Long-term heart failure (HF) treatment has been shown to result in reverse chamber remodeling. Ho... more Long-term heart failure (HF) treatment has been shown to result in reverse chamber remodeling. However, it is unknown whether sizes of cardiac chambers acutely change during HF therapy and whether these changes are associated with favorable clinical outcomes. Using the Evaluation Study of Congestive Heart Failure and Pulsmonary Artery Catheterization Effectiveness (ESCAPE) trial database, echocardiographic parameters at baseline and discharge, changes from baseline to discharge, and their association with the combined endpoint of death or HF rehospitalization (HFH) at 6 months were evaluated in patients admitted with acute decompensated HF (ADHF). Also, the correlation between changes in invasive hemodynamic parameters compared with changes in echocardiographic parameters was analyzed. During the treatment of ADHF, right atrium, right ventricle, and inferior vena cava (IVC) sizes decreased acutely. Mitral regurgitation severity and mitral inflow parameters also improved significantly. However, the majority of acute changes in echocardiographic parameters did not have an impact on clinical outcome, except for the reduction in left ventricular (LV) end-diastolic and end-systolic volumes, which was associated with a reduction in the combined outcome of HFH or death. The change in invasive hemodynamics that best correlated with change in echocardiographic parameters was change in pulmonary capillary wedge pressure with change in IVC diameter and IVC collapsibility. This is the first study to identify the echocardiographic parameters that change during the treatment of ADHF and the echocardiographic parameters that most reliably correlate with invasive hemodynamic changes. Most changes in echocardiographic parameters were not associated with clinical outcomes, except for the reduction in LV volume, which was associated with a reduction in HFH or death.
Diabetes mellitus (DM) and congestive heart failure (HF) commonly coexist in the same patient, an... more Diabetes mellitus (DM) and congestive heart failure (HF) commonly coexist in the same patient, and the presence of DM in HF patients is associated with increased adverse events compared with patients without DM. Recent guidelines regarding glycemic control stress individualization of glycemic therapy based on patient comorbid conditions and potential adverse effects of medical therapy. This balance in glycemic control may be particularly relevant in patients with DM and HF. In this review, we address data regarding the influence that certain HF medications may have on glycemic control. Despite potential modest changes in glycemic control, clinical benefits of proven pharmacologic HF therapies extend to patients with DM and HF. In addition, we review potential benefits and challenges associated with commonly used glycemic medications in HF patients. Finally, recent data and controversies on optimal glycemic targets in HF patients are discussed. Given the large number of patients with DM and HF and the health burden of these conditions, much needed future work is necessary to define the optimal glycemic treatment in HF patients with DM.
The US Food and Drug Administration (FDA) has approved three low-molecular-weight heparins (LMWHs... more The US Food and Drug Administration (FDA) has approved three low-molecular-weight heparins (LMWHs) (enoxaparin, dalteparin, and ardeparin) for prophylaxis of venous thromboembolism and one LMWH, enoxaparin, for treatment of unstable angina/non-Q-wave myocardial ...
International Journal of Gynecological Pathology, 2002
I read with interest the article published by Baker et al. ( 1 ) reporting the presence of florid... more I read with interest the article published by Baker et al. ( 1 ) reporting the presence of florid vascular proliferation in ovarian immature teratomas characterized by an extensive proliferation of endothelial and perithelial cells with glomeruloid or cord-like arrangements. This phenomenon is well ...
The prognosis associated with metabolic syndrome and high-sensitivity C-reactive protein (hs-CRP)... more The prognosis associated with metabolic syndrome and high-sensitivity C-reactive protein (hs-CRP) in patients with stable coronary artery disease has not been well established. The WIZARD study was to determine the effects of 12 weeks of antibiotic therapy on coronary heart disease events in patients with stable coronary artery disease and known Chlamydia pneumoniae exposure. Baseline metabolic risk factors were available for 3319 patients enrolled from 1997 to 1998. The primary outcome was the first occurrence of death, recurrent myocardial infarction, coronary revascularization procedure, or hospitalization for angina. Of the 3319 subjects, 825 patients experienced the primary outcome during the mean follow-up of 37 months. For the composite outcome, there was an increased hazard ratio (HR) for metabolic syndrome (HR 1.40, 95% CI 1.22-1.61) (unadjusted) and for hs-CRP (HR 1.60, 95% CI 1.38-1.85) (unadjusted). Both the metabolic syndrome and hs-CRP indicated, in a multivariable model including age and sex, an increased HR for the primary outcome (metabolic syndrome: HR 1.33, 95% CI 1.15-1.53; hs-CRP: HR 1.52, 95% CI 1.30-1.76). Although related, the presence of the metabolic syndrome and increased levels of hs-CRP were associated with increased risk of adverse cardiovascular outcomes.
The study objective was to define muscle metabolic and cardiovascular changes after surgical inte... more The study objective was to define muscle metabolic and cardiovascular changes after surgical intervention in clinically severe obese patients.Obesity is a state of metabolic dysregulation that can lead to maladaptive changes in heart and skeletal muscle, including insulin resistance and heart failure. In a prospective longitudinal study, 43 consecutive patients underwent metabolic profiling, skeletal muscle biopsies, and resting echocardiograms at baseline and 3 and 9 months after bariatric surgery.Body mass index decreased (mean changes, 95% confidence interval [CI]): 7.7 kg/m2 (95% CI, 6.70-8.89) at 3 months and 5.6 kg/m2 (95% CI, 4.45-6.80; P < .0001) at 9 months after surgery, with restoration of insulin sensitivity and decreases in plasma leptin at the same time points. Concurrent with these changes were dramatic decreases in skeletal muscle transcript levels of stearoyl coenzyme-A desaturase and pyruvate dehydrogenase kinase-4 at 3 and 9 months (P < .0001, for both) and a significant decrease in peroxisome proliferation activated receptor-α–regulated genes at 9 months. Left ventricular relaxation impairment, assessed by tissue Doppler imaging, normalized 9 months after surgery.Weight loss results in the reversal of systemic and muscle metabolic derangements and is accompanied by a normalization of left ventricular diastolic function.
Journal of the American College of Cardiology, 2013
The aim of this study was to describe the relationship between ankle brachial index (ABI) and the... more The aim of this study was to describe the relationship between ankle brachial index (ABI) and the risk for heart failure (HF). The ABI is a simple, noninvasive measure associated with atherosclerotic cardiovascular disease and death; however, the relationship between ABI and risk for HF is less well characterized. Between 1987 and 1989 in the ARIC (Atherosclerosis Risk In Communities) study, an oscillometric device was used to measure blood pressure in a single upper and randomly chosen lower extremity to determine the ABI. Incident HF events were defined by the first hospitalization with an International Classification of Diseases, Ninth Revision, code of 428.x through 2008. The risk for HF was assessed across the ABI range using restricted cubic splines and Cox proportional hazards models. ABI was available in 13,150 participants free from prevalent HF. Over a mean 17.7 years of follow-up, 1,809 incident HF events occurred. After adjustment for traditional HF risk factors, prevalent coronary heart disease, subclinical carotid atherosclerosis, and interim myocardial infarction, compared with an ABI of 1.01 to 1.40, participants with ABIs ≤0.90 were at increased risk for HF (hazard ratio: 1.40; 95% confidence interval: 1.12 to 1.74), as were participants with ABIs of 0.91 to 1.00 (hazard ratio: 1.36; 95% confidence interval: 1.17 to 1.59). In a middle-age community cohort, an ABI ≤1.00 was significantly associated with an increased risk for HF, independent of traditional HF risk factors, prevalent coronary heart disease, carotid atherosclerosis, and interim myocardial infarction. Low ABI may reflect not only overt atherosclerosis but also pathologic processes in the development of HF beyond epicardial atherosclerotic disease and myocardial infarction alone. A low ABI, as a simple, noninvasive measure, may be a risk marker for HF.
Several lines of evidence have suggested a link between obesity and heart failure, including chro... more Several lines of evidence have suggested a link between obesity and heart failure, including chronic inflammation, increased sympathetic tone, and insulin resistance. The goal of this study was to evaluate the changes in systemic metabolism, anthropometrics, and left ventricular (LV) contraction, as well as geometry, in clinically severe obese women after bariatric surgery.Enrollment was offered consecutively to 22 women with clinically severe obesity. Participants underwent abdominal magnetic resonance imaging to quantify the visceral adipose tissue (VAT) area and tissue Doppler imaging echocardiography to measure the LV contractile function. Fasting blood chemistries were drawn to measure inflammatory markers and to calculate insulin sensitivity. All tests were performed before surgery and 3 months postoperatively.Three months after surgery, a significant increase in insulin sensitivity (mean change ± SEM 34.0 ± 10.4, P <.0001) was present. The VAT area had significantly decreased (−66.1 ± 17.8 cm2, P = .002) and was associated with decreases in body mass index, serum glucose concentrations, and high-sensitivity C-reactive protein levels (r = .61 and P = .005, r = .48 and P = .033, and r = .53 and P = .016, respectively). The LV mass decreased significantly (−3.8 ± 1.7 g/m2.7, P = .037), and this decrease was associated with a decrease in glucose concentration (r = .46, P = .041). The LV systolic and diastolic contractile function were normal at baseline, and no change occurred after surgery.The early phase of weight loss after bariatric surgery produces favorable changes in LV geometry, and these are associated with normalization in the glucose metabolism.
Journal of The American College of Cardiology, 2004
We assessed the influence of alcohol intake on the development of symptomatic heart failure (HF) ... more We assessed the influence of alcohol intake on the development of symptomatic heart failure (HF) in patients with left ventricular (LV) dysfunction after a myocardial infarction (MI).In contrast to protection from coronary heart disease, alcohol consumption has been linked to cardiodepressant effects and has been considered contraindicated in patients with HF.The Survival And Ventricular Enlargement (SAVE) trial randomized 2,231 patients with a LV ejection fraction (EF) <40% following MI to an angiotensin-converting enzyme inhibitor or placebo. Patients were classified as nondrinkers, light-to-moderate drinkers (1 to 10 drinks/week), or heavy drinkers (>10 drinks/week) based on alcohol consumption reported at baseline. The primary outcome was hospitalization for HF or need for an open-label angiotensin-converting enzyme inhibitor. Analyses were repeated using alcohol consumption reported three months after MI.Nondrinkers were older and had more comorbidities than light-to-moderate and heavy drinkers. In univariate analyses, baseline light-to-moderate alcohol intake was associated with a lower incidence of HF compared with nondrinkers (hazard ratio [HR] 0.71; 95% confidence interval [CI] 0.57 to 0.87), whereas heavy drinking was not (HR 0.91; 95% CI 0.67 to 1.23). After adjustment for baseline differences, light-to-moderate baseline alcohol consumption no longer significantly influenced the development of HF (light-to-moderate drinkers HR 0.93; 95% CI 0.75 to 1.17; heavy drinkers HR 1.25; 95% CI 0.91 to 1.72). Alcohol consumption reported three months after the MI similarly did not modify the risk of adverse outcome.In patients with LV dysfunction after an MI, light-to-moderate alcohol intake either at baseline or following MI did not alter the risk for the development of HF requiring hospitalization or an open-label angiotensin-converting enzyme inhibitor.
The US Food and Drug Administration (FDA) has approved three low-molecular-weight heparins (LMWHs... more The US Food and Drug Administration (FDA) has approved three low-molecular-weight heparins (LMWHs) (enoxaparin, dalteparin, and ardeparin) for prophylaxis of venous thromboembolism and one LMWH, enoxaparin, for treatment of unstable angina/non-Q-wave myocardial ...
Journal of The American College of Cardiology, 2007
This study sought to examine the relationship between thiazolidinedione (TZD) use and outcomes in... more This study sought to examine the relationship between thiazolidinedione (TZD) use and outcomes in ambulatory patients with diabetes and heart failure (HF).Thiazolidinediones have been relatively contraindicated in diabetic patients with HF.We conducted a retrospective study of a national cohort of veterans with HF and diabetes treated in ambulatory clinics at Veterans Affairs medical centers. Patients were classified into those using TZDs and those not using insulin-sensitizing medication based on prescriptions filled 90 days before or 30 days after the index outpatient visit. The outcomes were time to hospitalization for HF and time to death.Of 7,147 ambulatory HF patients receiving diabetic therapy, 818 (11.4%) were receiving a TZD and 4,700 (65.8%) were not receiving insulin sensitizers. Over 2 years of follow-up, 134 (16.4%) patients receiving TZDs and 741 (15.8%) patients not receiving insulin-sensitizing medications required HF hospitalization (adjusted hazard ratio 1.00, 95% confidence interval 0.81 to 1.24, p = 0.97). A total of 168 (20.5%) patients receiving TZDs and 1,192 (25.4%) patients not receiving insulin-sensitizing medications died (adjusted hazard ratio 0.98, 95% confidence interval 0.81 to 1.17, p = 0.80).In ambulatory patients with established HF and diabetes, the use of TZDs was not associated with an increased risk of HF hospitalization or total mortality when compared with those not receiving insulin-sensitizing medications.
Journal of The American College of Cardiology, 2009
This study was designed to examine the relationship between glycosylated hemoglobin (HbA1C) and a... more This study was designed to examine the relationship between glycosylated hemoglobin (HbA1C) and adverse outcomes in diabetic patients with established heart failure (HF).Despite the common coexistence of diabetes and HF, previous studies examining the association between HbA1C and outcomes in this population have been limited and have reported discrepant results.We assessed the association between increasing quintiles (Q1 to Q5) of HbA1C and risk of death or risk of HF hospitalization by conducting a retrospective study in a national cohort of 5,815 veterans with HF and diabetes treated in ambulatory clinics at Veterans Affairs medical centers.At 2 years of follow-up, death occurred in 25% of patients in Q1 (HbA1C ≤6.4%), 23% in Q2 (6.4% < HbA1c ≤7.1%), 17.7% in Q3 (7.1% < HbA1c ≤7.8%), 22.5% in Q4 (7.8% < HbA1c ≤9.0%), and 23.2% in Q5 (HbA1c >9.0%). After adjustment for potential confounders, the middle quintile (Q3) had reduced mortality when compared with the lowest quintile (risk-adjusted hazard ratio: 0.73, 95% confidence interval: 0.61 to 0.88, p = 0.001). Hospitalization rates for HF at 2 years increased with increasing quintiles of HbA1C (Q1: 13.3%, Q2: 13.1%, Q3: 15.5%, Q4: 16.4%, and Q5: 18.2%), but this association was not statistically significant when adjusted for potential confounders.The association between mortality and HbA1C in diabetic patients with HF appears U-shaped, with the lowest risk of death in those patients with modest glucose control (7.1% < HbA1C ≤7.8%). Future prospective studies are necessary to define optimal treatment goals in these patients.
Long-term heart failure (HF) treatment has been shown to result in reverse chamber remodeling. Ho... more Long-term heart failure (HF) treatment has been shown to result in reverse chamber remodeling. However, it is unknown whether sizes of cardiac chambers acutely change during HF therapy and whether these changes are associated with favorable clinical outcomes. Using the Evaluation Study of Congestive Heart Failure and Pulsmonary Artery Catheterization Effectiveness (ESCAPE) trial database, echocardiographic parameters at baseline and discharge, changes from baseline to discharge, and their association with the combined endpoint of death or HF rehospitalization (HFH) at 6 months were evaluated in patients admitted with acute decompensated HF (ADHF). Also, the correlation between changes in invasive hemodynamic parameters compared with changes in echocardiographic parameters was analyzed. During the treatment of ADHF, right atrium, right ventricle, and inferior vena cava (IVC) sizes decreased acutely. Mitral regurgitation severity and mitral inflow parameters also improved significantly. However, the majority of acute changes in echocardiographic parameters did not have an impact on clinical outcome, except for the reduction in left ventricular (LV) end-diastolic and end-systolic volumes, which was associated with a reduction in the combined outcome of HFH or death. The change in invasive hemodynamics that best correlated with change in echocardiographic parameters was change in pulmonary capillary wedge pressure with change in IVC diameter and IVC collapsibility. This is the first study to identify the echocardiographic parameters that change during the treatment of ADHF and the echocardiographic parameters that most reliably correlate with invasive hemodynamic changes. Most changes in echocardiographic parameters were not associated with clinical outcomes, except for the reduction in LV volume, which was associated with a reduction in HFH or death.
Diabetes mellitus (DM) and congestive heart failure (HF) commonly coexist in the same patient, an... more Diabetes mellitus (DM) and congestive heart failure (HF) commonly coexist in the same patient, and the presence of DM in HF patients is associated with increased adverse events compared with patients without DM. Recent guidelines regarding glycemic control stress individualization of glycemic therapy based on patient comorbid conditions and potential adverse effects of medical therapy. This balance in glycemic control may be particularly relevant in patients with DM and HF. In this review, we address data regarding the influence that certain HF medications may have on glycemic control. Despite potential modest changes in glycemic control, clinical benefits of proven pharmacologic HF therapies extend to patients with DM and HF. In addition, we review potential benefits and challenges associated with commonly used glycemic medications in HF patients. Finally, recent data and controversies on optimal glycemic targets in HF patients are discussed. Given the large number of patients with DM and HF and the health burden of these conditions, much needed future work is necessary to define the optimal glycemic treatment in HF patients with DM.
The US Food and Drug Administration (FDA) has approved three low-molecular-weight heparins (LMWHs... more The US Food and Drug Administration (FDA) has approved three low-molecular-weight heparins (LMWHs) (enoxaparin, dalteparin, and ardeparin) for prophylaxis of venous thromboembolism and one LMWH, enoxaparin, for treatment of unstable angina/non-Q-wave myocardial ...
International Journal of Gynecological Pathology, 2002
I read with interest the article published by Baker et al. ( 1 ) reporting the presence of florid... more I read with interest the article published by Baker et al. ( 1 ) reporting the presence of florid vascular proliferation in ovarian immature teratomas characterized by an extensive proliferation of endothelial and perithelial cells with glomeruloid or cord-like arrangements. This phenomenon is well ...
The prognosis associated with metabolic syndrome and high-sensitivity C-reactive protein (hs-CRP)... more The prognosis associated with metabolic syndrome and high-sensitivity C-reactive protein (hs-CRP) in patients with stable coronary artery disease has not been well established. The WIZARD study was to determine the effects of 12 weeks of antibiotic therapy on coronary heart disease events in patients with stable coronary artery disease and known Chlamydia pneumoniae exposure. Baseline metabolic risk factors were available for 3319 patients enrolled from 1997 to 1998. The primary outcome was the first occurrence of death, recurrent myocardial infarction, coronary revascularization procedure, or hospitalization for angina. Of the 3319 subjects, 825 patients experienced the primary outcome during the mean follow-up of 37 months. For the composite outcome, there was an increased hazard ratio (HR) for metabolic syndrome (HR 1.40, 95% CI 1.22-1.61) (unadjusted) and for hs-CRP (HR 1.60, 95% CI 1.38-1.85) (unadjusted). Both the metabolic syndrome and hs-CRP indicated, in a multivariable model including age and sex, an increased HR for the primary outcome (metabolic syndrome: HR 1.33, 95% CI 1.15-1.53; hs-CRP: HR 1.52, 95% CI 1.30-1.76). Although related, the presence of the metabolic syndrome and increased levels of hs-CRP were associated with increased risk of adverse cardiovascular outcomes.
The study objective was to define muscle metabolic and cardiovascular changes after surgical inte... more The study objective was to define muscle metabolic and cardiovascular changes after surgical intervention in clinically severe obese patients.Obesity is a state of metabolic dysregulation that can lead to maladaptive changes in heart and skeletal muscle, including insulin resistance and heart failure. In a prospective longitudinal study, 43 consecutive patients underwent metabolic profiling, skeletal muscle biopsies, and resting echocardiograms at baseline and 3 and 9 months after bariatric surgery.Body mass index decreased (mean changes, 95% confidence interval [CI]): 7.7 kg/m2 (95% CI, 6.70-8.89) at 3 months and 5.6 kg/m2 (95% CI, 4.45-6.80; P < .0001) at 9 months after surgery, with restoration of insulin sensitivity and decreases in plasma leptin at the same time points. Concurrent with these changes were dramatic decreases in skeletal muscle transcript levels of stearoyl coenzyme-A desaturase and pyruvate dehydrogenase kinase-4 at 3 and 9 months (P < .0001, for both) and a significant decrease in peroxisome proliferation activated receptor-α–regulated genes at 9 months. Left ventricular relaxation impairment, assessed by tissue Doppler imaging, normalized 9 months after surgery.Weight loss results in the reversal of systemic and muscle metabolic derangements and is accompanied by a normalization of left ventricular diastolic function.
Journal of the American College of Cardiology, 2013
The aim of this study was to describe the relationship between ankle brachial index (ABI) and the... more The aim of this study was to describe the relationship between ankle brachial index (ABI) and the risk for heart failure (HF). The ABI is a simple, noninvasive measure associated with atherosclerotic cardiovascular disease and death; however, the relationship between ABI and risk for HF is less well characterized. Between 1987 and 1989 in the ARIC (Atherosclerosis Risk In Communities) study, an oscillometric device was used to measure blood pressure in a single upper and randomly chosen lower extremity to determine the ABI. Incident HF events were defined by the first hospitalization with an International Classification of Diseases, Ninth Revision, code of 428.x through 2008. The risk for HF was assessed across the ABI range using restricted cubic splines and Cox proportional hazards models. ABI was available in 13,150 participants free from prevalent HF. Over a mean 17.7 years of follow-up, 1,809 incident HF events occurred. After adjustment for traditional HF risk factors, prevalent coronary heart disease, subclinical carotid atherosclerosis, and interim myocardial infarction, compared with an ABI of 1.01 to 1.40, participants with ABIs ≤0.90 were at increased risk for HF (hazard ratio: 1.40; 95% confidence interval: 1.12 to 1.74), as were participants with ABIs of 0.91 to 1.00 (hazard ratio: 1.36; 95% confidence interval: 1.17 to 1.59). In a middle-age community cohort, an ABI ≤1.00 was significantly associated with an increased risk for HF, independent of traditional HF risk factors, prevalent coronary heart disease, carotid atherosclerosis, and interim myocardial infarction. Low ABI may reflect not only overt atherosclerosis but also pathologic processes in the development of HF beyond epicardial atherosclerotic disease and myocardial infarction alone. A low ABI, as a simple, noninvasive measure, may be a risk marker for HF.
Several lines of evidence have suggested a link between obesity and heart failure, including chro... more Several lines of evidence have suggested a link between obesity and heart failure, including chronic inflammation, increased sympathetic tone, and insulin resistance. The goal of this study was to evaluate the changes in systemic metabolism, anthropometrics, and left ventricular (LV) contraction, as well as geometry, in clinically severe obese women after bariatric surgery.Enrollment was offered consecutively to 22 women with clinically severe obesity. Participants underwent abdominal magnetic resonance imaging to quantify the visceral adipose tissue (VAT) area and tissue Doppler imaging echocardiography to measure the LV contractile function. Fasting blood chemistries were drawn to measure inflammatory markers and to calculate insulin sensitivity. All tests were performed before surgery and 3 months postoperatively.Three months after surgery, a significant increase in insulin sensitivity (mean change ± SEM 34.0 ± 10.4, P <.0001) was present. The VAT area had significantly decreased (−66.1 ± 17.8 cm2, P = .002) and was associated with decreases in body mass index, serum glucose concentrations, and high-sensitivity C-reactive protein levels (r = .61 and P = .005, r = .48 and P = .033, and r = .53 and P = .016, respectively). The LV mass decreased significantly (−3.8 ± 1.7 g/m2.7, P = .037), and this decrease was associated with a decrease in glucose concentration (r = .46, P = .041). The LV systolic and diastolic contractile function were normal at baseline, and no change occurred after surgery.The early phase of weight loss after bariatric surgery produces favorable changes in LV geometry, and these are associated with normalization in the glucose metabolism.
Journal of The American College of Cardiology, 2004
We assessed the influence of alcohol intake on the development of symptomatic heart failure (HF) ... more We assessed the influence of alcohol intake on the development of symptomatic heart failure (HF) in patients with left ventricular (LV) dysfunction after a myocardial infarction (MI).In contrast to protection from coronary heart disease, alcohol consumption has been linked to cardiodepressant effects and has been considered contraindicated in patients with HF.The Survival And Ventricular Enlargement (SAVE) trial randomized 2,231 patients with a LV ejection fraction (EF) <40% following MI to an angiotensin-converting enzyme inhibitor or placebo. Patients were classified as nondrinkers, light-to-moderate drinkers (1 to 10 drinks/week), or heavy drinkers (>10 drinks/week) based on alcohol consumption reported at baseline. The primary outcome was hospitalization for HF or need for an open-label angiotensin-converting enzyme inhibitor. Analyses were repeated using alcohol consumption reported three months after MI.Nondrinkers were older and had more comorbidities than light-to-moderate and heavy drinkers. In univariate analyses, baseline light-to-moderate alcohol intake was associated with a lower incidence of HF compared with nondrinkers (hazard ratio [HR] 0.71; 95% confidence interval [CI] 0.57 to 0.87), whereas heavy drinking was not (HR 0.91; 95% CI 0.67 to 1.23). After adjustment for baseline differences, light-to-moderate baseline alcohol consumption no longer significantly influenced the development of HF (light-to-moderate drinkers HR 0.93; 95% CI 0.75 to 1.17; heavy drinkers HR 1.25; 95% CI 0.91 to 1.72). Alcohol consumption reported three months after the MI similarly did not modify the risk of adverse outcome.In patients with LV dysfunction after an MI, light-to-moderate alcohol intake either at baseline or following MI did not alter the risk for the development of HF requiring hospitalization or an open-label angiotensin-converting enzyme inhibitor.
The US Food and Drug Administration (FDA) has approved three low-molecular-weight heparins (LMWHs... more The US Food and Drug Administration (FDA) has approved three low-molecular-weight heparins (LMWHs) (enoxaparin, dalteparin, and ardeparin) for prophylaxis of venous thromboembolism and one LMWH, enoxaparin, for treatment of unstable angina/non-Q-wave myocardial ...
Journal of The American College of Cardiology, 2007
This study sought to examine the relationship between thiazolidinedione (TZD) use and outcomes in... more This study sought to examine the relationship between thiazolidinedione (TZD) use and outcomes in ambulatory patients with diabetes and heart failure (HF).Thiazolidinediones have been relatively contraindicated in diabetic patients with HF.We conducted a retrospective study of a national cohort of veterans with HF and diabetes treated in ambulatory clinics at Veterans Affairs medical centers. Patients were classified into those using TZDs and those not using insulin-sensitizing medication based on prescriptions filled 90 days before or 30 days after the index outpatient visit. The outcomes were time to hospitalization for HF and time to death.Of 7,147 ambulatory HF patients receiving diabetic therapy, 818 (11.4%) were receiving a TZD and 4,700 (65.8%) were not receiving insulin sensitizers. Over 2 years of follow-up, 134 (16.4%) patients receiving TZDs and 741 (15.8%) patients not receiving insulin-sensitizing medications required HF hospitalization (adjusted hazard ratio 1.00, 95% confidence interval 0.81 to 1.24, p = 0.97). A total of 168 (20.5%) patients receiving TZDs and 1,192 (25.4%) patients not receiving insulin-sensitizing medications died (adjusted hazard ratio 0.98, 95% confidence interval 0.81 to 1.17, p = 0.80).In ambulatory patients with established HF and diabetes, the use of TZDs was not associated with an increased risk of HF hospitalization or total mortality when compared with those not receiving insulin-sensitizing medications.
Journal of The American College of Cardiology, 2009
This study was designed to examine the relationship between glycosylated hemoglobin (HbA1C) and a... more This study was designed to examine the relationship between glycosylated hemoglobin (HbA1C) and adverse outcomes in diabetic patients with established heart failure (HF).Despite the common coexistence of diabetes and HF, previous studies examining the association between HbA1C and outcomes in this population have been limited and have reported discrepant results.We assessed the association between increasing quintiles (Q1 to Q5) of HbA1C and risk of death or risk of HF hospitalization by conducting a retrospective study in a national cohort of 5,815 veterans with HF and diabetes treated in ambulatory clinics at Veterans Affairs medical centers.At 2 years of follow-up, death occurred in 25% of patients in Q1 (HbA1C ≤6.4%), 23% in Q2 (6.4% < HbA1c ≤7.1%), 17.7% in Q3 (7.1% < HbA1c ≤7.8%), 22.5% in Q4 (7.8% < HbA1c ≤9.0%), and 23.2% in Q5 (HbA1c >9.0%). After adjustment for potential confounders, the middle quintile (Q3) had reduced mortality when compared with the lowest quintile (risk-adjusted hazard ratio: 0.73, 95% confidence interval: 0.61 to 0.88, p = 0.001). Hospitalization rates for HF at 2 years increased with increasing quintiles of HbA1C (Q1: 13.3%, Q2: 13.1%, Q3: 15.5%, Q4: 16.4%, and Q5: 18.2%), but this association was not statistically significant when adjusted for potential confounders.The association between mortality and HbA1C in diabetic patients with HF appears U-shaped, with the lowest risk of death in those patients with modest glucose control (7.1% < HbA1C ≤7.8%). Future prospective studies are necessary to define optimal treatment goals in these patients.
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Papers by David Aguilar