1
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Maqsood MH, Messerli FH, Skolnick AH, Newman JD, Berger JS, Bangalore S. Timing of Antihypertensive Drug Therapy: A Systematic Review and Meta-Analysis of Randomized Clinical Trials. Hypertension 2023. [PMID: 37212152 DOI: 10.1161/hypertensionaha.122.20862] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/23/2023]
Abstract
BACKGROUND The timing of antihypertensive drugs administration is controversial. The aim was to compare the efficacy of dosing of antihypertensive drugs in the morning versus evening. METHODS A PubMed, EMBASE, and clinicaltrials.gov databases search for randomized clinical trials of antihypertensive therapies where patients were randomized to morning versus evening dosing. The outcomes were ambulatory blood pressure parameters (day-time, night-time, and 24/48-hour systolic blood pressure [SBP] and diastolic blood pressure [DBP]) and cardiovascular outcomes. RESULTS Of 72 randomized controlled trials included, evening dosing significantly reduced ambulatory blood pressure parameters: 24/48-hour SBP (mean difference [MD]=1.41 mm Hg; [95% CI, 0.48-2.34]), DBP (MD=0.60 mm Hg [95% CI, 0.12-1.08]), night-time SBP (MD=4.09 mm Hg [95% CI, 3.01-5.16]), DBP (MD, 2.57 mm Hg [95% CI, 1.92-3.22]), with a smaller reduction in day-time SBP (MD=0.94 mm Hg [95% CI, 0.01-1.87]), and DBP (MD=0.87 mm Hg [95% CI, 0.10-1.63]), and numerically lower cardiovascular events compared with morning dosing. However, when controversial data by Hermida (23 trials, 25 734 patients) were omitted (Pheterogeneity<0.05 for most outcomes), the above effect of evening dosing attenuated with no significant effect on 24/48-hour ambulatory blood pressure, day-time blood pressure, and MACE and smaller reduction in night-time ambulatory SBP and DBP. CONCLUSIONS Evening dosing of antihypertensive drugs significantly reduced ambulatory blood pressure parameters and lowered cardiovascular events but the effect was mainly driven by trials by Hermida group. Unless the intention is to specifically lower night-time blood pressure, antihypertensive drugs should be taken at a time of day that is convenient, optimizes adherence, and minimizes undesirable effects.
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Affiliation(s)
| | - Franz H Messerli
- Department of Cardiology and Clinical Research, University Hospital, Bern, Switzerland (F.H.M.)
- Division of Cardiology, Mount Sinai Medical Center, Icahn School of Medicine, New York (F.H.M.)
| | - Adam H Skolnick
- Leon H. Charney Division of Cardiology, New York University Langone Medical Center, New York City (A.H.S.)
| | - Jonathan D Newman
- Division of Cardiology and the Center for the Prevention of Cardiovascular Disease (J.D.N.)
| | - Jeffrey S Berger
- Leon H. Charney Division of Cardiology, Department of Medicine, New York University School of Medicine (J.S.B.)
| | - Sripal Bangalore
- Division of Cardiovascular Medicine, New York University Grossman School of Medicine (S.B.)
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2
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Blachman NL, Skolnick AH. Silence is gilded: atrial fibrillation in the golden years. J Am Geriatr Soc 2022; 70:2761-2763. [PMID: 36098276 DOI: 10.1111/jgs.18028] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/23/2022] [Accepted: 08/17/2022] [Indexed: 11/29/2022]
Affiliation(s)
- Nina L Blachman
- Division of Geriatrics, Department of Medicine, NYU Langone Health, New York, New York, USA
| | - Adam H Skolnick
- Leon H. Charney Division of Cardiology, Department of Medicine, NYU Langone Health, New York, New York, USA
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3
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Weerasekare JM, Zhou F, Skolnick AH, Jilaihawi H, Williams MR, Dasari S, McPhail ED, Theis JD, Dao LN, Bois JP, Maleszewski JJ, Bois MC. Amyloid Deposition in an Explanted Bioprosthetic Aortic Valve: Case Report and Review of the Literature. Cardiovasc Pathol 2022; 61:107469. [PMID: 36038051 DOI: 10.1016/j.carpath.2022.107469] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/18/2022] [Revised: 08/03/2022] [Accepted: 08/15/2022] [Indexed: 11/03/2022] Open
Abstract
Herein we present a case of an 80-year-old gentleman who presented with exertional dyspnea status post aortic valve replacement with #23 Trifecta pericardial St. Jude aortic bioprosthetic valve (BV) 12 years prior. He subsequently underwent valve re-replacement due cusp calcification. Histologically, the surgically explanted BV revealed Congophilic deposits with birefringence under cross-polarized light. Extensive work-up identified no systemic source of amyloid in this patient. Liquid chromatography-tandem mass spectrometry-based (LC-MS/MS) proteomics showed the amyloid was composed of human-origin amyloid signature proteins (apolipoprotein A4, apolipoprotein E, serum amyloid P) and human-origin mu heavy chains. Background bovine collagen was also present. Transmission electron microscopy (TEM) showed collections of 7.5-10 nm nonbranching fibrils, consistent with amyloid. Using these techniques, we classified the amyloid as Mu heavy chain, deposition of which is highly unusual in BV. Finally, we provide a review of the literature regarding isolated amyloid deposition in BV.
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Affiliation(s)
| | - Fang Zhou
- Department of Pathology, New York University Langone Health, New York, NY, USA
| | - Adam H Skolnick
- Department of Medicine, Leon H. Charney Division of Cardiology, New York University Health, New York, NY, USA
| | - Hasan Jilaihawi
- Department of Cardiothoracic Surgery, New York University Health, New York, NY, USA
| | - Mathew R Williams
- Department of Cardiothoracic Surgery, New York University Health, New York, NY, USA
| | - Surendra Dasari
- Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, MN, USA
| | - Ellen D McPhail
- Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, MN, USA
| | - Jason D Theis
- Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, MN, USA
| | - Linda N Dao
- Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, MN, USA
| | - John P Bois
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, MN, USA
| | - Joseph J Maleszewski
- Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, MN, USA; Department of Cardiovascular Medicine, Mayo Clinic, Rochester, MN, USA
| | - Melanie C Bois
- Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, MN, USA.
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4
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Ali T, Garshick MS, Saric M, Skolnick AH. Aortic closure signal length on doppler echocardiography differentiates aortic patient-prosthesis mismatch from prosthetic stenosis. J Clin Ultrasound 2021; 49:644-649. [PMID: 33665868 DOI: 10.1002/jcu.23002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/18/2020] [Revised: 01/27/2021] [Accepted: 02/23/2021] [Indexed: 06/12/2023]
Abstract
PURPOSE The purpose of this study was to investigate the diagnostic potential of the aortic closure (A2) signal length on Doppler echocardiography in distinguishing aortic patient-prosthesis mismatch (PPM) from prosthetic stenosis among patients with elevated gradients over bioprosthetic valves. METHODS The A2 signal length was retrospectively measured for 150 patients with bioprosthetic aortic valves (50 with PPM, 50 with prosthetic stenosis, and 50 with normally functioning valves) from transthoracic echocardiograms performed at NYU Langone Health between 01/01/2012 and 08/01/2018. RESULTS Mean A2 signal length was shorter among patients with PPM (11.1 ms ± 5.2 ms), than among those with prosthetic stenosis (21.1 ms ± 6.0 ms), P < .001 and controls (21.7 ms ± 7.4 ms), P < .001. There was no difference in A2 signal length between prosthetic stenosis and controls. The A2 signal length yielded an AUC of 0.89 (95% CI 0.82-0.95) for predicting PPM over prosthetic stenosis. CONCLUSION Among patients with bioprosthetic aortic valves, the length of the A2 signal on Doppler echocardiography is shorter in PPM than in prosthetic stenosis and normally functioning valves. The A2 signal length may represent a novel metric to distinguish PPM from prosthetic stenosis.
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Affiliation(s)
- Thara Ali
- Department of Internal Medicine, New York University Langone Medical Center, New York City, New York, USA
| | - Michael S Garshick
- Leon H. Charney Division of Cardiology, New York University Langone Medical Center, New York City, New York, USA
| | - Muhamed Saric
- Leon H. Charney Division of Cardiology, New York University Langone Medical Center, New York City, New York, USA
| | - Adam H Skolnick
- Leon H. Charney Division of Cardiology, New York University Langone Medical Center, New York City, New York, USA
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5
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Garshick MS, Mulliken J, Schoenfeld M, Riedy K, Guo Y, Zhong J, Dodson JA, Saric M, Skolnick AH. Average e' velocity on transthoracic echocardiogram is a novel predictor of left atrial appendage sludge or thrombus in patients with atrial fibrillation. Echocardiography 2018; 35:1939-1946. [PMID: 30315597 PMCID: PMC10723071 DOI: 10.1111/echo.14148] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/16/2018] [Revised: 08/21/2018] [Accepted: 09/09/2018] [Indexed: 12/22/2022] Open
Abstract
BACKGROUND Studies have demonstrated the value of transthoracic echocardiogram (TTE) diastolic parameters in predicting left atrial appendage (LAA) thrombus; however, these studies have been small. We aim to clarify the relationship between TTE diastolic parameters, in particular average e', and LAA thrombus or sludge. METHODS A case-control review was conducted of subjects with non-valvular atrial fibrillation (n = 2263) who had undergone TEE (transesophageal echocardiogram) and had a TTE within 1 year of TEE. Cases of LAA sludge or thrombus were matched to controls by age, sex, left ventricular ejection fraction (LVEF), and anticoagulation status. RESULTS Forty-three subjects (mean age 73 ± 12, 65% male, LVEF 47%, 44% on anticoagulation) with LAA sludge or thrombus were identified. Compared to matched controls, average TTE e' (7.3 ± 2.1 cm/s vs 8.7 ± 2.1 cm/s, P < 0.001) and the E:e' ratio (15 ± 7 cm/s vs 12 ± 5 cm/s; P = 0.005) were significant predictors of LAA sludge or thrombus. Average TTE e' value of >11 cm/s had 100% sensitivity for ruling out LAA sludge or thrombus. CONCLUSION In individuals with atrial fibrillation, average e' >11 cm/s on TTE is a promising independent predictor of the absence of LAA sludge or thrombus on TEE.
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Affiliation(s)
- Michael S. Garshick
- Leon H. Charney Division of Cardiology, NYU Langone Health, New York City, New York
| | - Jennifer Mulliken
- Department of Internal Medicine, NYU Health Langone, New York City, New York
| | - Matthew Schoenfeld
- Leon H. Charney Division of Cardiology, NYU Langone Health, New York City, New York
| | - Katherine Riedy
- Department of Internal Medicine, NYU Health Langone, New York City, New York
| | - Yu Guo
- Division of Biostatistics, Department of Population Health, NYU Langone Health, New York City, New York
| | - Judy Zhong
- Division of Biostatistics, Department of Population Health, NYU Langone Health, New York City, New York
| | - John A. Dodson
- Leon H. Charney Division of Cardiology, NYU Langone Health, New York City, New York
| | - Muhamed Saric
- Leon H. Charney Division of Cardiology, NYU Langone Health, New York City, New York
| | - Adam H. Skolnick
- Leon H. Charney Division of Cardiology, NYU Langone Health, New York City, New York
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6
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Grant EV, Skolnick AH, Chodosh J, Perskin MH, Orr NM, Blaum C, Dodson JA. Improving Care Using a Bidirectional Geriatric Cardiology Consultative Conference. J Am Geriatr Soc 2018. [PMID: 29542108 DOI: 10.1111/jgs.15356] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/23/2023]
Abstract
More than 13 million persons in the United States aged 65 and older have cardiovascular disease (CVD), and this population is expected to increase exponentially over the next several decades. In the absence of clinical studies that would inform how best to manage this population, there is an urgent need for collaborative, thoughtful approaches to their care. Although cardiologists are traditionally regarded as leaders in the care of older adults with CVD, these individuals have multiple comorbidities, physiological differences, and distinct goals of care than younger patients that require a specialized geriatric lens. Thus, collaboration is needed between geriatricians, cardiologists, and other specialists to address the unique needs of this growing population. Accordingly, clinicians at New York University Langone Health and School of Medicine established a monthly Geriatric Cardiology Conference to foster an integrative approach to the care of older adults with CVD by uniting specialists across disciplines to collaborate on treatment strategies. At each conference, an active case is discussed and analyzed in detail, and a consensus is reached among participants regarding optimal treatment strategies. The conference attracts faculty and trainees at multiple levels from geriatrics, cardiology, and cardiothoracic surgery. The model may serve as a paradigm for other institutions moving towards geriatric-informed care of older adults with CVD.
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Affiliation(s)
- Eleonore V Grant
- Leon H. Charney Division of Cardiology, Department of Medicine, New York University, New York, New York
| | - Adam H Skolnick
- Leon H. Charney Division of Cardiology, Department of Medicine, New York University, New York, New York
| | - Joshua Chodosh
- Division of Geriatrics, Department of Medicine, New York University, New York, New York
| | - Michael H Perskin
- Division of Geriatrics, Department of Medicine, New York University, New York, New York
| | - Nicole M Orr
- Division of Cardiology and the Cardiovascular Center, Tufts Medical Center, Boston, Massachusetts
| | - Caroline Blaum
- Division of Geriatrics, Department of Medicine, New York University, New York, New York.,Division of Healthcare Delivery Science, Department of Population Health, School of Medicine, New York University, New York, New York
| | - John A Dodson
- Leon H. Charney Division of Cardiology, Department of Medicine, New York University, New York, New York.,Division of Healthcare Delivery Science, Department of Population Health, School of Medicine, New York University, New York, New York
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7
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Underwood K, Vorsanger M, Saric M, Skolnick AH. Positional Right Ventricular Obstruction in Pectus Excavatum. Am J Cardiol 2017; 119:1288-1289. [PMID: 28214505 DOI: 10.1016/j.amjcard.2016.12.019] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/21/2016] [Revised: 12/12/2016] [Accepted: 12/12/2016] [Indexed: 11/24/2022]
Abstract
Pectus excavatum is one of the most common congenital chest wall deformities. The degree of sternal depression, which may result in compression of the right heart by the chest wall, is variable. While typically asymptomatic, there are various symptoms that can result from severe pectus excavatum. We report on a patient with severe pectus excavatum leading to dynamic obstruction of the right ventricular outflow tract in the seated position.
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8
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Rich MW, Chyun DA, Skolnick AH, Alexander KP, Forman DE, Kitzman DW, Maurer MS, McClurken JB, Resnick BM, Shen WK, Tirschwell DL. Knowledge Gaps in Cardiovascular Care of Older Adults: A Scientific Statement from the American Heart Association, American College of Cardiology, and American Geriatrics Society: Executive Summary. J Am Geriatr Soc 2016; 64:2185-2192. [PMID: 27673575 DOI: 10.1111/jgs.14576] [Citation(s) in RCA: 47] [Impact Index Per Article: 5.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
The incidence and prevalence of most cardiovascular disorders increase with age, and cardiovascular disease (CVD) is the leading cause of death and major disability in adults aged 75 and older. Despite the effect of CVD on quality of life, morbidity, and mortality in older adults, individuals aged 75 and older have been markedly underrepresented in most major cardiovascular trials, and virtually all trials have excluded older adults with complex comorbidities, significant physical or cognitive disabilities, frailty, or residence in nursing homes and assisted living facilities. As a result, current guidelines are unable to provide evidence-based recommendations for diagnosis and treatment of older adults typical of those encountered in routine clinical practice. The objectives of this scientific statement are to summarize current guideline recommendations as they apply to older adults, identify critical gaps in knowledge that preclude informed evidence-based decision-making, and recommend future research to close existing knowledge gaps. To achieve these objectives, a detailed review was conducted of current American College of Cardiology/American Heart Association (ACC/AHA) and American Stroke Association (ASA) guidelines to identify content and recommendations that explicitly targeted older adults. A pervasive lack of evidence to guide clinical decision-making in older adults with CVD was found, as well as a paucity of data on the effect of diagnostic and therapeutic interventions on outcomes that are particularly important to older adults, such as quality of life, physical function, and maintenance of independence. Accordingly, there is a critical need for a multitude of large population-based studies and clinical trials that include a broad spectrum of older adults representative of those seen in clinical practice and that incorporate relevant outcomes important to older adults in the study design. The results of these studies will provide the foundation for future evidence-based guidelines applicable to older adults and enhance person-centered care of older individuals with CVD in the United States and around the world.
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Affiliation(s)
- Michael W Rich
- School of Medicine, Washington University, St. Louis, Missouri
| | | | - Adam H Skolnick
- Leon H. Charney Division of Cardiology, NYU Langone Medical Center, New York, New York
| | - Karen P Alexander
- Duke Clinical Research Institute, Duke University Medical Center, Durham, North Carolina
| | - Daniel E Forman
- University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania.,Department of Veterans Affairs, Geriatric, Research, Education, and Clinical Center, Pittsburgh, Pennsylvania
| | - Dalane W Kitzman
- School of Medicine, Wake Forest University, Winston-Salem, North Carolina
| | | | - James B McClurken
- RA Reif Heart Institute, Doylestown Hospital, Doylestown, Pennsylvania.,Temple University, Philadelphia, Pennsylvania
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9
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Cymerman RM, Skolnick AH, Cole WJ, Nabati C, Curcio CA, Smith RT. Coronary Artery Disease and Reticular Macular Disease, a Subphenotype of Early Age-Related Macular Degeneration. Curr Eye Res 2016; 41:1482-1488. [PMID: 27159771 DOI: 10.3109/02713683.2015.1128552] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
PURPOSE Reticular macular disease (RMD) is the highest risk form of early age-related macular degeneration and also specifically confers decreased longevity. However, because RMD requires advanced retinal imaging for adequate detection of its characteristic subretinal drusenoid deposits (SDD), it has not yet been completely studied with respect to coronary artery disease (CAD), the leading cause of death in the developed world. Because CAD appears in middle age, our purpose was to screen patients aged 45-80 years, documented either with or without CAD, to determine if CAD is associated with RMD. DESIGN A prospective cohort study of patients with documented CAD status and no known retinal disease in a clinical practice setting at one institution. Subjects and Controls: A number of 76 eyes from 38 consecutive patients (23 with documented CAD, 15 controls documented without CAD; 47.4% female; mean age 66.7 years). METHODS Patients were imaged with near-infrared reflectance/spectral domain optical coherence tomography and assessed in masked fashion by two graders for the presence of SDD lesions of RMD and soft drusen. MAIN OUTCOME MEASURES Presence or absence of RMD/SDD and soft drusen. RESULTS RMD was more frequent in patients with CAD versus those without (Relative Risk [RR] = 2.1, CI = 1.08-3.95, P = 0.03). There was no association of CAD with soft drusen. CONCLUSIONS A specific relationship between CAD and RMD suggests common systemic causes for both and warrants further study.
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Affiliation(s)
- Rachel M Cymerman
- a Department of Ophthalmology , New York University School of Medicine , New York , New York , USA
| | - Adam H Skolnick
- a Department of Ophthalmology , New York University School of Medicine , New York , New York , USA
| | - William J Cole
- a Department of Ophthalmology , New York University School of Medicine , New York , New York , USA
| | - Camellia Nabati
- a Department of Ophthalmology , New York University School of Medicine , New York , New York , USA
| | - Christine A Curcio
- b Department of Ophthalmology , University of Alabama at Birmingham School of Medicine , Birmingham , Alabama , USA
| | - R Theodore Smith
- a Department of Ophthalmology , New York University School of Medicine , New York , New York , USA
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10
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Rich MW, Chyun DA, Skolnick AH, Alexander KP, Forman DE, Kitzman DW, Maurer MS, McClurken JB, Resnick BM, Shen WK, Tirschwell DL. Knowledge Gaps in Cardiovascular Care of the Older Adult Population: A Scientific Statement From the American Heart Association, American College of Cardiology, and American Geriatrics Society. J Am Coll Cardiol 2016; 67:2419-2440. [PMID: 27079335 DOI: 10.1016/j.jacc.2016.03.004] [Citation(s) in RCA: 117] [Impact Index Per Article: 14.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
The incidence and prevalence of most cardiovascular disorders increase with age, and cardiovascular disease is the leading cause of death and major disability in adults ≥75 years of age; however, despite the large impact of cardiovascular disease on quality of life, morbidity, and mortality in older adults, patients aged ≥75 years have been markedly underrepresented in most major cardiovascular trials, and virtually all trials have excluded older patients with complex comorbidities, significant physical or cognitive disabilities, frailty, or residence in a nursing home or assisted living facility. As a result, current guidelines are unable to provide evidence-based recommendations for diagnosis and treatment of older patients typical of those encountered in routine clinical practice. The objectives of this scientific statement are to summarize current guideline recommendations as they apply to older adults, identify critical gaps in knowledge that preclude informed evidence-based decision making, and recommend future research to close existing knowledge gaps. To achieve these objectives, we conducted a detailed review of current American College of Cardiology/American Heart Association and American Stroke Association guidelines to identify content and recommendations that explicitly targeted older patients. We found that there is a pervasive lack of evidence to guide clinical decision making in older patients with cardiovascular disease, as well as a paucity of data on the impact of diagnostic and therapeutic interventions on key outcomes that are particularly important to older patients, such as quality of life, physical function, and maintenance of independence. Accordingly, there is a critical need for a multitude of large population-based studies and clinical trials that include a broad spectrum of older patients representative of those seen in clinical practice and that incorporate relevant outcomes important to older patients in the study design. The results of these studies will provide the foundation for future evidence-based guidelines applicable to older patients, thereby enhancing patient-centered evidence-based care of older people with cardiovascular disease in the United States and around the world.
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11
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Rich MW, Chyun DA, Skolnick AH, Alexander KP, Forman DE, Kitzman DW, Maurer MS, McClurken JB, Resnick BM, Shen WK, Tirschwell DL. Knowledge Gaps in Cardiovascular Care of the Older Adult Population. Circulation 2016; 133:2103-22. [DOI: 10.1161/cir.0000000000000380] [Citation(s) in RCA: 111] [Impact Index Per Article: 13.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
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12
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Heffron SP, Alviar CL, Towe C, Geisler BP, Axel L, Galloway AC, Skolnick AH. Dyspnea and Chest Pain in a Young Woman Caused by a Giant Pericardial Lymphohemangioma: Diagnosis and Treatment. Can J Cardiol 2015; 32:1260.e23-1260.e25. [PMID: 26961665 DOI: 10.1016/j.cjca.2015.12.001] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/05/2015] [Revised: 11/25/2015] [Accepted: 12/02/2015] [Indexed: 11/29/2022] Open
Abstract
We describe a 21-year-old woman who presented with chest pain and dyspnea on exertion and who was found to have a large pericardial mass. Multimodality imaging was instrumental in narrowing the differential diagnosis and planning surgical treatment, which included coronary artery bypass and right-sided heart reconstruction. The final pathologic diagnosis was lymphohemangioma; to our knowledge, this was the largest cardiac/pericardial vascular tumor ever to be reported in the literature.
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Affiliation(s)
- Sean P Heffron
- Leon H. Charney Division of Cardiology, Department of Medicine, New York University Langone Medical Center, New York University School of Medicine, New York, New York, USA
| | - Carlos L Alviar
- Leon H. Charney Division of Cardiology, Department of Medicine, New York University Langone Medical Center, New York University School of Medicine, New York, New York, USA
| | - Christopher Towe
- Division of Cardiothoracic Surgery, Department of Surgery, New York University Langone Medical Center, New York University School of Medicine, New York, New York, USA
| | - Benjamin P Geisler
- Leon H. Charney Division of Cardiology, Department of Medicine, New York University Langone Medical Center, New York University School of Medicine, New York, New York, USA
| | - Leon Axel
- Leon H. Charney Division of Cardiology, Department of Medicine, New York University Langone Medical Center, New York University School of Medicine, New York, New York, USA; Department of Radiology, New York University Langone Medical Center, New York University School of Medicine, New York, New York, USA
| | - Aubrey C Galloway
- Division of Cardiothoracic Surgery, Department of Surgery, New York University Langone Medical Center, New York University School of Medicine, New York, New York, USA
| | - Adam H Skolnick
- Leon H. Charney Division of Cardiology, Department of Medicine, New York University Langone Medical Center, New York University School of Medicine, New York, New York, USA.
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13
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Affiliation(s)
- Adam H. Skolnick
- From the Leon H. Charney Division of Cardiology, NYU Langone Medical Center, New York (A.H.S.); and Division of Cardiology, Duke University Medical Center, and Duke Clinical Research Institute, Durham, NC (K.P.A.)
| | - Karen P. Alexander
- From the Leon H. Charney Division of Cardiology, NYU Langone Medical Center, New York (A.H.S.); and Division of Cardiology, Duke University Medical Center, and Duke Clinical Research Institute, Durham, NC (K.P.A.)
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14
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Hastings RS, McElhinney DB, Saric M, Ngai C, Skolnick AH. Embolic myocardial infarction in a patient with a Fontan circulation. World J Pediatr Congenit Heart Surg 2014; 5:631-4. [PMID: 25324270 DOI: 10.1177/2150135114540180] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Coronary artery embolism is an uncommon cause of acute myocardial infarction (MI). We present a patient with pulmonary atresia and severe right heart hypoplasia who underwent a lateral tunnel Fontan procedure in childhood and presented with an acute ST-segment elevation MI at 19 years of age. In addition to the known risk of thrombotic complications associated with a Fontan circulation, potential predisposing factors to thromboembolism in this patient included a right ventricle to left anterior descending coronary connection and a Fontan baffle leak. The patient was treated with device closure of the baffle leak and anticoagulation. This is one of the first reports of an embolic MI in a patient with a Fontan circulation. The optimal method of reducing thromboembolic risk in this patient, and those with a Fontan circulation in general, is complicated and no consensus exists.
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Affiliation(s)
- Ramin S Hastings
- Leon H. Charney Division of Cardiology, NYU School of Medicine, New York, NY, USA
| | - Doff B McElhinney
- Leon H. Charney Division of Cardiology, NYU School of Medicine, New York, NY, USA
| | - Muhamed Saric
- Leon H. Charney Division of Cardiology, NYU School of Medicine, New York, NY, USA
| | - Calvin Ngai
- Leon H. Charney Division of Cardiology, NYU School of Medicine, New York, NY, USA
| | - Adam H Skolnick
- Leon H. Charney Division of Cardiology, NYU School of Medicine, New York, NY, USA
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Balakrishnan R, Skolnick AH, Saric M. Choosing postoperative echocardiograms wisely: harmonization of the guidelines. Ann Thorac Surg 2013; 96:2284-5. [PMID: 24296211 DOI: 10.1016/j.athoracsur.2013.05.040] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/06/2013] [Revised: 04/10/2013] [Accepted: 05/14/2013] [Indexed: 11/20/2022]
Affiliation(s)
- Revathi Balakrishnan
- New York University Langone Medical Center, Leon H. Charney Division of Cardiology, New York University School of Medicine, 560 First Ave, New York, NY 10016
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Rudominer R, Saric M, Benenstein R, Skolnick AH. An unusually accentuated diastolic anterior motion of the mitral valve in aortic insufficiency. J Clin Ultrasound 2013; 41:392-393. [PMID: 22678922 DOI: 10.1002/jcu.21948] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/03/2011] [Accepted: 04/09/2012] [Indexed: 06/01/2023]
Abstract
A 55-year-old woman was diagnosed with endocarditis involving the aortic valve and resulting in moderate aortic insufficiency. Transesophageal and transthoracic echocardiography demonstrated an unusually accentuated diastolic anterior motion of the anterior mitral valve leaflet toward the interventricular septum. The anterior leaflet remained within a few millimeters of the septum throughout diastole, with a narrow jet of aortic insufficiency separating the anterior leaflet from the septum. We hypothesize that the particularly long anterior mitral leaflet was drawn toward the septum during diastole due to the Venturi effect of the aortic insufficiency jet within a narrow ventricular outflow tract. This accentuated diastolic anterior motion may be a diastolic correlate of systolic anterior motion of the mitral valve.
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Affiliation(s)
- Rebecca Rudominer
- Department of Medicine, Leon H. Charney Division of Cardiology, NY University School of Medicine, New York, NY 10016, USA
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Savji N, Rockman CB, Skolnick AH, Guo Y, Adelman MA, Riles T, Berger JS. Association between advanced age and vascular disease in different arterial territories: a population database of over 3.6 million subjects. J Am Coll Cardiol 2013; 61:1736-43. [PMID: 23500290 DOI: 10.1016/j.jacc.2013.01.054] [Citation(s) in RCA: 183] [Impact Index Per Article: 16.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/04/2012] [Revised: 12/14/2012] [Accepted: 01/08/2013] [Indexed: 12/12/2022]
Abstract
OBJECTIVES This study sought to determine the relationship between vascular disease in different arterial territories and advanced age. BACKGROUND Vascular disease in the peripheral circulation is associated with significant morbidity and mortality. There is little data to assess the prevalence of different phenotypes of vascular disease in the very elderly. METHODS Over 3.6 million self-referred participants from 2003 to 2008 who completed a medical and lifestyle questionnaire in the United States were evaluated by screening ankle brachial indices <0.9 for peripheral artery disease (PAD), and ultrasound imaging for carotid artery stenosis (CAS) >50% and abdominal aortic aneurysm (AAA) >3 cm. Participants were stratified by decade of life. Multivariate logistic regression analysis was used to estimate odds of disease in different age categories. RESULTS Overall, the prevalence of PAD, CAS, and AAA, was 3.7%, 3.9%, and 0.9%, respectively. Prevalence of any vascular disease increased with age (40 to 50 years: 2%, 51 to 60 years: 3.5%, 61 to 70 years: 7.1%, 71 to 80 years: 13.0%, 81 to 90 years: 22.3%, 91 to 100 years: 32.5%; p < 0.0001). Prevalence of disease in each vascular territory increased with age. After adjustment for sex, race/ethnicity, body mass index, family history of cardiovascular disease, smoking, diabetes, hypertension, hypercholesterolemia, and exercise, the odds of PAD (odds ratio [OR]: 2.14; 95% confidence interval [CI]: 2.12 to 2.15), CAS (OR: 1.80; 95% CI: 1.79 to 1.81), and AAA (OR: 2.33; 95% CI: 2.30 to 2.36) increased with every decade of life. CONCLUSIONS There is a dramatic increase in the prevalence of PAD, CAS, and AAA with advanced age. More than 20% and 30% of octogenarians and nonagenarians, respectively, have vascular disease in at least 1 arterial territory.
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Affiliation(s)
- Nazir Savji
- Department of Medicine, Division of Cardiology, School of Medicine, New York University, New York, New York 10016, USA
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Tran HA, Srichai MB, Lim R, Skolnick AH, Loulmet D, Saric M. Apico-aortic valved conduit for the treatment of severe aortic stenosis and porcelain aorta. Eur Heart J Cardiovasc Imaging 2012; 13:877. [PMID: 22822157 DOI: 10.1093/ehjci/jes152] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Affiliation(s)
- Henry A Tran
- New York University Langone Medical Center, New York, NY, USA.
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Skolnick AH, Osranek M, Formica P, Kronzon I. Osteoporosis treatment and progression of aortic stenosis. Am J Cardiol 2009; 104:122-4. [PMID: 19576331 DOI: 10.1016/j.amjcard.2009.02.051] [Citation(s) in RCA: 47] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/29/2008] [Revised: 02/25/2009] [Accepted: 02/25/2009] [Indexed: 11/17/2022]
Abstract
A decrease in bone mineral density has been reported to be associated with increased progression of aortic stenosis (AS). We hypothesized that osteoporosis treatment (OT) is associated with decreased progression of AS. We performed an observational study of patients with AS from our echocardiographic database comparing 18 patients on OT (bisphosphonates, calcitonin, or estrogen receptor modulators) with 37 patients not on OT. All patients had serial echocardiograms. Patients with mitral stenosis, aortic valve replacement, renal failure, calcium disorders, or left ventricular ejection fraction <40% were excluded. Aortic valve area (AVA) was calculated using the continuity equation. There was no significant difference in age, gender, renal function, hypertension, statin use, diabetes, or calcium level between the 2 groups. Mean baseline AVA was 1.33 cm(2) and not significantly different between groups. After a mean of 2.4 +/- 1.0 years, mean annual changes in AVA were -0.22 +/- 0.22 cm(2) in those not on OT and -0.10 +/- 0.18 cm(2) in patients receiving OT (p = 0.025). There was a graded association between AS progression rate and OT. In a multivariable analysis including age, gender, and statin use, only OT was associated with a change in AVA. In conclusion, OT is strongly and independently associated with decreased progression of AS. This association warrants investigation in a larger, prospective study.
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Abstract
A patient with atrial tachycardia presented with dyspnoea on exertion. Transoesophageal echocardiography revealed idiopathic left atrial appendage stenosis. The mouth of the atrial appendage was narrowed, and there was a high velocity to and fro jet between the left atrial body and the left atrial appendage. The study, therefore, suggested isolated left atrial appendage orifice stenosis.
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Affiliation(s)
- Joshua D Stern
- NYU Langone Medical Center Non-Invasive Cardiology Laboratory, 550 First Avenue, New York, NY 10016, USA.
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Abstract
A 74-year-old woman presented with an acute cerebrovascular infarct involving multiple vascular territories, suggestive of an embolic event. The initial transesophageal images create the impression of an echogenic mass in the left atrial appendage. A small pericardial effusion was also seen surrounding the left atrial appendage. After further views were obtained, the echogenic mass appeared to be in this fluid-filled space rather than in the appendage itself. To confirm this finding, echo contrast (Definity) was administered. After contrast injection, the left atrial appendage was opacified, while the effusion around the appendage and the echodensity within this space were not opacified. Our case highlights the utility of contrast-enhanced echocardiography in clearly delineating the boundaries of the endocardium in cases, when a pericardial effusion surrounds the left atrial appendage.
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Affiliation(s)
- Adam H Skolnick
- Division of Cardiovascular Medicine, New York University School of Medicine, New York, New York, USA
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Skolnick AH, Alexander KP, Chen AY, Roe MT, Pollack CV, Ohman EM, Rumsfeld JS, Gibler WB, Peterson ED, Cohen DJ. Characteristics, management, and outcomes of 5,557 patients age > or =90 years with acute coronary syndromes: results from the CRUSADE Initiative. J Am Coll Cardiol 2007; 49:1790-7. [PMID: 17466230 DOI: 10.1016/j.jacc.2007.01.066] [Citation(s) in RCA: 119] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/14/2006] [Revised: 01/05/2007] [Accepted: 01/05/2007] [Indexed: 02/06/2023]
Abstract
OBJECTIVES The goal of this work was to explore the treatment and outcomes of patients with non-ST-segment elevation acute coronary syndromes (NSTE-ACS) age > or =90 years. BACKGROUND The elderly are often excluded from clinical trials of NSTE-ACS and are underrepresented in clinical registries. METHODS We used data from the CRUSADE registry to study 5,557 patients with NSTE-ACS age > or =90 years and compared their baseline characteristics, treatment patterns, and in-hospital outcomes with a cohort age 75 to 89 years (n = 46,270). RESULTS Although both groups had much in common, compared with the younger elderly, the older elderly were less likely to be diabetic, smokers, or obese. Among patients without contraindications, the older elderly were less likely to receive glycoprotein IIb/IIIa inhibitors and statins during the first 24 h and were less likely to undergo cardiac catheterization within 48 h. The older elderly were more likely to die (12.0% vs. 7.8%) and experienced more frequent adverse events (26.8% vs. 21.3%) during the hospitalization-differences that persisted after adjustment for baseline patient and hospital characteristics. Increasing adherence to guideline-recommended therapies was associated with both increased bleeding and a graded reduction in risk-adjusted in-hospital mortality across both age groups. CONCLUSIONS In this large population of nonagenarians and centenarians with NSTE-ACS, increasing adherence to guideline-recommended therapies was associated with decreased mortality. These findings reinforce the importance of optimizing care patterns for even the oldest patients with NSTE-ACS, while examining novel approaches to reduce the risk of bleeding in this rapidly expanding patient population.
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Affiliation(s)
- Adam H Skolnick
- Cardiovascular Division, Beth Israel Deaconess Medical Center, Boston, Massachusetts, USA
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Skolnick AH. Letter to the editor by Dr. Adam H. Skolnick. Am Heart J 2006; 152:e39. [PMID: 16996818 DOI: 10.1016/j.ahj.2006.05.033] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/19/2006] [Revised: 04/21/2006] [Accepted: 05/08/2006] [Indexed: 11/24/2022]
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Abstract
BACKGROUND The role of arthroscopic débridement in the treatment of osteoarthritis of the knee remains to be defined, and few clinical and radiographic characteristics have been quantitatively associated with the outcome. The hypothesis of this study was that the outcome of arthroscopic débridement for osteoarthritis of the knee is associated with preoperative clinical and radiographic features and intraoperative characteristics and that there are subsets of patients who are more and less likely to respond favorably to the treatment. METHODS We performed a cross-sectional study of a consecutive cohort of 122 patients who underwent arthroscopic débridement for the treatment of osteoarthritis of the knee that had been unresponsive to anti-inflammatory therapy. One hundred and ten patients were followed for a mean of thirty-four months. Pain was assessed with the pain domain of the Knee Society scoring system. Radiographs were scored with the Kellgren-Lawrence method, and limb alignment and the widths of the medial and lateral joint spaces were measured. The severity of cartilage lesions was scored intraoperatively with a modified Noyes grading system. Specific methods of data collection and analysis were incorporated to minimize bias. RESULTS Fifty-two (90%) of fifty-eight knees with mild arthritis, normal alignment, and a joint space width of > or = 3 mm were improved after arthroscopic débridement. Conversely, only five (25%) of twenty knees with severe arthritis, limb malalignment, and a joint space width of < 2 mm had substantial relief of symptoms. Of seventy-two patients who had improvement, forty-four (61%) had it within six months after the arthroscopy. The severity of the lesion was highly predictive of the clinical outcome both in patients with mild arthritis and in those with severe arthritis. CONCLUSIONS The severity of the arthritis, as assessed preoperatively with radiography and intraoperatively by rating the severity of cartilage lesions, influences the clinical outcome of arthroscopic débridement of an osteoarthritic knee. Knees with severe arthritis fare poorly, whereas those with mild arthritis fare well. We could not predict the outcome for knees with moderate arthritis. We believe that these observations are relevant for establishing indications for arthroscopy in patients with osteoarthritis of the knee and may be useful for designing studies with a more rigorous experimental design.
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Affiliation(s)
- Roy K Aaron
- Department of Orthopaedics, Brown Medical School, 100 Butler Drive, Providence, RI 02906, USA.
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Pinto DS, Skolnick AH, Kirtane AJ, Murphy SA, Barron HV, Giugliano RP, Cannon CP, Braunwald E, Gibson CM. U-Shaped Relationship of Blood Glucose With Adverse Outcomes Among Patients With ST-Segment Elevation Myocardial Infarction. J Am Coll Cardiol 2005; 46:178-80. [PMID: 15992655 DOI: 10.1016/j.jacc.2005.03.052] [Citation(s) in RCA: 128] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/13/2005] [Revised: 03/03/2005] [Accepted: 03/10/2005] [Indexed: 11/30/2022]
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