1
|
Iyngkaran P, Hespe C, Hanna F, Horowitz JD, Battersby M, Nelson C, Andrew S, de Courten MP. The Wider Considerations in Closing Chronic Disease Gaps - Focus on Heart Failure and Implementation. Curr Cardiol Rev 2023; 19:e120522204690. [PMID: 35549873 PMCID: PMC10201899 DOI: 10.2174/1573403x18666220512160737] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/17/2021] [Revised: 02/09/2022] [Accepted: 03/08/2022] [Indexed: 11/22/2022] Open
Abstract
BACKGROUND Heart failure (HF) is predominately a chronic disease. There are overlaps in HF and chronic disease research and care. Chronic disease and HF research are conducted with multiple goals. The overarching goal is "optimized patient outcomes at maximum costeffectiveness". However, observations on patients can come with many variables; thus, we see differences in clinical translation. This document discusses an argument for three important gaps common to HF and chronic disease, i.e., screening, self-management, and patient-reported outcomes (PRO), and provides a glance of how it could fit into the evidence tree. Pertinent arguments for a framework for health services and models of care are provided as a prelude to future consensus. METHODOLOGY 1) A preliminary literature review to identify a taxonomy for cardiovascular research, and 2) a review of the published literature describing the translation of research studies into clinical practice for cardiovascular disorders. A spectrum from observational to large randomized controlled trials to post-marketing studies were identified. DISCUSSION A brief discussion on traditional research and differences focusing on screening, mixed methods research concepts, and chronic diseases models of care. Six steps to facilitate this: 1) Research design; 2) Research application (translation) i. routine ii. challenges; 3. Transforming research to translational level; 4. Funding and infrastructure; 5. Clinical Centres of Research Excellence (CCRE) and collaboration; 6. Governance and cost-effectiveness. CONCLUSION Implementation research that aims to link research findings to improved patient outcomes in an efficient and effective way is a neglected area. Skills required to perform implementation research are complex. Ways to maximize translational impacts for chronic disease research to clinical practice are described in a HF context.
Collapse
Affiliation(s)
- Pupalan Iyngkaran
- Heart Failure & Cardiac Imaging, University of Notre Dame, Werribee Mercy Sub School, School of Medicine Sydney; Research Fellow Mitchell Institute, Victoria University, Victoria, Australia
| | - Charlotte Hespe
- General Practice and Primary Care Research, School of Medicine, Sydney, The University of Notre Dame Australia, 160 Oxford St, Darlinghurst, NSW 2010, PO Box 944 Broadway, NSW 2007, Australia
| | - Fahad Hanna
- Program of Public Health, Department of Health, Torrens University Australia, Australia
| | | | - Malcolm Battersby
- College of Medicine and Public Health, Flinders University Mental Health Program Lead, Flinders Health and Medical Research Institute, Southern Adelaide Local Health Network Mental Health Service, Melbourne, Australia
| | - Craig Nelson
- Division of Chronic and Complex Care and the Director of Nephrology, Melbourne, Australia
| | - Sharon Andrew
- Adjunct Professor of Nursing, Institute Health and Sport, Victoria University, PO Box 14428 Melbourne, Victoria 8001, Australia
| | - Maximilian P. de Courten
- Mitchell Institute for Education and Health Policy, Victoria University, 300 Queen St, Melbourne 3000, Australia
| |
Collapse
|
2
|
Ren Y, Li Y, Pan W, Yin D, Du J. Predictive value of CAC score combined with clinical features for obstructive coronary heart disease on coronary computed tomography angiography: a machine learning method. BMC Cardiovasc Disord 2022; 22:569. [PMID: 36572879 PMCID: PMC9793556 DOI: 10.1186/s12872-022-03022-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/14/2022] [Accepted: 12/19/2022] [Indexed: 12/27/2022] Open
Abstract
OBJECTIVE We investigated the predictive value of clinical factors combined with coronary artery calcium (CAC) score based on a machine learning method for obstructive coronary heart disease (CAD) on coronary computed tomography angiography (CCTA) in individuals with atypical chest pain. METHODS The study included data from 1,906 individuals undergoing CCTA and CAC scanning because of atypical chest pain and without evidence for the previous CAD. A total of 63 variables including traditional cardiovascular risk factors, CAC score, laboratory results, and imaging parameters were used to build the Random forests (RF) model. Among all the participants, 70% were randomly selected to train the models on which fivefold cross-validation was done and the remaining 30% were regarded as a validation set. The prediction performance of the RF model was compared with two traditional logistic regression (LR) models. RESULTS The incidence of obstructive CAD was 16.4%. The area under the receiver operator characteristic (ROC) for obstructive CAD of the RF model was 0.841 (95% CI 0.820-0.860), the CACS model was 0.746 (95% CI 0.722-0.769), and the clinical model was 0.810 (95% CI 0.788-0.831). The RF model was significantly superior to the other two models (p < 0.05). Furthermore, the calibration curve and Hosmer-Lemeshow test showed that the RF model had good classification performance (p = 0.556). CAC score, age, glucose, homocysteine, and neutrophil were the top five important variables in the RF model. CONCLUSION RF model was superior to the traditional models in the prediction of obstructive CAD. In clinical practice, the RF model may improve risk stratification and optimize individual management.
Collapse
Affiliation(s)
- Yongkui Ren
- grid.24696.3f0000 0004 0369 153XBeijing Anzhen Hospital, Capital Medical University, No. 2 Anzhen Road, Chaoyang District, Beijing, China ,grid.411971.b0000 0000 9558 1426Department of Cardiology, 1st Affiliated Hospital of Dalian Medical University, Dalian, China
| | - Yulin Li
- grid.24696.3f0000 0004 0369 153XBeijing Anzhen Hospital, Capital Medical University, No. 2 Anzhen Road, Chaoyang District, Beijing, China ,grid.419897.a0000 0004 0369 313XKey Laboratory of Remodeling-Related Cardiovascular Diseases, Ministry of Education, Beijing, China ,grid.411606.40000 0004 1761 5917Beijing Institute of Heart, Lung, and Blood Vessel Disease, Beijing, China
| | - Weili Pan
- grid.411971.b0000 0000 9558 1426Department of Cardiology, 1st Affiliated Hospital of Dalian Medical University, Dalian, China
| | - Da Yin
- grid.440218.b0000 0004 1759 7210Department of Cardiology, Shenzhen People’s Hospital, 2nd Clinical Medical College of JINAN University, 1st Affiliated Hospital of Southern University of Science and Technology, ShenZhen, China
| | - Jie Du
- grid.24696.3f0000 0004 0369 153XBeijing Anzhen Hospital, Capital Medical University, No. 2 Anzhen Road, Chaoyang District, Beijing, China ,grid.419897.a0000 0004 0369 313XKey Laboratory of Remodeling-Related Cardiovascular Diseases, Ministry of Education, Beijing, China ,grid.411606.40000 0004 1761 5917Beijing Institute of Heart, Lung, and Blood Vessel Disease, Beijing, China
| |
Collapse
|
3
|
Paul SK, Montvida O, Best JH, Gale S, Pethö-Schramm A, Sarsour K. Association of biological antirheumatic therapy with risk for type 2 diabetes: a retrospective cohort study in incident rheumatoid arthritis. BMJ Open 2021; 11:e042246. [PMID: 34135030 PMCID: PMC8211068 DOI: 10.1136/bmjopen-2020-042246] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
OBJECTIVE To explore possible associations of treatment with biological disease-modifying antirheumatic drugs (bDMARDs), including T-cell-based and interleukin-6 inhibition (IL-6i)-based therapies, and the risk for type 2 diabetes mellitus (T2DM) in patients with rheumatoid arthritis (RA). STUDY DESIGN, SETTING AND PARTICIPANTS Five treatment groups were selected from a United States Electronic Medical Records database of 283 756 patients with RA (mean follow-up, 5 years): never received bDMARD (No bDMARD, n=125 337), tumour necrosis factor inhibitors (TNFi, n=34 873), IL-6i (n=1884), T-cell inhibitors (n=5935) and IL-6i+T cell inhibitor abatacept (n=1213). Probability and risk for T2DM were estimated with adjustment for relevant confounders. RESULTS In the cohort of 169 242 patients with a mean 4.5 years of follow-up and a mean 641 200 person years of follow-up, the adjusted probability of developing T2DM was significantly lower in the IL-6i (probability, 1%; 95% CI 0.6 to 2.0), T-cell inhibitor (probability, 3%; 95% CI 2.3 to 3.3) and IL-6i+T cell inhibitor (probability, 2%; 95% CI 0.1 to 2.9) groups than in the No bDMARD (probability, 5%; 95% CI 4.6 to 4.9) and TNFi (probability, 4%; 95% CI 3.7 to 4.7) groups. Compared with No bDMARD, the IL-6i and IL-6i+T cell inhibitor groups had 37% (95% CI of HR 0.42 to 0.96) and 34% (95% CI of HR 0.46 to 0.93) significantly lower risk for T2DM, respectively; there was no significant difference in risk in the TNFi (HR 0.99; 95% CI 0.93 to 1.06) and T-cell inhibitor (HR 0.96; 95% CI 0.82 to 1.12) groups. CONCLUSIONS Treatment with IL-6i, with or without T-cell inhibitors, was associated with reduced risk for T2DM compared with TNFi or No bDMARDs; a less pronounced association was observed for the T-cell inhibitor abatacept.
Collapse
Affiliation(s)
- Sanjoy K Paul
- Melbourne EpiCentre, University of Melbourne and Melbourne Health, Parkville, Victoria, Australia
| | - Olga Montvida
- Melbourne EpiCentre, University of Melbourne and Melbourne Health, Parkville, Victoria, Australia
| | - Jennie H Best
- Pharmaceuticals Division, Genentech, South San Francisco, California, USA
| | - Sara Gale
- Pharmaceuticals Division, Genentech, South San Francisco, California, USA
| | - Attila Pethö-Schramm
- Pharmaceuticals Division, F Hoffmann-La Roche AG, Basel, Basel-Stadt, Switzerland
| | - Khaled Sarsour
- Pharmaceuticals Division, Genentech, South San Francisco, California, USA
| |
Collapse
|
4
|
Comparative effectiveness of different contemporary drug-eluting stents in routine clinical practice. Coron Artery Dis 2019; 30:255-262. [DOI: 10.1097/mca.0000000000000730] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
|
5
|
Lee KY, Chang K. Understanding Vulnerable Plaques: Current Status and Future Directions. Korean Circ J 2019; 49:1115-1122. [PMID: 31760703 PMCID: PMC6875591 DOI: 10.4070/kcj.2019.0211] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/03/2019] [Revised: 09/30/2019] [Accepted: 10/07/2019] [Indexed: 01/19/2023] Open
Abstract
The main cause of acute myocardial infarction is plaque rupture accompanied by superimposed coronary thrombosis. Thin-cap fibroatheromas (TCFAs) have been suggested as a type of lesion with a vulnerability that can cause plaque rupture. However, not only the existence of a TCFA but also the fine and complex interactions of other anatomical and hemodynamic factors, such as microcalcification in the fibrous cap, cholesterol crystal-induced inflammasome activation, the apoptosis of intraplaque macrophages, and endothelial shear stress distribution should precede a clinical event caused by plaque rupture. Recent studies are being conducted to identify these mechanisms through molecular imaging and hemodynamic assessment using computational fluid dynamics, which will result in better clinical results through selective coronary interventions.
Collapse
Affiliation(s)
- Kwan Yong Lee
- Cardiovascular Center and Cardiology Division, Incheon St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Korea
| | - Kiyuk Chang
- Cardiovascular Center and Cardiology Division, Seoul St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Korea.
| |
Collapse
|
6
|
Coronary Computed Tomography Angiography Versus Stress Echocardiography in Acute Chest Pain. JACC Cardiovasc Imaging 2018; 11:1288-1297. [DOI: 10.1016/j.jcmg.2018.03.024] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/27/2018] [Accepted: 03/28/2018] [Indexed: 12/12/2022]
|
7
|
Affiliation(s)
- Pamela S Douglas
- Duke Clinical Research Institute, Duke University, Durham, North Carolina.
| | - Melissa A Daubert
- Duke Clinical Research Institute, Duke University, Durham, North Carolina
| |
Collapse
|
8
|
Nguyen KT, Olgin JE, Pletcher MJ, Ng M, Kaye L, Moturu S, Gladstone RA, Malladi C, Fann AH, Maguire C, Bettencourt L, Christensen MA, Marcus GM. Smartphone-Based Geofencing to Ascertain Hospitalizations. Circ Cardiovasc Qual Outcomes 2017; 10:CIRCOUTCOMES.116.003326. [PMID: 28325751 DOI: 10.1161/circoutcomes.116.003326] [Citation(s) in RCA: 35] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/25/2016] [Accepted: 01/13/2017] [Indexed: 01/13/2023]
Abstract
BACKGROUND Ascertainment of hospitalizations is critical to assess quality of care and the effectiveness and adverse effects of various therapies. Smartphones, mobile geolocators that are ubiquitous, have not been leveraged to ascertain hospitalizations. Therefore, we evaluated the use of smartphone-based geofencing to track hospitalizations. METHODS AND RESULTS Participants aged ≥18 years installed a mobile application programmed to geofence all hospitals using global positioning systems and cell phone tower triangulation and to trigger a smartphone-based questionnaire when located in a hospital for ≥4 hours. An in-person study included consecutive consenting patients scheduled for electrophysiology and cardiac catheterization procedures. A remote arm invited Health eHeart Study participants who consented and engaged with the study via the internet only. The accuracy of application-detected hospitalizations was confirmed by medical record review as the reference standard. Of 22 eligible in-person patients, 17 hospitalizations were detected (sensitivity 77%; 95% confidence interval, 55%-92%). The length of stay according to the application was positively correlated with the length of stay ascertained via the electronic medical record (r=0.53; P=0.03). In the remote arm, the application was downloaded by 3443 participants residing in all 50 US states; 243 hospital visits at 119 different hospitals were detected through the application. The positive predictive value for an application-reported hospitalization was 65% (95% confidence interval, 57%-72%). CONCLUSIONS Mobile application-based ascertainment of hospitalizations can be achieved with modest accuracy. This first proof of concept may ultimately be applicable to geofencing other types of prespecified locations to facilitate healthcare research and patient care.
Collapse
Affiliation(s)
- Kaylin T Nguyen
- From the Division of Cardiology (K.T.N., J.E.O., M.N., R.A.G., C.M., A.H.F., C.M., L.B., M.A.C., G.M.M) and Department of Epidemiology and Biostatistics (M.J.P.), University of California, San Francisco; Ginger.io, San Francisco, CA (L.K., S.M.)
| | - Jeffrey E Olgin
- From the Division of Cardiology (K.T.N., J.E.O., M.N., R.A.G., C.M., A.H.F., C.M., L.B., M.A.C., G.M.M) and Department of Epidemiology and Biostatistics (M.J.P.), University of California, San Francisco; Ginger.io, San Francisco, CA (L.K., S.M.)
| | - Mark J Pletcher
- From the Division of Cardiology (K.T.N., J.E.O., M.N., R.A.G., C.M., A.H.F., C.M., L.B., M.A.C., G.M.M) and Department of Epidemiology and Biostatistics (M.J.P.), University of California, San Francisco; Ginger.io, San Francisco, CA (L.K., S.M.)
| | - Madelena Ng
- From the Division of Cardiology (K.T.N., J.E.O., M.N., R.A.G., C.M., A.H.F., C.M., L.B., M.A.C., G.M.M) and Department of Epidemiology and Biostatistics (M.J.P.), University of California, San Francisco; Ginger.io, San Francisco, CA (L.K., S.M.)
| | - Leanne Kaye
- From the Division of Cardiology (K.T.N., J.E.O., M.N., R.A.G., C.M., A.H.F., C.M., L.B., M.A.C., G.M.M) and Department of Epidemiology and Biostatistics (M.J.P.), University of California, San Francisco; Ginger.io, San Francisco, CA (L.K., S.M.)
| | - Sai Moturu
- From the Division of Cardiology (K.T.N., J.E.O., M.N., R.A.G., C.M., A.H.F., C.M., L.B., M.A.C., G.M.M) and Department of Epidemiology and Biostatistics (M.J.P.), University of California, San Francisco; Ginger.io, San Francisco, CA (L.K., S.M.)
| | - Rachel A Gladstone
- From the Division of Cardiology (K.T.N., J.E.O., M.N., R.A.G., C.M., A.H.F., C.M., L.B., M.A.C., G.M.M) and Department of Epidemiology and Biostatistics (M.J.P.), University of California, San Francisco; Ginger.io, San Francisco, CA (L.K., S.M.)
| | - Chaitanya Malladi
- From the Division of Cardiology (K.T.N., J.E.O., M.N., R.A.G., C.M., A.H.F., C.M., L.B., M.A.C., G.M.M) and Department of Epidemiology and Biostatistics (M.J.P.), University of California, San Francisco; Ginger.io, San Francisco, CA (L.K., S.M.)
| | - Amy H Fann
- From the Division of Cardiology (K.T.N., J.E.O., M.N., R.A.G., C.M., A.H.F., C.M., L.B., M.A.C., G.M.M) and Department of Epidemiology and Biostatistics (M.J.P.), University of California, San Francisco; Ginger.io, San Francisco, CA (L.K., S.M.)
| | - Carol Maguire
- From the Division of Cardiology (K.T.N., J.E.O., M.N., R.A.G., C.M., A.H.F., C.M., L.B., M.A.C., G.M.M) and Department of Epidemiology and Biostatistics (M.J.P.), University of California, San Francisco; Ginger.io, San Francisco, CA (L.K., S.M.)
| | - Laura Bettencourt
- From the Division of Cardiology (K.T.N., J.E.O., M.N., R.A.G., C.M., A.H.F., C.M., L.B., M.A.C., G.M.M) and Department of Epidemiology and Biostatistics (M.J.P.), University of California, San Francisco; Ginger.io, San Francisco, CA (L.K., S.M.)
| | - Matthew A Christensen
- From the Division of Cardiology (K.T.N., J.E.O., M.N., R.A.G., C.M., A.H.F., C.M., L.B., M.A.C., G.M.M) and Department of Epidemiology and Biostatistics (M.J.P.), University of California, San Francisco; Ginger.io, San Francisco, CA (L.K., S.M.)
| | - Gregory M Marcus
- From the Division of Cardiology (K.T.N., J.E.O., M.N., R.A.G., C.M., A.H.F., C.M., L.B., M.A.C., G.M.M) and Department of Epidemiology and Biostatistics (M.J.P.), University of California, San Francisco; Ginger.io, San Francisco, CA (L.K., S.M.).
| |
Collapse
|
9
|
Comparative Effectiveness Trials of Imaging-Guided Strategies in Stable Ischemic Heart Disease. JACC Cardiovasc Imaging 2017; 10:321-334. [PMID: 28279380 DOI: 10.1016/j.jcmg.2016.10.016] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/18/2016] [Revised: 10/24/2016] [Accepted: 10/25/2016] [Indexed: 12/21/2022]
Abstract
The evaluation of patients with suspected stable ischemic heart disease is among the most common diagnostic evaluations with nearly 20 million imaging and exercise stress tests performed annually in the United States. Over the past decade, there has been an evolution in imaging research with an ever-increasing focus on larger registries and randomized trials comparing the effectiveness of varying diagnostic algorithms. The current review highlights recent randomized trial evidence with a particular focus comparing the effectiveness of cardiac imaging procedures within the stable ischemic heart disease evaluation for coronary artery disease detection, angina, and other quality of life measures, and major clinical outcomes. Also highlighted are secondary analyses from these trials on the economic findings related to comparative cost differences across diagnostic testing strategies.
Collapse
|
10
|
Kolossváry M, Szilveszter B, Merkely B, Maurovich-Horvat P. Plaque imaging with CT-a comprehensive review on coronary CT angiography based risk assessment. Cardiovasc Diagn Ther 2017; 7:489-506. [PMID: 29255692 PMCID: PMC5716945 DOI: 10.21037/cdt.2016.11.06] [Citation(s) in RCA: 60] [Impact Index Per Article: 8.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/21/2016] [Accepted: 12/08/2016] [Indexed: 01/07/2023]
Abstract
CT based technologies have evolved considerably in recent years. Coronary CT angiography (CTA) provides robust assessment of coronary artery disease (CAD). Early coronary CTA imaging-as a gate-keeper of invasive angiography-has focused on the presence of obstructive stenosis. Coronary CTA is currently the only non-invasive imaging modality for the evaluation of non-obstructive CAD, which has been shown to contribute to adverse cardiac events. Importantly, improved spatial resolution of CT scanners and novel image reconstruction algorithms enable the quantification and characterization of atherosclerotic plaques. State-of-the-art CT imaging can therefore reliably assess the extent of CAD and differentiate between various plaque features. Recent studies have demonstrated the incremental prognostic value of adverse plaque features over luminal stenosis. Comprehensive coronary plaque assessment holds potential to significantly improve individual risk assessment incorporating adverse plaque characteristics, the extent and severity of atherosclerotic plaque burden. As a result, several coronary CTA based composite risk scores have been proposed recently to determine patients at high risk for adverse events. Coronary CTA became a promising modality for the evaluation of functional significance of coronary lesions using CT derived fractional flow reserve (FFR-CT) and/or rest/dynamic myocardial CT perfusion. This could lead to substantial reduction in unnecessary invasive catheterization procedures and provide information on ischemic burden of CAD. Discordance between the degree of stenosis and ischemia has been recognized in clinical landmark trials using invasive FFR. Both lesion stenosis and composition are possibly related to myocardial ischemia. The evaluation of lesion-specific ischemia using combined functional and morphological plaque information could ultimately improve the diagnostic performance of CTA and thus patient care. In this review we aimed to summarize current evidence on comprehensive coronary artery plaque assessment using coronary CTA.
Collapse
Affiliation(s)
- Márton Kolossváry
- MTA-SE Cardiovascular Imaging Research Group, Heart and Vascular Center, Semmelweis University, Budapest, Hungary
| | - Bálint Szilveszter
- MTA-SE Cardiovascular Imaging Research Group, Heart and Vascular Center, Semmelweis University, Budapest, Hungary
| | - Béla Merkely
- MTA-SE Cardiovascular Imaging Research Group, Heart and Vascular Center, Semmelweis University, Budapest, Hungary
| | - Pál Maurovich-Horvat
- MTA-SE Cardiovascular Imaging Research Group, Heart and Vascular Center, Semmelweis University, Budapest, Hungary
| |
Collapse
|
11
|
Ahmad FS, Chan C, Rosenman MB, Post WS, Fort DG, Greenland P, Liu KJ, Kho AN, Allen NB. Validity of Cardiovascular Data From Electronic Sources: The Multi-Ethnic Study of Atherosclerosis and HealthLNK. Circulation 2017; 136:1207-1216. [PMID: 28687707 DOI: 10.1161/circulationaha.117.027436] [Citation(s) in RCA: 42] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/05/2017] [Accepted: 06/28/2017] [Indexed: 12/23/2022]
Abstract
BACKGROUND Understanding the validity of data from electronic data research networks is critical to national research initiatives and learning healthcare systems for cardiovascular care. Our goal was to evaluate the degree of agreement of electronic data research networks in comparison with data collected by standardized research approaches in a cohort study. METHODS We linked individual-level data from MESA (Multi-Ethnic Study of Atherosclerosis), a community-based cohort, with HealthLNK, a 2006 to 2012 database of electronic health records from 6 Chicago health systems. To evaluate the correlation and agreement of blood pressure in HealthLNK in comparison with in-person MESA examinations, and body mass index in HealthLNK in comparison with MESA, we used Pearson correlation coefficients and Bland-Altman plots. Using diagnoses in MESA as the criterion standard, we calculated the performance of HealthLNK for hypertension, obesity, and diabetes mellitus diagnosis by using International Classification of Diseases, Ninth Revision codes and clinical data. We also identified potential myocardial infarctions, strokes, and heart failure events in HealthLNK and compared them with adjudicated events in MESA. RESULTS Of the 1164 MESA participants enrolled at the Chicago Field Center, 802 (68.9%) participants had data in HealthLNK. The correlation was low for systolic blood pressure (0.39; P<0.0001). In comparison with MESA, HealthLNK overestimated systolic blood pressure by 6.5 mm Hg (95% confidence interval, 4.2-7.8). There was a high correlation between body mass index in MESA and HealthLNK (0.94; P<0.0001). HealthLNK underestimated body mass index by 0.3 kg/m2 (95% confidence interval, -0.4 to -0.1). With the use of International Classification of Diseases, Ninth Revision codes and clinical data, the sensitivity and specificity of HealthLNK queries for hypertension were 82.4% and 59.4%, for obesity were 73.0% and 89.8%, and for diabetes mellitus were 79.8% and 93.3%. In comparison with adjudicated cardiovascular events in MESA, the concordance rates for myocardial infarction, stroke, and heart failure were, respectively, 41.7% (5/12), 61.5% (8/13), and 62.5% (10/16). CONCLUSIONS These findings illustrate the limitations and strengths of electronic data repositories in comparison with information collected by traditional standardized epidemiological approaches for the ascertainment of cardiovascular risk factors and events.
Collapse
Affiliation(s)
- Faraz S Ahmad
- From Division of Epidemiology, Department of Preventive Medicine (F.S.A., C.C., P.G., K.J.L., N.B.A.); Division of Cardiology, Department of Medicine (F.S.A., P.G.); Department of Pediatrics (M.B.R.); The Center for Health Information Partnerships (CHiP), Institute of Public Health & Medicine (M.B.R., A.N.K.); Division of Health and Biomedical Informatics, Department of Preventive Medicine (D.G.F.); Division of General Internal Medicine and Geriatrics, Department of Medicine (A.N.K.), Northwestern University Feinberg School of Medicine, Chicago, IL; Division of Cardiology, Department of Medicine, Ciccarone Center for the Prevention of Heart Disease, Johns Hopkins University School of Medicine, Baltimore, MD (W.S.P.); Department of Epidemiology, Welch Center for Prevention, Epidemiology, and Clinical Research, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD (W.S.P.)
| | - Cheeling Chan
- From Division of Epidemiology, Department of Preventive Medicine (F.S.A., C.C., P.G., K.J.L., N.B.A.); Division of Cardiology, Department of Medicine (F.S.A., P.G.); Department of Pediatrics (M.B.R.); The Center for Health Information Partnerships (CHiP), Institute of Public Health & Medicine (M.B.R., A.N.K.); Division of Health and Biomedical Informatics, Department of Preventive Medicine (D.G.F.); Division of General Internal Medicine and Geriatrics, Department of Medicine (A.N.K.), Northwestern University Feinberg School of Medicine, Chicago, IL; Division of Cardiology, Department of Medicine, Ciccarone Center for the Prevention of Heart Disease, Johns Hopkins University School of Medicine, Baltimore, MD (W.S.P.); Department of Epidemiology, Welch Center for Prevention, Epidemiology, and Clinical Research, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD (W.S.P.)
| | - Marc B Rosenman
- From Division of Epidemiology, Department of Preventive Medicine (F.S.A., C.C., P.G., K.J.L., N.B.A.); Division of Cardiology, Department of Medicine (F.S.A., P.G.); Department of Pediatrics (M.B.R.); The Center for Health Information Partnerships (CHiP), Institute of Public Health & Medicine (M.B.R., A.N.K.); Division of Health and Biomedical Informatics, Department of Preventive Medicine (D.G.F.); Division of General Internal Medicine and Geriatrics, Department of Medicine (A.N.K.), Northwestern University Feinberg School of Medicine, Chicago, IL; Division of Cardiology, Department of Medicine, Ciccarone Center for the Prevention of Heart Disease, Johns Hopkins University School of Medicine, Baltimore, MD (W.S.P.); Department of Epidemiology, Welch Center for Prevention, Epidemiology, and Clinical Research, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD (W.S.P.)
| | - Wendy S Post
- From Division of Epidemiology, Department of Preventive Medicine (F.S.A., C.C., P.G., K.J.L., N.B.A.); Division of Cardiology, Department of Medicine (F.S.A., P.G.); Department of Pediatrics (M.B.R.); The Center for Health Information Partnerships (CHiP), Institute of Public Health & Medicine (M.B.R., A.N.K.); Division of Health and Biomedical Informatics, Department of Preventive Medicine (D.G.F.); Division of General Internal Medicine and Geriatrics, Department of Medicine (A.N.K.), Northwestern University Feinberg School of Medicine, Chicago, IL; Division of Cardiology, Department of Medicine, Ciccarone Center for the Prevention of Heart Disease, Johns Hopkins University School of Medicine, Baltimore, MD (W.S.P.); Department of Epidemiology, Welch Center for Prevention, Epidemiology, and Clinical Research, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD (W.S.P.)
| | - Daniel G Fort
- From Division of Epidemiology, Department of Preventive Medicine (F.S.A., C.C., P.G., K.J.L., N.B.A.); Division of Cardiology, Department of Medicine (F.S.A., P.G.); Department of Pediatrics (M.B.R.); The Center for Health Information Partnerships (CHiP), Institute of Public Health & Medicine (M.B.R., A.N.K.); Division of Health and Biomedical Informatics, Department of Preventive Medicine (D.G.F.); Division of General Internal Medicine and Geriatrics, Department of Medicine (A.N.K.), Northwestern University Feinberg School of Medicine, Chicago, IL; Division of Cardiology, Department of Medicine, Ciccarone Center for the Prevention of Heart Disease, Johns Hopkins University School of Medicine, Baltimore, MD (W.S.P.); Department of Epidemiology, Welch Center for Prevention, Epidemiology, and Clinical Research, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD (W.S.P.)
| | - Philip Greenland
- From Division of Epidemiology, Department of Preventive Medicine (F.S.A., C.C., P.G., K.J.L., N.B.A.); Division of Cardiology, Department of Medicine (F.S.A., P.G.); Department of Pediatrics (M.B.R.); The Center for Health Information Partnerships (CHiP), Institute of Public Health & Medicine (M.B.R., A.N.K.); Division of Health and Biomedical Informatics, Department of Preventive Medicine (D.G.F.); Division of General Internal Medicine and Geriatrics, Department of Medicine (A.N.K.), Northwestern University Feinberg School of Medicine, Chicago, IL; Division of Cardiology, Department of Medicine, Ciccarone Center for the Prevention of Heart Disease, Johns Hopkins University School of Medicine, Baltimore, MD (W.S.P.); Department of Epidemiology, Welch Center for Prevention, Epidemiology, and Clinical Research, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD (W.S.P.)
| | - Kiang J Liu
- From Division of Epidemiology, Department of Preventive Medicine (F.S.A., C.C., P.G., K.J.L., N.B.A.); Division of Cardiology, Department of Medicine (F.S.A., P.G.); Department of Pediatrics (M.B.R.); The Center for Health Information Partnerships (CHiP), Institute of Public Health & Medicine (M.B.R., A.N.K.); Division of Health and Biomedical Informatics, Department of Preventive Medicine (D.G.F.); Division of General Internal Medicine and Geriatrics, Department of Medicine (A.N.K.), Northwestern University Feinberg School of Medicine, Chicago, IL; Division of Cardiology, Department of Medicine, Ciccarone Center for the Prevention of Heart Disease, Johns Hopkins University School of Medicine, Baltimore, MD (W.S.P.); Department of Epidemiology, Welch Center for Prevention, Epidemiology, and Clinical Research, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD (W.S.P.)
| | - Abel N Kho
- From Division of Epidemiology, Department of Preventive Medicine (F.S.A., C.C., P.G., K.J.L., N.B.A.); Division of Cardiology, Department of Medicine (F.S.A., P.G.); Department of Pediatrics (M.B.R.); The Center for Health Information Partnerships (CHiP), Institute of Public Health & Medicine (M.B.R., A.N.K.); Division of Health and Biomedical Informatics, Department of Preventive Medicine (D.G.F.); Division of General Internal Medicine and Geriatrics, Department of Medicine (A.N.K.), Northwestern University Feinberg School of Medicine, Chicago, IL; Division of Cardiology, Department of Medicine, Ciccarone Center for the Prevention of Heart Disease, Johns Hopkins University School of Medicine, Baltimore, MD (W.S.P.); Department of Epidemiology, Welch Center for Prevention, Epidemiology, and Clinical Research, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD (W.S.P.)
| | - Norrina B Allen
- From Division of Epidemiology, Department of Preventive Medicine (F.S.A., C.C., P.G., K.J.L., N.B.A.); Division of Cardiology, Department of Medicine (F.S.A., P.G.); Department of Pediatrics (M.B.R.); The Center for Health Information Partnerships (CHiP), Institute of Public Health & Medicine (M.B.R., A.N.K.); Division of Health and Biomedical Informatics, Department of Preventive Medicine (D.G.F.); Division of General Internal Medicine and Geriatrics, Department of Medicine (A.N.K.), Northwestern University Feinberg School of Medicine, Chicago, IL; Division of Cardiology, Department of Medicine, Ciccarone Center for the Prevention of Heart Disease, Johns Hopkins University School of Medicine, Baltimore, MD (W.S.P.); Department of Epidemiology, Welch Center for Prevention, Epidemiology, and Clinical Research, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD (W.S.P.).
| |
Collapse
|
12
|
Plaque characteristics and inflammatory markers for the prediction of major cardiovascular events in patients with ST-segment elevation myocardial infarction. Int J Cardiovasc Imaging 2017; 33:1445-1454. [DOI: 10.1007/s10554-017-1135-x] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/20/2016] [Accepted: 04/06/2017] [Indexed: 10/19/2022]
|
13
|
Hecht H, Blaha MJ, Berman DS, Nasir K, Budoff M, Leipsic J, Blankstein R, Narula J, Rumberger J, Shaw LJ. Clinical indications for coronary artery calcium scoring in asymptomatic patients: Expert consensus statement from the Society of Cardiovascular Computed Tomography. J Cardiovasc Comput Tomogr 2017; 11:157-168. [PMID: 28283309 DOI: 10.1016/j.jcct.2017.02.010] [Citation(s) in RCA: 217] [Impact Index Per Article: 31.0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/08/2017] [Accepted: 02/20/2017] [Indexed: 12/21/2022]
Abstract
This expert consensus statement summarizes the available data regarding the prognostic value of CAC in the asymptomatic population and its ability to refine individual risk prediction, addresses the limitations identified in the current traditional risk factor-based treatment strategies recommended by the 2013 ACC/AHA Prevention guidelines including use of the Pooled Cohort Equations (PCE), and the US Preventive Services Task Force (USPSTF) Recommendation Statement for Statin Use for the Primary Prevention of Cardiovascular Disease in Adults. It provides CAC based treatment recommendations both within the context of the shared decision making model espoused by the 2013 ACC/AHA Prevention guidelines and independent of these guidelines.
Collapse
Affiliation(s)
- Harvey Hecht
- Division of Cardiology, Icahn School of Medicine at Mount Sinai, Mount Sinai St. Luke's Medical Center, New York, NY, USA.
| | - Michael J Blaha
- The Johns Hopkins Ciccarone Center for the Prevention of Heart Disease, Baltimore, MD, USA
| | - Daniel S Berman
- Department of Medicine, David Geffen School of Medicine, University of California, Los Angeles, CA, USA
| | - Khurram Nasir
- Miami Cardiac and Vascular Institute, Baptist Health South Florida, Miami, FL, USA
| | - Matthew Budoff
- Division of Cardiology, Los Angeles Biomedical Research Institute at Harbor-UCLA Medical Center, Torrance, CA, USA
| | - Jonathon Leipsic
- Department of Medicine and Radiology, University of British Columbia, Vancouver, Canada
| | - Ron Blankstein
- Non-Invasive Cardiovascular Imaging Program, Departments of Medicine (Cardiovascular Division) and Radiology, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Jagat Narula
- Division of Cardiology, Icahn School of Medicine at Mount Sinai, Mount Sinai St. Luke's Medical Center, New York, NY, USA
| | | | - Leslee J Shaw
- Department of Medicine, Emory University School of Medicine, Atlanta, GA, USA
| |
Collapse
|
14
|
Cao C, Clark AL, Suri RM. Robotic surgery is the optimal approach for mitral surgery. Ann Cardiothorac Surg 2016; 5:563-566. [PMID: 27942488 DOI: 10.21037/acs.2016.10.01] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
This report presented an overview of the patient selection, technical considerations and clinical evidence for robotic mitral valve surgery. A review of comparative outcomes to medical therapy, sternotomy approach, and the MitraClip device suggested that robotic mitral valve surgery is safe and effective in specialized centres. Potential benefits include a reliable and durable repair, with reduced perioperative morbidity and improved quality of life. Future studies should aim to delineate mid- and long-term clinical and echocardiographic outcomes following robotic mitral valve repair compared to the conventional sternotomy approach.
Collapse
Affiliation(s)
- Christopher Cao
- Collaborative Research Group, Macquarie University, Sydney, Australia; ; University of New South Wales, Sydney, Australia
| | - Ashleigh L Clark
- Collaborative Research Group, Macquarie University, Sydney, Australia
| | - Rakesh M Suri
- Department of Thoracic and Cardiovascular Surgery, Cleveland Clinic Foundation, Cleveland, USA
| |
Collapse
|
15
|
Qiao H, Wang Y, Zhang R, Gao Q, Liang X, Gao L, Jiang Z, Qiao R, Han D, Zhang Y, Qiu Y, Tian J, Gao M, Cao F. MRI/optical dual-modality imaging of vulnerable atherosclerotic plaque with an osteopontin-targeted probe based on Fe 3O 4 nanoparticles. Biomaterials 2016; 112:336-345. [PMID: 27788352 DOI: 10.1016/j.biomaterials.2016.10.011] [Citation(s) in RCA: 61] [Impact Index Per Article: 7.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/21/2016] [Revised: 08/22/2016] [Accepted: 10/10/2016] [Indexed: 01/11/2023]
Abstract
Rupture of vulnerable atherosclerotic plaque is the major pathological cause of luminal thrombosis in acute coronary syndromes. Since foamy macrophages have been identified as a prominent component in vulnerable atherosclerotic lesions and osteopontin (OPN) is reported to be highly expressed in foamy macrophages, OPN could be a potential target for vulnerable atherosclerotic plaque imaging. The current study designed an OPN-specific MRI/optical dual-modality probe to detect vulnerable plaques. Fluorescence imaging revealed that 24 h after injection of the Cy5.5-OPN-DMSA-MNPs (COD-MNPs), the atherosclerotic plaques in carotid artery exhibited significant higher signals in high fat diet (HFD) fed mice in comparison to the group injected with Cy5.5-IgG-DMSA-MNPs (CID-MNPs) or normal diet fed group injected with COD-MNPs (1.87 ± 0.19 × 1010 vs. 0.74 ± 0.04 × 1010, 0.73 ± 0.03 × 1010 p/sec/cm2/sr, P < 0.05). Meanwhile, MRI displayed stronger T2 contrast enhancement 24 h post-injection at the area of atherosclerotic plaques in the carotid of HFD fed group injected with COD-MNPs than group injected with CID-MNPs or normal diet fed group injected with COD-MNPs (post/pre signal ratio: 0.64 ± 0.04 vs. 0.95 ± 0.02, 0.98 ± 0.01, P < 0.05). As a dual-modality molecular probe, the resulting COD-MNPs conjugates exhibit promising potentials for noninvasive detection of vulnerable atherosclerotic plaque in vivo.
Collapse
Affiliation(s)
- Hongyu Qiao
- Department of Cardiology, Chinese PLA General Hospital, Beijing, 100853, China; Department of Cardiology, Xijing Hospital, Fourth Military Medical University, Xi'an, 710032, China
| | - Yabin Wang
- Department of Cardiology, Chinese PLA General Hospital, Beijing, 100853, China
| | - Ruohan Zhang
- Department of Hepato-Biliary and Pancreto-Splenic Surgery, Xijing Hospital, Fourth Military Medical University, Xi'an, 710032, China
| | - Quansheng Gao
- Laboratory of the Animal Center, Academy of Military Medical Science, Beijing, 100850, China
| | - Xiao Liang
- Institute of Automation, Chinese Academy of Sciences, Beijing, 100190, China
| | - Lei Gao
- Department of Cardiology, Chinese PLA General Hospital, Beijing, 100853, China
| | - Zhenhua Jiang
- Department of Cardiology, Xijing Hospital, Fourth Military Medical University, Xi'an, 710032, China
| | - Ruirui Qiao
- Institute of Chemistry, Chinese Academy of Sciences, Bei Yi Jie 2, Zhong Guan Cun, Beijing, 100190, China
| | - Dong Han
- Department of Cardiology, Xijing Hospital, Fourth Military Medical University, Xi'an, 710032, China
| | - Yan Zhang
- Department of Cardiology, Chinese PLA General Hospital, Beijing, 100853, China
| | - Ya Qiu
- Department of Cardiology, Chinese PLA General Hospital, Beijing, 100853, China
| | - Jie Tian
- Institute of Automation, Chinese Academy of Sciences, Beijing, 100190, China
| | - Mingyuan Gao
- Institute of Chemistry, Chinese Academy of Sciences, Bei Yi Jie 2, Zhong Guan Cun, Beijing, 100190, China.
| | - Feng Cao
- Department of Cardiology, Chinese PLA General Hospital, Beijing, 100853, China; Department of Cardiology, Xijing Hospital, Fourth Military Medical University, Xi'an, 710032, China.
| |
Collapse
|
16
|
Robinson JG, Heistad DD, Fox KA. Atherosclerosis stabilization with PCSK-9 inhibition: An evolving concept for cardiovascular prevention. Atherosclerosis 2015; 243:593-7. [PMID: 26545013 DOI: 10.1016/j.atherosclerosis.2015.10.023] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/28/2015] [Revised: 10/13/2015] [Accepted: 10/20/2015] [Indexed: 10/22/2022]
|
17
|
Naci H, Cooper J, Mossialos E. Timely publication and sharing of trial data: opportunities and challenges for comparative effectiveness research in cardiovascular disease. EUROPEAN HEART JOURNAL. QUALITY OF CARE & CLINICAL OUTCOMES 2015; 1:58-65. [PMID: 29474595 DOI: 10.1093/ehjqcco/qcv012] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/22/2015] [Indexed: 11/12/2022]
Abstract
There is growing enthusiasm for the timely publication and sharing of clinical trial data. The rationale for open access includes greater transparency, reproducibility, and efficiency of the research enterprise. In cardiovascular diseases, routinely sharing clinical trial data would create opportunities for undertaking comparative effectiveness research, providing much needed evidence on how different interventions compare to each other on key outcomes. Access to individual patient-level data would strengthen the validity of such research. Novel methodological approaches like network meta-analyses using individual patient-level data could reliably compare interventions that have not been compared with each other in head-to-head trials. However, there are significant practical, methodological, financial, and legal challenges to this utopian open access that need to be continually addressed. Sharing clinical trial data openly will only occur when the previously tolerated process of clinical research involving direct ownership and secrecy is abandoned for a new culture in which medical science is open to all of its stakeholders. With this new culture, data will be accessible, reanalysis will be considered commonplace, and comparative effectiveness research through novel synthesis approaches, such as network meta-analyses, can thrive-as long as measures are taken to adequately ensure the goal remains to promote public health.
Collapse
Affiliation(s)
- Huseyin Naci
- LSE Health, Department of Social Policy, London School of Economics and Political Science, London UK
| | - Jacob Cooper
- LSE Health, Department of Social Policy, London School of Economics and Political Science, London UK
| | - Elias Mossialos
- LSE Health, Department of Social Policy, London School of Economics and Political Science, London UK
| |
Collapse
|
18
|
Affiliation(s)
- Xiaoyan Huang
- From Providence Heart Clinic, Portland, OR (X.H.); and Department of Health Policy and Management, Harvard School of Public Health, Boston, MA (M.B.R.).
| | - Meredith B Rosenthal
- From Providence Heart Clinic, Portland, OR (X.H.); and Department of Health Policy and Management, Harvard School of Public Health, Boston, MA (M.B.R.)
| |
Collapse
|
19
|
Levsky JM, Spevack DM, Travin MI, Menegus MA, Huang PW, Clark ET, Kim CW, Hirschhorn E, Freeman KD, Tobin JN, Haramati LB. Coronary Computed Tomography Angiography Versus Radionuclide Myocardial Perfusion Imaging in Patients With Chest Pain Admitted to Telemetry: A Randomized Trial. Ann Intern Med 2015; 163:174-83. [PMID: 26052677 PMCID: PMC4703121 DOI: 10.7326/m14-2948] [Citation(s) in RCA: 59] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/17/2023] Open
Abstract
BACKGROUND The role of coronary computed tomography angiography (CCTA) in the management of symptomatic patients suspected of having coronary artery disease is expanding. However, prospective intermediate-term outcomes are lacking. OBJECTIVE To compare CCTA with conventional noninvasive testing. DESIGN Randomized, controlled comparative effectiveness trial. (ClinicalTrials.gov: NCT00705458). SETTING Telemetry-monitored wards of an inner-city medical center. PATIENTS 400 patients with acute chest pain (mean age, 57 years); 63% women; 54% Hispanic and 37% African-American; and low socioeconomic status. INTERVENTION CCTA or radionuclide stress myocardial perfusion imaging (MPI). MEASUREMENTS The primary outcome was cardiac catheterization not leading to revascularization within 1 year. Secondary outcomes included length of stay, resource utilization, and patient experience. Safety outcomes included death, major cardiovascular events, and radiation exposure. RESULTS Thirty (15%) patients who had CCTA and 32 (16%) who had MPI underwent cardiac catheterization within 1 year. Fifteen (7.5%) and 20 (10%) of these patients, respectively, did not undergo revascularization (difference, -2.5 percentage points [95% CI, -8.6 to 3.5 percentage points]; hazard ratio, 0.77 [CI, 0.40 to 1.49]; P = 0.44). Median length of stay was 28.9 hours for the CCTA group and 30.4 hours for the MPI group (P = 0.057). Median follow-up was 40.4 months. For the CCTA and MPI groups, the incidence of death (0.5% versus 3%; P = 0.12), nonfatal cardiovascular events (4.5% versus 4.5%), rehospitalization (43% versus 49%), emergency department visit (63% versus 58%), and outpatient cardiology visit (23% versus 21%) did not differ. Long-term, all-cause radiation exposure was lower for the CCTA group (24 versus 29 mSv; P < 0.001). More patients in the CCTA group graded their experience favorably (P = 0.001) and would undergo the examination again (P = 0.003). LIMITATION This was a single-site study, and the primary outcome depended on clinical management decisions. CONCLUSION The CCTA and MPI groups did not significantly differ in outcomes or resource utilization over 40 months. Compared with MPI, CCTA was associated with less radiation exposure and with a more positive patient experience. PRIMARY FUNDING SOURCE American Heart Association.
Collapse
Affiliation(s)
- Jeffrey M. Levsky
- From Montefiore Medical Center and Albert Einstein College of Medicine, Bronx, New York
| | - Daniel M. Spevack
- From Montefiore Medical Center and Albert Einstein College of Medicine, Bronx, New York
| | - Mark I. Travin
- From Montefiore Medical Center and Albert Einstein College of Medicine, Bronx, New York
| | - Mark A. Menegus
- From Montefiore Medical Center and Albert Einstein College of Medicine, Bronx, New York
| | - Paul W. Huang
- From Montefiore Medical Center and Albert Einstein College of Medicine, Bronx, New York
| | - Elana T. Clark
- From Montefiore Medical Center and Albert Einstein College of Medicine, Bronx, New York
| | - Choo-won Kim
- From Montefiore Medical Center and Albert Einstein College of Medicine, Bronx, New York
| | - Esther Hirschhorn
- From Montefiore Medical Center and Albert Einstein College of Medicine, Bronx, New York
| | - Katherine D. Freeman
- From Montefiore Medical Center and Albert Einstein College of Medicine, Bronx, New York
| | - Jonathan N. Tobin
- From Montefiore Medical Center and Albert Einstein College of Medicine, Bronx, New York
| | - Linda B. Haramati
- From Montefiore Medical Center and Albert Einstein College of Medicine, Bronx, New York
| |
Collapse
|
20
|
Arbab-Zadeh A, Fuster V. The myth of the "vulnerable plaque": transitioning from a focus on individual lesions to atherosclerotic disease burden for coronary artery disease risk assessment. J Am Coll Cardiol 2015; 65:846-855. [PMID: 25601032 DOI: 10.1016/j.jacc.2014.11.041] [Citation(s) in RCA: 317] [Impact Index Per Article: 35.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/06/2014] [Revised: 11/04/2014] [Accepted: 11/25/2014] [Indexed: 01/04/2023]
Abstract
The cardiovascular science community has pursued the quest to identify vulnerable atherosclerotic plaque in patients for decades, hoping to prevent acute coronary events. However, despite major advancements in imaging technology that allow visualization of rupture-prone plaques, clinical studies have not demonstrated improved risk prediction compared with traditional approaches. Considering the complex relationship between plaque rupture and acute coronary event risk suggested by pathology studies and confirmed by clinical investigations, these results are not surprising. This review summarizes the evidence supporting a multifaceted hypothesis of the natural history of atherosclerotic plaque rupture. Managing patients at risk of acute coronary events mandates a greater focus on the atherosclerotic disease burden rather than on features of individual plaques.
Collapse
Affiliation(s)
- Armin Arbab-Zadeh
- Department of Medicine, Cardiology Division, Johns Hopkins University, Baltimore, Maryland.
| | - Valentin Fuster
- Mount Sinai Medical Center, Icahn School of Medicine, New York, New York
| |
Collapse
|
21
|
Boriani G, Berti E, Belotti LMB, Biffi M, Carboni A, Bandini A, Casali E, Tomasi C, Toselli T, Baraldi P, Bottoni N, Barbato G, Sassone B. Cardiac resynchronization therapy: implant rates, temporal trends and relationships with heart failure epidemiology. J Cardiovasc Med (Hagerstown) 2014; 15:147-54. [PMID: 23811841 DOI: 10.2459/jcm.0b013e3283638d90] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Abstract
BACKGROUND Consensus guidelines define indications for cardiac resynchronization therapy (CRT), but the variability in implant rates in 'real world' clinical practice, as well as the relationship with the epidemiology of heart failure are not defined. METHODS AND RESULTS In Emilia-Romagna, an Italian region with around 4.4 million inhabitants, a registry was instituted to collect data on implanted devices for CRT, with (CRT-D) or without defibrillation (CRT-P) capabilities. Data from all consecutive patients resident in this region who underwent a first implant of a CRT device in years 2006-2010 were collected and standardized (considering each of the nine provinces of the region). The number of CRT implants increased progressively, with a 71% increase in 2010 compared to 2006. Between 84 and 90% of implants were with CRT-D devices. The variability in standardized implant rates among the provinces was substantial and the ratio between the provinces with the highest and the lowest implant rates was always greater than 2. Considering prevalent cases of heart failure in the period 2006-2010, the proportion of patients implanted with CRT per year ranged between 0.23 and 0.30%. CONCLUSIONS The application in 'real world' clinical practice of CRT in heart failure is quite heterogeneous, with substantial variability even among areas belonging to the same region, with the need to make the access to this treatment more equitable. Despite the increased use of CRT, its overall rate of adoption is low, if a population of prevalent heart failure patients is selected on the basis of administrative data on hospitalizations.
Collapse
Affiliation(s)
- Giuseppe Boriani
- aInstitute of Cardiology, University of Bologna, Azienda Ospedaliera S. Orsola-Malpighi bAgency for Health and Social Care of Emilia-Romagna, Bologna cDivision of Cardiology, Parma dDivision of Cardiology, Forli' eDivision of Cardiology, Modena fDivision of Cardiology, Ravenna gDivision of Cardiology, Ferrara hDivision of Cardiology, Baggiovara (MO) iDivision of Cardiology, Reggio Emilia jDivision of Cardiology, Maggiore Hospital, Bologna kOspedale SS Annunziata Cento, AUSL Ferrara, Cento (FE), Italy
| | | | | | | | | | | | | | | | | | | | | | | | | | | |
Collapse
|
22
|
de Keyser CE, Leening MJG, Romio SA, Jukema JW, Hofman A, Ikram MA, Franco OH, Stijnen T, Stricker BH. Comparing a marginal structural model with a Cox proportional hazard model to estimate the effect of time-dependent drug use in observational studies: statin use for primary prevention of cardiovascular disease as an example from the Rotterdam Study. Eur J Epidemiol 2014; 29:841-50. [DOI: 10.1007/s10654-014-9951-y] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/25/2014] [Accepted: 09/01/2014] [Indexed: 10/24/2022]
|
23
|
Smith FGD, Brogan RA, Alabas O, Laut KG, Quinn T, Bugiardini R, Gale CP. Comparative care and outcomes for acute coronary syndromes in Central and Eastern European Transitional countries: A review of the literature. EUROPEAN HEART JOURNAL-ACUTE CARDIOVASCULAR CARE 2014; 4:537-54. [DOI: 10.1177/2048872614551545] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/26/2014] [Accepted: 08/26/2014] [Indexed: 11/15/2022]
Affiliation(s)
- Fraser GD Smith
- Division of Epidemiology and Biostatistics, University of Leeds, UK
| | - Richard A Brogan
- Division of Epidemiology and Biostatistics, University of Leeds, UK
- York Teaching Hospital, NHS Foundation Trust, UK
| | - Oras Alabas
- Division of Epidemiology and Biostatistics, University of Leeds, UK
| | - Kristina G Laut
- Department of Cardiology, Aarhus University Hospital, Denmark
| | - Tom Quinn
- Faculty of Health and Medical Sciences, University of Surrey, UK
| | - Raffaele Bugiardini
- Dipartimento di Medicina Specialistica, Diagnostica e Sperimentale, University of Bologna, Italy
| | - Chris P Gale
- Division of Epidemiology and Biostatistics, University of Leeds, UK
- York Teaching Hospital, NHS Foundation Trust, UK
| |
Collapse
|
24
|
Douglas PS, Hoffmann U, Lee KL, Mark DB, Al-Khalidi HR, Anstrom K, Dolor RJ, Kosinski A, Krucoff MW, Mudrick DW, Patel MR, Picard MH, Udelson JE, Velazquez EJ, Cooper L. PROspective Multicenter Imaging Study for Evaluation of chest pain: rationale and design of the PROMISE trial. Am Heart J 2014; 167:796-803.e1. [PMID: 24890527 PMCID: PMC4044617 DOI: 10.1016/j.ahj.2014.03.003] [Citation(s) in RCA: 90] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/15/2013] [Accepted: 03/05/2014] [Indexed: 12/24/2022]
Abstract
BACKGROUND Suspected coronary artery disease (CAD) is one of the most common, potentially life-threatening diagnostic problems clinicians encounter. However, no large outcome-based randomized trials have been performed to guide the selection of diagnostic strategies for these patients. METHODS The PROMISE study is a prospective, randomized trial comparing the effectiveness of 2 initial diagnostic strategies in patients with symptoms suspicious for CAD. Patients are randomized to either (1) functional testing (exercise electrocardiogram, stress nuclear imaging, or stress echocardiogram) or (2) anatomical testing with ≥64-slice multidetector coronary computed tomographic angiography. Tests are interpreted locally in real time by subspecialty certified physicians, and all subsequent care decisions are made by the clinical care team. Sites are provided results of central core laboratory quality and completeness assessment. All subjects are followed up for ≥1 year. The primary end point is the time to occurrence of the composite of death, myocardial infarction, major procedural complications (stroke, major bleeding, anaphylaxis, and renal failure), or hospitalization for unstable angina. RESULTS More than 10,000 symptomatic subjects were randomized in 3.2 years at 193 US and Canadian cardiology, radiology, primary care, urgent care, and anesthesiology sites. CONCLUSION Multispecialty community practice enrollment into a large pragmatic trial of diagnostic testing strategies is both feasible and efficient. The PROMISE trial will compare the clinical effectiveness of an initial strategy of functional testing against an initial strategy of anatomical testing in symptomatic patients with suspected CAD. Quality of life, resource use, cost-effectiveness, and radiation exposure will be assessed.
Collapse
Affiliation(s)
- Pamela S Douglas
- Duke Clinical Research Institute, Duke University School of Medicine, Columbus, OH.
| | - Udo Hoffmann
- Massachusetts General Hospital, Harvard Medical School, Columbus, OH
| | - Kerry L Lee
- Duke Clinical Research Institute, Duke University School of Medicine, Columbus, OH
| | - Daniel B Mark
- Duke Clinical Research Institute, Duke University School of Medicine, Columbus, OH
| | - Hussein R Al-Khalidi
- Duke Clinical Research Institute, Duke University School of Medicine, Columbus, OH
| | - Kevin Anstrom
- Duke Clinical Research Institute, Duke University School of Medicine, Columbus, OH
| | - Rowena J Dolor
- Duke Clinical Research Institute, Duke University School of Medicine, Columbus, OH
| | - Andrzej Kosinski
- Duke Clinical Research Institute, Duke University School of Medicine, Columbus, OH
| | - Mitchell W Krucoff
- Duke Clinical Research Institute, Duke University School of Medicine, Columbus, OH
| | - Daniel W Mudrick
- Duke Clinical Research Institute, Duke University School of Medicine, Columbus, OH; McConnell Heart Health Center, Columbus, OH
| | - Manesh R Patel
- Duke Clinical Research Institute, Duke University School of Medicine, Columbus, OH
| | - Michael H Picard
- Massachusetts General Hospital, Harvard Medical School, Columbus, OH
| | - James E Udelson
- Tufts Medical Center, Tufts University School of Medicine, Boston, MA
| | - Eric J Velazquez
- Duke Clinical Research Institute, Duke University School of Medicine, Columbus, OH
| | - Lawton Cooper
- National Heart, Lung, and Blood Institute, Bethesda, MD
| |
Collapse
|
25
|
Bainey KR, Gafni A, Rao-Melacini P, Tong W, Steg PG, Faxon DP, Lamy A, Granger CB, Yusuf S, Mehta SR. The cost implications of an early versus delayed invasive strategy in Acute Coronary Syndromes: the TIMACS study. J Med Econ 2014; 17:415-22. [PMID: 24702256 DOI: 10.3111/13696998.2014.911184] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
BACKGROUND The Timing of Intervention in Acute Coronary Syndromes (TIMACS) trial demonstrated that early invasive intervention (within 24 hours) was similar to a delayed approach (after 36 hours) overall but improved outcomes were seen in patients at high risk. However, the cost implications of an early versus delayed invasive strategy are unknown. METHODS AND RESULTS A third-party perspective of direct cost was chosen and United States Medicare costs were calculated using average diagnosis related grouping (DRG) units. Direct medical costs included those of the index hospitalization (including clinical, procedural and hospital stay costs) as well as major adverse cardiac events during 6 months of follow-up. Sensitivity and sub-group analyses were performed. The average total cost per patient in the early intervention group was lower compared with the delayed intervention group (-$1170; 95% CI -$2542 to $202). From the bootstrap analysis (5000 replications), the early invasive approach was associated with both lower costs and better clinical outcomes regarding death/myocardial infarction (MI)/stroke in 95.1% of the cases (dominant strategy). In high-risk patients (GRACE score ≥141), the net reduction in cost was greatest (-$3720; 95% CI -$6270 to -$1170). Bootstrap analysis revealed 99.8% of cases were associated with both lower costs and better clinical outcomes (death/MI/stroke). LIMITATIONS We were unable to evaluate the effect of community care and investigations without hospitalization (office visits, non-invasive testing, etc). Medication costs were not captured. Indirect costs such as loss of productivity and family care were not included. CONCLUSIONS An early invasive management strategy is as effective as a delayed approach and is likely to be less costly in most patients with acute coronary syndromes.
Collapse
Affiliation(s)
- Kevin R Bainey
- University of Alberta, Mazankowski Alberta Heart Institute , Edmonton, Alberta , Canada
| | | | | | | | | | | | | | | | | | | |
Collapse
|
26
|
Miedema MD, Duprez DA, Misialek JR, Blaha MJ, Nasir K, Silverman MG, Blankstein R, Budoff MJ, Greenland P, Folsom AR. Use of coronary artery calcium testing to guide aspirin utilization for primary prevention: estimates from the multi-ethnic study of atherosclerosis. Circ Cardiovasc Qual Outcomes 2014; 7:453-60. [PMID: 24803472 DOI: 10.1161/circoutcomes.113.000690] [Citation(s) in RCA: 165] [Impact Index Per Article: 16.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND Aspirin for the primary prevention of coronary heart disease (CHD) is only recommended for individuals at high risk for CHD although the majority of CHD events occur in individuals who are at low to intermediate risk. METHODS AND RESULTS To estimate the potential of coronary artery calcium (CAC) scoring to guide aspirin use for primary prevention of CHD, we studied 4229 participants from the Multi-Ethnic Study of Atherosclerosis who were not on aspirin at baseline and were free of diabetes mellitus. Using data from median 7.6-year follow-up, 5-year number-needed-to-treat estimations were calculated by applying an 18% relative CHD reduction to the observed event rates. This was contrasted to 5-year number-needed-to-harm estimations based on the risk of major bleeding reported in an aspirin meta-analysis. Results were stratified by a 10% 10-year CHD Framingham Risk Score (FRS). Individuals with CAC≥100 had an estimated net benefit with aspirin regardless of their traditional risk status (estimated 5-year number needed to treat of 173 for individuals <10% FRS and 92 for individuals ≥10% FRS, estimated 5-year number needed to harm of 442 for a major bleed). Conversely, individuals with zero CAC had unfavorable estimations (estimated 5-year number needed to treat of 2036 for individuals <10% FRS and 808 for individuals ≥10% FRS, estimated 5-year number needed to harm of 442 for a major bleed). Sex-specific and age-stratified analyses showed similar results. CONCLUSIONS For the primary prevention of CHD, Multi-Ethnic Study of Atherosclerosis participants with CAC≥100 had favorable risk/benefit estimations for aspirin use while participants with zero CAC were estimated to receive net harm from aspirin.
Collapse
Affiliation(s)
- Michael D Miedema
- From the Minneapolis Heart Institute and Minneapolis Heart Institute Foundation, Minneapolis, MN (M.D.M.); Brigham and Women's Hospital and Boston VA Healthcare System, Harvard Medical School, Boston, MA (M.D.M.); Cardiovascular Division, University of Minnesota, Minneapolis (D.A.D.); Division of Epidemiology and Community Health, School of Public Health, University of Minnesota, Minneapolis (J.R.M., A.R.F.); Ciccarone Preventive Cardiology Center, Johns Hopkins School of Medicine, Baltimore, MD (M.J.B., K.N., M.G.S.); Center for Prevention and Wellness Research, Baptist Health South Florida, Miami, FL (K.N.); Department of Epidemiology, Robert Stempel College of Public Health, Florida International University, Miami (K.N.); Department of Medicine, Herbert Wertheim College of Medicine, Miami, FL (K.N.); Cardiovascular Division, Brigham and Women's Hospital, Boston, MA (R.B.); Los Angeles Biomedical Research Institute at Harbor-UCLA, Torrance, CA (M.J.B.); and Department of Preventive Medicine (P.G.) and Department of Medicine (P.G.), Northwestern University Feinberg School of Medicine, Chicago, IL.
| | - Daniel A Duprez
- From the Minneapolis Heart Institute and Minneapolis Heart Institute Foundation, Minneapolis, MN (M.D.M.); Brigham and Women's Hospital and Boston VA Healthcare System, Harvard Medical School, Boston, MA (M.D.M.); Cardiovascular Division, University of Minnesota, Minneapolis (D.A.D.); Division of Epidemiology and Community Health, School of Public Health, University of Minnesota, Minneapolis (J.R.M., A.R.F.); Ciccarone Preventive Cardiology Center, Johns Hopkins School of Medicine, Baltimore, MD (M.J.B., K.N., M.G.S.); Center for Prevention and Wellness Research, Baptist Health South Florida, Miami, FL (K.N.); Department of Epidemiology, Robert Stempel College of Public Health, Florida International University, Miami (K.N.); Department of Medicine, Herbert Wertheim College of Medicine, Miami, FL (K.N.); Cardiovascular Division, Brigham and Women's Hospital, Boston, MA (R.B.); Los Angeles Biomedical Research Institute at Harbor-UCLA, Torrance, CA (M.J.B.); and Department of Preventive Medicine (P.G.) and Department of Medicine (P.G.), Northwestern University Feinberg School of Medicine, Chicago, IL
| | - Jeffrey R Misialek
- From the Minneapolis Heart Institute and Minneapolis Heart Institute Foundation, Minneapolis, MN (M.D.M.); Brigham and Women's Hospital and Boston VA Healthcare System, Harvard Medical School, Boston, MA (M.D.M.); Cardiovascular Division, University of Minnesota, Minneapolis (D.A.D.); Division of Epidemiology and Community Health, School of Public Health, University of Minnesota, Minneapolis (J.R.M., A.R.F.); Ciccarone Preventive Cardiology Center, Johns Hopkins School of Medicine, Baltimore, MD (M.J.B., K.N., M.G.S.); Center for Prevention and Wellness Research, Baptist Health South Florida, Miami, FL (K.N.); Department of Epidemiology, Robert Stempel College of Public Health, Florida International University, Miami (K.N.); Department of Medicine, Herbert Wertheim College of Medicine, Miami, FL (K.N.); Cardiovascular Division, Brigham and Women's Hospital, Boston, MA (R.B.); Los Angeles Biomedical Research Institute at Harbor-UCLA, Torrance, CA (M.J.B.); and Department of Preventive Medicine (P.G.) and Department of Medicine (P.G.), Northwestern University Feinberg School of Medicine, Chicago, IL
| | - Michael J Blaha
- From the Minneapolis Heart Institute and Minneapolis Heart Institute Foundation, Minneapolis, MN (M.D.M.); Brigham and Women's Hospital and Boston VA Healthcare System, Harvard Medical School, Boston, MA (M.D.M.); Cardiovascular Division, University of Minnesota, Minneapolis (D.A.D.); Division of Epidemiology and Community Health, School of Public Health, University of Minnesota, Minneapolis (J.R.M., A.R.F.); Ciccarone Preventive Cardiology Center, Johns Hopkins School of Medicine, Baltimore, MD (M.J.B., K.N., M.G.S.); Center for Prevention and Wellness Research, Baptist Health South Florida, Miami, FL (K.N.); Department of Epidemiology, Robert Stempel College of Public Health, Florida International University, Miami (K.N.); Department of Medicine, Herbert Wertheim College of Medicine, Miami, FL (K.N.); Cardiovascular Division, Brigham and Women's Hospital, Boston, MA (R.B.); Los Angeles Biomedical Research Institute at Harbor-UCLA, Torrance, CA (M.J.B.); and Department of Preventive Medicine (P.G.) and Department of Medicine (P.G.), Northwestern University Feinberg School of Medicine, Chicago, IL
| | - Khurram Nasir
- From the Minneapolis Heart Institute and Minneapolis Heart Institute Foundation, Minneapolis, MN (M.D.M.); Brigham and Women's Hospital and Boston VA Healthcare System, Harvard Medical School, Boston, MA (M.D.M.); Cardiovascular Division, University of Minnesota, Minneapolis (D.A.D.); Division of Epidemiology and Community Health, School of Public Health, University of Minnesota, Minneapolis (J.R.M., A.R.F.); Ciccarone Preventive Cardiology Center, Johns Hopkins School of Medicine, Baltimore, MD (M.J.B., K.N., M.G.S.); Center for Prevention and Wellness Research, Baptist Health South Florida, Miami, FL (K.N.); Department of Epidemiology, Robert Stempel College of Public Health, Florida International University, Miami (K.N.); Department of Medicine, Herbert Wertheim College of Medicine, Miami, FL (K.N.); Cardiovascular Division, Brigham and Women's Hospital, Boston, MA (R.B.); Los Angeles Biomedical Research Institute at Harbor-UCLA, Torrance, CA (M.J.B.); and Department of Preventive Medicine (P.G.) and Department of Medicine (P.G.), Northwestern University Feinberg School of Medicine, Chicago, IL
| | - Michael G Silverman
- From the Minneapolis Heart Institute and Minneapolis Heart Institute Foundation, Minneapolis, MN (M.D.M.); Brigham and Women's Hospital and Boston VA Healthcare System, Harvard Medical School, Boston, MA (M.D.M.); Cardiovascular Division, University of Minnesota, Minneapolis (D.A.D.); Division of Epidemiology and Community Health, School of Public Health, University of Minnesota, Minneapolis (J.R.M., A.R.F.); Ciccarone Preventive Cardiology Center, Johns Hopkins School of Medicine, Baltimore, MD (M.J.B., K.N., M.G.S.); Center for Prevention and Wellness Research, Baptist Health South Florida, Miami, FL (K.N.); Department of Epidemiology, Robert Stempel College of Public Health, Florida International University, Miami (K.N.); Department of Medicine, Herbert Wertheim College of Medicine, Miami, FL (K.N.); Cardiovascular Division, Brigham and Women's Hospital, Boston, MA (R.B.); Los Angeles Biomedical Research Institute at Harbor-UCLA, Torrance, CA (M.J.B.); and Department of Preventive Medicine (P.G.) and Department of Medicine (P.G.), Northwestern University Feinberg School of Medicine, Chicago, IL
| | - Ron Blankstein
- From the Minneapolis Heart Institute and Minneapolis Heart Institute Foundation, Minneapolis, MN (M.D.M.); Brigham and Women's Hospital and Boston VA Healthcare System, Harvard Medical School, Boston, MA (M.D.M.); Cardiovascular Division, University of Minnesota, Minneapolis (D.A.D.); Division of Epidemiology and Community Health, School of Public Health, University of Minnesota, Minneapolis (J.R.M., A.R.F.); Ciccarone Preventive Cardiology Center, Johns Hopkins School of Medicine, Baltimore, MD (M.J.B., K.N., M.G.S.); Center for Prevention and Wellness Research, Baptist Health South Florida, Miami, FL (K.N.); Department of Epidemiology, Robert Stempel College of Public Health, Florida International University, Miami (K.N.); Department of Medicine, Herbert Wertheim College of Medicine, Miami, FL (K.N.); Cardiovascular Division, Brigham and Women's Hospital, Boston, MA (R.B.); Los Angeles Biomedical Research Institute at Harbor-UCLA, Torrance, CA (M.J.B.); and Department of Preventive Medicine (P.G.) and Department of Medicine (P.G.), Northwestern University Feinberg School of Medicine, Chicago, IL
| | - Matthew J Budoff
- From the Minneapolis Heart Institute and Minneapolis Heart Institute Foundation, Minneapolis, MN (M.D.M.); Brigham and Women's Hospital and Boston VA Healthcare System, Harvard Medical School, Boston, MA (M.D.M.); Cardiovascular Division, University of Minnesota, Minneapolis (D.A.D.); Division of Epidemiology and Community Health, School of Public Health, University of Minnesota, Minneapolis (J.R.M., A.R.F.); Ciccarone Preventive Cardiology Center, Johns Hopkins School of Medicine, Baltimore, MD (M.J.B., K.N., M.G.S.); Center for Prevention and Wellness Research, Baptist Health South Florida, Miami, FL (K.N.); Department of Epidemiology, Robert Stempel College of Public Health, Florida International University, Miami (K.N.); Department of Medicine, Herbert Wertheim College of Medicine, Miami, FL (K.N.); Cardiovascular Division, Brigham and Women's Hospital, Boston, MA (R.B.); Los Angeles Biomedical Research Institute at Harbor-UCLA, Torrance, CA (M.J.B.); and Department of Preventive Medicine (P.G.) and Department of Medicine (P.G.), Northwestern University Feinberg School of Medicine, Chicago, IL
| | - Philip Greenland
- From the Minneapolis Heart Institute and Minneapolis Heart Institute Foundation, Minneapolis, MN (M.D.M.); Brigham and Women's Hospital and Boston VA Healthcare System, Harvard Medical School, Boston, MA (M.D.M.); Cardiovascular Division, University of Minnesota, Minneapolis (D.A.D.); Division of Epidemiology and Community Health, School of Public Health, University of Minnesota, Minneapolis (J.R.M., A.R.F.); Ciccarone Preventive Cardiology Center, Johns Hopkins School of Medicine, Baltimore, MD (M.J.B., K.N., M.G.S.); Center for Prevention and Wellness Research, Baptist Health South Florida, Miami, FL (K.N.); Department of Epidemiology, Robert Stempel College of Public Health, Florida International University, Miami (K.N.); Department of Medicine, Herbert Wertheim College of Medicine, Miami, FL (K.N.); Cardiovascular Division, Brigham and Women's Hospital, Boston, MA (R.B.); Los Angeles Biomedical Research Institute at Harbor-UCLA, Torrance, CA (M.J.B.); and Department of Preventive Medicine (P.G.) and Department of Medicine (P.G.), Northwestern University Feinberg School of Medicine, Chicago, IL
| | - Aaron R Folsom
- From the Minneapolis Heart Institute and Minneapolis Heart Institute Foundation, Minneapolis, MN (M.D.M.); Brigham and Women's Hospital and Boston VA Healthcare System, Harvard Medical School, Boston, MA (M.D.M.); Cardiovascular Division, University of Minnesota, Minneapolis (D.A.D.); Division of Epidemiology and Community Health, School of Public Health, University of Minnesota, Minneapolis (J.R.M., A.R.F.); Ciccarone Preventive Cardiology Center, Johns Hopkins School of Medicine, Baltimore, MD (M.J.B., K.N., M.G.S.); Center for Prevention and Wellness Research, Baptist Health South Florida, Miami, FL (K.N.); Department of Epidemiology, Robert Stempel College of Public Health, Florida International University, Miami (K.N.); Department of Medicine, Herbert Wertheim College of Medicine, Miami, FL (K.N.); Cardiovascular Division, Brigham and Women's Hospital, Boston, MA (R.B.); Los Angeles Biomedical Research Institute at Harbor-UCLA, Torrance, CA (M.J.B.); and Department of Preventive Medicine (P.G.) and Department of Medicine (P.G.), Northwestern University Feinberg School of Medicine, Chicago, IL
| |
Collapse
|
27
|
Levsky JM, Haramati LB, Taub CC, Spevack DM, Menegus MA, Travin MI, Vega S, Lerer R, Brown-Manhertz D, Hirschhorn E, Tobin JN, Garcia MJ. Rationale and design of a randomized trial comparing initial stress echocardiography versus coronary CT angiography in low-to-intermediate risk emergency department patients with chest pain. Echocardiography 2013; 31:744-50. [PMID: 24372760 DOI: 10.1111/echo.12464] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022] Open
Abstract
BACKGROUND Comparative effectiveness research (CER) has become a major focus of cardiovascular disease investigation to optimize diagnosis and treatment paradigms and decrease healthcare expenditures. Acute chest pain is a highly prevalent reason for evaluation in the Emergency Department (ED) that results in hospital admission for many patients and excess expense. Improvement in noninvasive diagnostic algorithms can potentially reduce unnecessary admissions. OBJECTIVE To compare the performance of treadmill stress echocardiography (SE) and coronary computed tomography angiography (CTA) in ED chest pain patients with low-to-intermediate risk of significant coronary artery disease. DESIGN This is a single-center, randomized controlled trial (RCT) comparing SE and CTA head-to-head as the initial noninvasive imaging modality. The primary outcome measured is the incidence of hospitalization. The study is powered to detect a reduction in admissions from 28% to 15% with a sample size of 400. Secondary outcomes include length of stay in the ED/hospital and estimated cost of care. Safety outcomes include subsequent visits to the ED and hospitalizations, as well as major adverse cardiovascular events at 30 days and 1 year. Patients who do not meet study criteria or do not consent for randomization are offered entry into an observational registry. CONCLUSIONS This RCT will add to our understanding of the roles of different imaging modalities in triaging patients with suspected angina. It will increase the CER evidence base comparing SE and CTA and provide insight into potential benefits and limitations of appropriate use of treadmill SE in the ED.
Collapse
Affiliation(s)
- Jeffrey M Levsky
- Department of Radiology, Montefiore Medical Center and Albert Einstein College of Medicine, Bronx, New York
| | | | | | | | | | | | | | | | | | | | | | | |
Collapse
|
28
|
Smulders MW, Kietselaer BL, Das M, Wildberger JE, Crijns HJ, Veenstra LF, Brunner-La Rocca HP, van Dieijen-Visser MP, Mingels AM, Dagnelie PC, Post MJ, Gorgels AP, van Asselt AD, Vogel G, Schalla S, Kim RJ, Bekkers SC. The role of cardiovascular magnetic resonance imaging and computed tomography angiography in suspected non-ST-elevation myocardial infarction patients: design and rationale of the CARdiovascular Magnetic rEsoNance imaging and computed Tomography Angiography (CARMENTA) trial. Am Heart J 2013; 166:968-75. [PMID: 24268210 DOI: 10.1016/j.ahj.2013.09.012] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/22/2013] [Accepted: 09/23/2013] [Indexed: 10/26/2022]
Abstract
BACKGROUND Although high-sensitivity cardiac troponin (hs-cTn) substantially improves the early detection of myocardial injury, it lacks specificity for acute myocardial infarction (MI). In suspected non-ST-elevation MI, invasive coronary angiography (ICA) remains necessary to distinguish between acute MI and noncoronary myocardial disease (eg, myocarditis), unnecessarily subjecting the latter to ICA and associated complications. This trial investigates whether implementing cardiovascular magnetic resonance (CMR) or computed tomography angiography (CTA) early in the diagnostic process may help to differentiate between coronary and noncoronary myocardial disease, thereby preventing unnecessary ICA. STUDY DESIGN In this prospective, single-center, randomized controlled clinical trial, 321 consecutive patients with acute chest pain, elevated hs-cTnT, and nondiagnostic electrocardiogram are randomized to 1 of 3 strategies: (1) CMR, or (2) CTA early in the diagnostic process, or (3) routine clinical management. In the 2 investigational arms of the study, results of CMR or CTA will guide further clinical management. It is expected that noncoronary myocardial disease is detected more frequently after early noninvasive imaging as compared with routine clinical management, and unnecessary ICA will be prevented. The primary end point is the total number of patients undergoing ICA during initial admission. Secondary end points are 30-day and 1-year clinical outcome (major adverse cardiac events and major procedure-related complications), time to final diagnosis, quality of life, and cost-effectiveness. CONCLUSION The CARMENTA trial investigates whether implementing CTA or CMR early in the diagnostic process in suspected non-ST-elevation MI based on elevated hs-cTnT can prevent unnecessary ICA as compared with routine clinical management, with no detrimental effect on clinical outcome.
Collapse
|
29
|
Rossi A, Dharampal A, de Feyter PJ. Coronary CT angiography for patients with suspected coronary artery disease. Heart 2013; 100:976-84. [PMID: 23904359 DOI: 10.1136/heartjnl-2012-301949] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Affiliation(s)
- A Rossi
- Department of Cardiology and Radiology, Erasmus Medical Center-Thorax center, Rotterdam, The Netherlands
| | - A Dharampal
- Department of Cardiology and Radiology, Erasmus Medical Center-Thorax center, Rotterdam, The Netherlands
| | - P J de Feyter
- Department of Cardiology and Radiology, Erasmus Medical Center-Thorax center, Rotterdam, The Netherlands
| |
Collapse
|
30
|
|
31
|
Abstract
Observational methods are evolving in response to the widespread availability of data from clinical registries, electronic health records, and administrative databases. These approaches will never eliminate the need for randomized trials, but clearly have a role in evaluating the effect of therapies in unselected populations treated in routine practice.
Collapse
Affiliation(s)
- Mark A Hlatky
- Department of Health Research and Policy, Stanford University School of Medicine, Stanford, CA 94305-5405, USA.
| | | | | |
Collapse
|
32
|
Evaluating the Clinical Impact of Cardiovascular Imaging. J Am Coll Cardiol 2013; 61:185-6. [DOI: 10.1016/j.jacc.2012.09.044] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/17/2012] [Accepted: 09/25/2012] [Indexed: 11/22/2022]
|
33
|
Sen S, Davies JE, Malik IS, Foale RA, Mikhail GW, Hadjiloizou N, Hughes A, Mayet J, Francis DP. Why Does Primary Angioplasty Not Work in Registries? Quantifying the Susceptibility of Real-World Comparative Effectiveness Data to Allocation Bias. Circ Cardiovasc Qual Outcomes 2012; 5:759-66. [DOI: 10.1161/circoutcomes.112.966853] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
Abstract
Background—
Meta-analysis of registries (comparative effectiveness research) shows that primary angioplasty and fibrinolysis have equivalent real-world survival. Yet, randomized, controlled trials consistently find primary angioplasty superior. Can unequal allocation of higher-risk patients in registries have masked primary angioplasty benefit?
Methods and Results—
First, we constructed a model to demonstrate the potential effect of allocation bias. We then analyzed published registries (55022 patients) for allocation of higher-risk patients (Killip class ≥1) to determine whether the choice of reperfusion therapy was affected by the risk level of the patient. Meta-regression was used to examine the relationship between differences in allocation of high-risk patient to primary angioplasty or fibrinolysis and mortality. Initial modeling suggested that registry outcomes are sensitive to allocation bias of high-risk patients. Across the registries, the therapy receiving excess high-risk patients had worse mortality. Unequal distribution of high-risk status accounted for most of the between-registry variance (adjusted
R
2
meta
=83.1%). Accounting for differential allocation of higher-risk patients, primary angioplasty gave 22% lower mortality (odds ratio, 0.78; 95% confidence interval, 0.64–0.97;
P
=0.029). We derive a formula, called the number needed to abolish, highlighting situations in which comparative effectiveness studies are particularly vulnerable to this bias.
Conclusions—
In ST-segment elevation myocardial infarction, clinicians’ preference for management of a few high-risk patients can shift mortality substantially. Comparative effectiveness research in any disease is vulnerable to this, especially diseases with an immediately identifiable high-risk subgroup that clinicians prefer to allocate to 1 therapy. For this reason, preliminary indications from registry-based comparative effectiveness research should be definitively tested by randomized, controlled trials.
Collapse
Affiliation(s)
- Sayan Sen
- From the Imperial College Healthcare National Health Service Trust, St. Mary’s Hospital, Imperial College London, London, UK
| | - Justin E. Davies
- From the Imperial College Healthcare National Health Service Trust, St. Mary’s Hospital, Imperial College London, London, UK
| | - Iqbal S. Malik
- From the Imperial College Healthcare National Health Service Trust, St. Mary’s Hospital, Imperial College London, London, UK
| | - Rodney A. Foale
- From the Imperial College Healthcare National Health Service Trust, St. Mary’s Hospital, Imperial College London, London, UK
| | - Ghada W. Mikhail
- From the Imperial College Healthcare National Health Service Trust, St. Mary’s Hospital, Imperial College London, London, UK
| | - Nearchos Hadjiloizou
- From the Imperial College Healthcare National Health Service Trust, St. Mary’s Hospital, Imperial College London, London, UK
| | - Alun Hughes
- From the Imperial College Healthcare National Health Service Trust, St. Mary’s Hospital, Imperial College London, London, UK
| | - Jamil Mayet
- From the Imperial College Healthcare National Health Service Trust, St. Mary’s Hospital, Imperial College London, London, UK
| | - Darrel P. Francis
- From the Imperial College Healthcare National Health Service Trust, St. Mary’s Hospital, Imperial College London, London, UK
| |
Collapse
|