals with preserved immunity

Prevalence and risk factors associated with peripheral arterial disease in the hearts of Brazil project

FUNDAMENTO: A doença arterial obstrutiva periférica (DAOP) está associada ao maior índice de risco cardiovascular. No Brasil, faltam dados sobre sua prevalência e fatores de risco. OBJETIVO: Avaliar prevalência e fatores de risco associados à DAOP nas cidades brasileiras com > cem mil habitantes. MÉTODOS: Estudo transversal, multicêntrico, que avaliou 1.170 indivíduos (>18 anos), em 72 centros urbanos, participantes do Projeto Corações do Brasil. O diagnóstico de DAOP baseou-se na medida do índice tornozelo-braquial (ITB) < 0,90. A análise estatística utilizou teste Qui-quadrado (Pearson) corrigido para amostras complexas e intervalos de confiança. P < 0,05 foi considerado significativo. RESULTADOS: A prevalência de DAOP foi de 10,5% e apenas 9% dos portadores da doença apresentaram claudicação. A DAOP esteve associada à presença de diabetes, obesidade total e abdominal, acidente vascular cerebral (AVC) e doença isquêmica do coração (DIC). Houve tendência a maior prevalência de DAOP na presença de hipertensão, insuficiência cardíaca, insuficiência renal dialítica e tabagismo >20 anos/maço. Mulheres coronariopatas apresentaram risco 4,9 vezes maior de ter DAOP, do que aquelas sem coronariopatia e, entre homens diabéticos, o risco de DAOP foi 6,6 maior em comparação aos não diabéticos. CONCLUSÃO: A prevalência de DAOP foi elevada, considerando-se a baixa média de idade da população avaliada (44&plusmn;14,7 anos). A minoria dos portadores apresentava claudicação, o que denota o grande contingente de indivíduos assintomáticos. Os fatores mais fortemente associados à doença foram diabetes, obesidade, AVC e DIC. Os autores concluíram que a medida do ITB deve ser considerada na avaliação de pacientes de moderado e alto risco cardiovascular.BACKGROUND: Peripheral arterial disease (PAD) is associated with increased cardiovascular risk. In Brazil, data on PAD prevalence and risk factors are scarce. OBJECTIVE: To assess prevalence and risk factors related to PAD in Brazilian urban centers with more than 100,000 inhabitants. METHODS: National, multicenter, cross-sectional study of 1,170 individuals (>18 years), from 72 major Brazilian urban centers participating in the "Hearts of Brazil Project". PAD diagnosis was based on ankle-brachial index (ABI) < 0.90. The statistical analysis used the corrected Chi-square (Pearson) test for complex samples and confidence intervals. P< 0.05 was considered statitically significant. RESULTS: PAD prevalence was 10.5%. Intermittent claudication (IC) was present in only 9% of PAD patients. A significant association was found between PAD and the following factors: diabetes, total and abdominal obesity, stroke and ischemic heart disease (IHD). There was a trend of higher PAD prevalence among individuals with hypertension, heart failure, chronic renal failure on dialysis, as well as those who had smoked over 20 pack-years. For females, presence of IHD was associated with a 4.9-fold greater risk of PAD. Among males, a 6.6-fold increased risk of PAD was found for diabetic in comparison to non-diabetic individuals. CONCLUSION: PAD prevalence was markedly high, considering the low mean age of the studied population (44&plusmn;14.7 yrs). IC was detected in a minority of PAD subjects, indicating a considerable number of asymptomatic individuals. Diabetes, obesity, stroke and IHD were the stronger predictors of PAD. The authors concluded that ABI measurement should be considered in the evaluation of moderate to high cardiovascular risk patients.Empresa Libbs Farmacêutic

Uncertainty quantification of inflow boundary condition and proximal arterial stiffness coupled effect on pulse wave propagation in a vascular network

International audienceSUMMARY This work aims at quantifying the effect of inherent uncertainties from cardiac output on the sensitivity of a human compliant arterial network response based on stochastic simulations of a reduced-order pulse wave propagation model. A simple pulsatile output form is utilized to reproduce the most relevant cardiac features with a minimum number of parameters associated with left ventricle dynamics. Another source of critical uncertainty is the spatial heterogeneity of the aortic compliance which plays a key role in the propagation and damping of pulse waves generated at each cardiac cycle. A continuous representation of the aortic stiffness in the form of a generic random field of prescribed spatial correlation is then considered. Resorting to a stochastic sparse pseudospectral method, we investigate the spatial sensitivity of the pulse pressure and waves reflection magnitude with respect to the different model uncertainties. Results indicate that uncertainties related to the shape and magnitude of the prescribed inlet flow in the proximal aorta can lead to potent variation of both the mean value and standard deviation of blood flow velocity and pressure dynamics due to the interaction of different wave propagation and reflection features. These results have potential physiological and pathological implications. They will provide some guidance in clinical data acquisition and future coupling of arterial pulse wave propagation reduced-order model with more complex beating heart models

Amino acid intakes are inversely associated with arterial stiffness and central blood pressure in women

Background: Although data suggest that intake of total protein and specific amino acids (AAs) reduces blood pressure, data on other cardiovascular disease risk factors are limited. Objective: We examined associations between intake of AAs with known mechanistic links to cardiovascular health and direct measures of arterial stiffness, central blood pressure, and atherosclerosis. Methods: In a cross-sectional study of 1898 female twins aged 18–75 y from the TwinsUK registry, intake of 7 cardioprotective AAs (arginine, cysteine, glutamic acid, glycine, histidine, leucine, and tyrosine) was calculated from food-frequency questionnaires. Direct measures of arterial stiffness and atherosclerosis included central systolic blood pressure (cSBP), mean arterial pressure (MAP), augmentation index (AI), pulse wave velocity (PWV), and intima–media thickness (IMT). ANCOVA was used to assess the associations between endpoints of arterial stiffness and intake (per quintile), adjusting for potential confounders. Results: In multivariable analyses, higher intake of total protein and 7 potentially cardioprotective AAs was associated with lower cSBP, MAP, and PWV. Higher intake of glutamic acid, leucine, and tyrosine was most strongly associated with PWV, with respective differences of -0.4 ± 0.2 m/s (P-trend = 0.02),-0.4 ± 0.2 m/s (P-trend = 0.03), and -0.4 ± 0.2 m/s (P-trend = 0.03), comparing extreme quintiles. There was a significant interaction between AA intake and protein source, and higher intake of AAs from vegetable sources was associated with lower central blood pressure and AI. Higher intake of glutamic acid, leucine, and tyrosine from animal sources was associated with lower PWV. Conclusions: These data provide evidence to suggest that intake of several AAs is associated with cardiovascular benefits beyond blood pressure reduction in healthy women. The magnitude of the observed associations was similar to those previously reported for other lifestyle factors. Increasing intake of these AAs could be an important and readily achievable way to reduce cardiovascular disease risk

Hypertension in the very old; prevalence, awareness, treatment and control: a cross-sectional population-based study in a Spanish municipality

<p>Abstract</p> <p>Background</p> <p>Information on hypertension in the very elderly is sparse. Until recently evidence of benefits from pharmacological treatment was inconclusive. We estimated the prevalence of hypertension in subjects aged 80 or more, the proportion of awareness, treatment and control. Explanatory variables associated with good control were also studied.</p> <p>Methods</p> <p>Cross sectional, population-based study, conducted in Martorell, an urban Spanish municipality, in 2005. By simple random sampling from the census, 323 subjects aged 80 or more were included. Patients were visited at home or in the geriatric institution and after giving informed consent, the study variables were collected. These included: supine and standing blood pressure and information about diagnosis and treatment of hypertension. The estimation and 95% confidence interval were obtained and a logistic regression model was used to study explanatory variables associated with blood pressure below 140/90 mm Hg.</p> <p>Results</p> <p>The prevalence of hypertension was 72.8% (95%CI: 69.5 – 76.6%) and 93% of the patients were aware of this condition, of whom 96.3% (95%CI: 93.65 – 97.9%) had been prescribed pharmacological treatment and 30.7% (95%CI: 25.8 – 36.1%) had blood pressure below 140/90 mm Hg. Some of the patients (43%) had one antihypertensive drug and 39.5% had two in combination. Explanatory variables associated with blood pressure below 140/90 mm Hg included prescription of a diuretic, OR: 0.31 (95%CI: 0.14 – 0.66), and history of ischemic heart disease, OR: 0.21 (95%CI: 0.1 – 0.47).</p> <p>Conclusion</p> <p>The prevalence of hypertension in population aged 80 or more was over 70%. Most patients were aware of this condition and they had antihypertensive medication prescribed. Approximately one third of treated patients had blood pressure below 140/90 mm Hg. Patients with heart disease and with diuretics had more frequently blood pressure below this value.</p

2024 Recommendations for Validation of Noninvasive Arterial Pulse Wave Velocity Measurement Devices

BACKGROUND: Arterial stiffness, as measured by arterial pulse wave velocity (PWV), is an established biomarker for cardiovascular risk and target-organ damage in individuals with hypertension. With the emergence of new devices for assessing PWV, it has become evident that some of these devices yield results that display significant discrepancies compared with previous devices. This discrepancy underscores the importance of comprehensive validation procedures and the need for international recommendations. METHODS: A stepwise approach utilizing the modified Delphi technique, with the involvement of key scientific societies dedicated to arterial stiffness research worldwide, was adopted to formulate, through a multidisciplinary vision, a shared approach to the validation of noninvasive arterial PWV measurement devices. RESULTS: A set of recommendations has been developed, which aim to provide guidance to clinicians, researchers, and device manufacturers regarding the validation of new PWV measurement devices. The intention behind these recommendations is to ensure that the validation process can be conducted in a rigorous and consistent manner and to promote standardization and harmonization among PWV devices, thereby facilitating their widespread adoption in clinical practice. CONCLUSIONS: It is hoped that these recommendations will encourage both users and developers of PWV measurement devices to critically evaluate and validate their technologies, ultimately leading to improved consistency and comparability of results. This, in turn, will enhance the clinical utility of PWV as a valuable tool for assessing arterial stiffness and informing cardiovascular risk stratification and management in individuals with hypertension

Cardiovascular end points and mortality are not closer associated with central than peripheral pulsatile blood pressure components

none32Pulsatile blood pressure (BP) confers cardiovascular risk. Whether associations of cardiovascular end points are tighter for central systolic BP (cSBP) than peripheral systolic BP (pSBP) or central pulse pressure (cPP) than peripheral pulse pressure (pPP) is uncertain. Among 5608 participants (54.1% women; mean age, 54.2 years) enrolled in nine studies, median follow-up was 4.1 years. cSBP and cPP, estimated tonometrically from the radial waveform, averaged 123.7 and 42.5 mm Hg, and pSBP and pPP 134.1 and 53.9 mm Hg. The primary composite cardiovascular end point occurred in 255 participants (4.5%). Across fourths of the cPP distribution, rates increased exponentially (4.1, 5.0, 7.3, and 22.0 per 1000 person-years) with comparable estimates for cSBP, pSBP, and pPP. The multivariable-adjusted hazard ratios, expressing the risk per 1-SD increment in BP, were 1.50 (95% CI, 1.33-1.70) for cSBP, 1.36 (95% CI, 1.19-1.54) for cPP, 1.49 (95% CI, 1.33-1.67) for pSBP, and 1.34 (95% CI, 1.19-1.51) for pPP (P<0.001). Further adjustment of cSBP and cPP, respectively, for pSBP and pPP, and vice versa, removed the significance of all hazard ratios. Adding cSBP, cPP, pSBP, pPP to a base model including covariables increased the model fit (P<0.001) with generalized R2 increments ranging from 0.37% to 0.74% but adding a second BP to a model including already one did not. Analyses of the secondary end points, including total mortality (204 deaths), coronary end points (109) and strokes (89), and various sensitivity analyses produced consistent results. In conclusion, associations of the primary and secondary end points with SBP and pulse pressure were not stronger if BP was measured centrally compared with peripherally.noneHuang, Qi-Fang; Aparicio, Lucas S; Thijs, Lutgarde; Wei, Fang-Fei; Melgarejo, Jesus D; Cheng, Yi-Bang; Sheng, Chang-Sheng; Yang, Wen-Yi; Gilis-Malinowska, Natasza; Boggia, José; Niiranen, Teemu J; Wojciechowska, Wiktoria; Stolarz-Skrzypek, Katarzyna; Barochiner, Jessica; Ackermann, Daniel; Tikhonoff, Valérie; Ponte, Belen; Pruijm, Menno; Casiglia, Edoardo; Narkiewicz, Krzysztof; Filipovský, Jan; Czarnecka, Danuta; Kawecka-Jaszcz, Kalina; Jula, Antti M; Bochud, Murielle; Vanassche, Thomas; Verhamme, Peter; Struijker-Boudier, Harry A J; Wang, Ji-Guang; Zhang, Zhen-Yu; Li, Yan; Staessen, Jan AHuang, Qi-Fang; Aparicio, Lucas S; Thijs, Lutgarde; Wei, Fang-Fei; Melgarejo, Jesus D; Cheng, Yi-Bang; Sheng, Chang-Sheng; Yang, Wen-Yi; Gilis-Malinowska, Natasza; Boggia, José; Niiranen, Teemu J; Wojciechowska, Wiktoria; Stolarz-Skrzypek, Katarzyna; Barochiner, Jessica; Ackermann, Daniel; Tikhonoff, Valérie; Ponte, Belen; Pruijm, Menno; Casiglia, Edoardo; Narkiewicz, Krzysztof; Filipovský, Jan; Czarnecka, Danuta; Kawecka-Jaszcz, Kalina; Jula, Antti M; Bochud, Murielle; Vanassche, Thomas; Verhamme, Peter; Struijker-Boudier, Harry A J; Wang, Ji-Guang; Zhang, Zhen-Yu; Li, Yan; Staessen, Jan