American Journal of Medicine最新文献

Background: National heart failure guidelines recommend quadruple therapy with renin-angiotensin system inhibitors, beta-blockers, mineralocorticoid receptor antagonists, and sodium-glucose cotransporter 2 inhibitors for patients with heart failure with reduced ejection fraction (HFrEF), most of whom also receive loop diuretics. However, the guidelines are less clear about the safe approaches to discontinuing older drugs whose decreasing or residual benefit is less well understood. The objective of this study was to examine whether digoxin can be safely discontinued in patients with HFrEF receiving beta-blockers.

Methods: In OPTIMIZE-HF, of 2477 patients with HFrEF (EF ≤45%) receiving beta-blockers and digoxin, digoxin was discontinued in 450 patients. We assembled a propensity score-matched cohort of 433 pairs of patients in which digoxin continuation vs. discontinuation groups were balanced on 51 baseline characteristics. Using the same approach, from 992 patients not on beta-blockers, we assembled a matched cohort of 198 pairs of patients also balanced on 51 baseline characteristics. Hazard ratios (HRs) and 95% CIs for 1-year outcomes were estimated.

Results: Among patients receiving beta-blockers, digoxin discontinuation had no association with the combined endpoint of heart failure readmission or death (HR, 1.01; 95% CI, 0.85-1.19), heart failure readmission (HR, 1.03; 95% CI, 0.85-1.25) or death (HR, 0.91; 95% CI, 0.72-1.14). Respective HRs (95% CIs) among patients not receiving beta-blockers were 1.60 (1.25-2.04), 1.62 (1.18-2.22) and 1.43 (1.08-1.89).

Conclusions: Digoxin can be discontinued without increasing the risk of adverse outcomes in patients with HFrEF receiving beta-blockers. Future studies need to examine the residual benefit of older heart failure drugs to ensure their safe discontinuation in patients with HFrEF receiving newer guideline-directed medical therapy.

Objectives: This study aimed to compare the demographic features and socioeconomic status of patients who underwent coronary artery calcium screening to that of their local population.

Background: Coronary artery calcium scores provide important evidence of subclinical atherosclerosis. However, insurance often does not cover coronary artery calcium testing, which could exclude people of lower socioeconomic status.

Methods: Demographic and occupational data were obtained for all patients referred for coronary artery calcium in a metropolitan area between October 2010 and August 2023. Household income and population reference information were taken from US Census Data and matched to zip code and regional metropolitan area.

Results: Coronary artery calcium tests were performed on 627 patients with a median age of 63 years and equal gender representation (52% female, 48% male). Patients were predominately White (77%) and English-speaking (98%), which is incongruent with local demographic data (P < .001). Healthcare workers were the largest workforce (22%), followed by people involved in education (12%), which is higher than the local healthcare workforce of 10% (P < .001). Those with graduate/professional degrees accounted for 32% of patients, significantly more than the local population (P < .001). The average median annual income ($94,116) of patients who underwent CAC testing was greater than that of the metropolitan median income of $81,264 (P < .001).

Conclusion: The disproportionate distribution of coronary artery calcium screening favoring educated, affluent, White English speakers indicates that higher-income and healthcare personnel are more likely to receive testing. Disparities in coronary artery calcium testing, especially in minorities and non-English speaking individuals, should be further explored.

Background: Post-acute COVID-19 syndrome (PACS) has been linked to microvascular endothelial dysfunction as a potential underlying pathomechanism and can manifest even following a mild course of the initial infection. Prevalence of microvascular endothelial dysfunction and circulating natriuretic peptides in such PACS patients remains unknown.

Methods: This prospective, cross-sectional cohort study enrolled 92 patients (82% females, median age 48 years) with PACS. Reactive hyperemia index (RHI) was evaluated with peripheral arterial tonometry, where <1.67 was defined as microvascular endothelial dysfunction, 1.67-2.0 as impaired function, and >2 normal endothelial function, on average 31 months after the acute infection. N-terminal pro-B-type natriuretic peptide (NT-proBNP) levels were collected at 2 different time points within over a 1-year span.

Results: In total, 41% of PACS subjects had microvascular endothelial dysfunction and 20% had impaired RHI. No major differences in clinical characteristics, routine chemistry laboratory testing, or symptom burden were observed across the groups. Only subjects with microvascular endothelial dysfunction and impaired endothelial function had a significant increase in NT-proBNP levels over time, and those with larger increase in NT-proBNP had significantly lower RHI. There was a significant correlation between relative or absolute increase in NT-proBNP and RHI, which remained significant in a multivariable adjusted linear regression.

Conclusions: Peripheral microvascular endothelial dysfunction was prevalent in a symptomatic PACS population long after recovery from a mild acute infection. Increases in NT-proBNP levels were associated with microvascular endothelial dysfunction, suggesting a link between, and providing a foundation for, future studies on post viral microvascular endothelial dysfunction in PACS.