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Kaur G, Abdelrahman K, Berman AN, Biery DW, Shiyovich A, Huck D, Garshick M, Blankstein R, Weber B. Lipoprotein(a): Emerging insights and therapeutics. Am J Prev Cardiol 2024; 18:100641. [PMID: 38646022 PMCID: PMC11033089 DOI: 10.1016/j.ajpc.2024.100641] [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] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2023] [Revised: 02/08/2024] [Accepted: 02/24/2024] [Indexed: 04/23/2024] Open
Abstract
The strong association between lipoprotein (a) [Lp(a)] and atherosclerotic cardiovascular disease has led to considerations of Lp(a) being a potential target for mitigating residual cardiovascular risk. While approximately 20 % of the population has an Lp(a) level greater than 50 mg/dL, there are no currently available pharmacological lipid-lowering therapies that have demonstrated substantial reduction in Lp(a). Novel therapies to lower Lp(a) include antisense oligonucleotides and small-interfering ribonucleic acid molecules and have shown promising results in phase 2 trials. Phase 3 trials are currently underway and will test the causal relationship between Lp(a) and ASCVD and whether lowering Lp(a) reduces cardiovascular outcomes. In this review, we summarize emerging insights related to Lp(a)'s role as a risk-enhancing factor for ASCVD, association with calcific aortic stenosis, effects of existing therapies on Lp(a) levels, and variations amongst patient populations. The evolving therapeutic landscape of emerging therapeutics is further discussed.
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Affiliation(s)
- Gurleen Kaur
- Department of Medicine, Brigham and Women's Hospital, Boston, MA, USA
| | | | - Adam N. Berman
- Division of Cardiovascular Medicine, Brigham and Women's Hospital, Boston, MA, USA
| | - David W. Biery
- Division of Cardiovascular Medicine, Brigham and Women's Hospital, Boston, MA, USA
- Albert Einstein College of Medicine, New York, NY, USA
| | - Arthur Shiyovich
- Division of Cardiovascular Medicine, Brigham and Women's Hospital, Boston, MA, USA
| | - Daniel Huck
- Division of Cardiovascular Medicine, Brigham and Women's Hospital, Boston, MA, USA
| | | | - Ron Blankstein
- Division of Cardiovascular Medicine, Brigham and Women's Hospital, Boston, MA, USA
| | - Brittany Weber
- Division of Cardiovascular Medicine, Brigham and Women's Hospital, Boston, MA, USA
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Slavin SD, Berman AN, Beam AL, Navar AM, Mittleman MA. Statin Twitter: Human and Automated Bot Contributions, 2010 to 2022. J Am Heart Assoc 2024; 13:e032678. [PMID: 38533942 DOI: 10.1161/jaha.123.032678] [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] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/12/2023] [Accepted: 12/06/2023] [Indexed: 03/28/2024]
Abstract
BACKGROUND Many individuals eligible for statin therapy decline treatment, often due to fear of adverse effects. Misinformation about statins is common and drives statin reluctance, but its prevalence on social media platforms, such as Twitter (now X) remains unclear. Social media bots are known to proliferate medical misinformation, but their involvement in statin-related discourse is unknown. This study examined temporal trends in volume, author type (bot or human), and sentiment of statin-related Twitter posts (tweets). METHODS AND RESULTS We analyzed original tweets with statin-related terms from 2010 to 2022 using a machine learning-derived classifier to determine the author's bot probability, natural language processing to assign each tweet a negative or positive sentiment, and manual qualitative analysis to identify statin skepticism in a random sample of all tweets and in highly influential tweets. We identified 1 155 735 original statin-related tweets. Bots produced 333 689 (28.9%), humans produced 699 876 (60.6%), and intermediate probability accounts produced 104 966 (9.1%). Over time, the proportion of bot tweets decreased from 47.8% to 11.3%, and human tweets increased from 43.6% to 79.8%. The proportion of negative-sentiment tweets increased from 27.8% to 43.4% for bots and 30.9% to 38.4% for humans. Manually coded statin skepticism increased from 8.0% to 19.0% for bots and from 26.0% to 40.0% for humans. CONCLUSIONS Over the past decade, humans have overtaken bots as generators of statin-related content on Twitter. Negative sentiment and statin skepticism have increased across all user types. Twitter may be an important forum to combat statin-related misinformation.
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Affiliation(s)
- Samuel D Slavin
- Brigham and Women's Hospital Boston MA USA
- Harvard T.H. Chan School of Public Health Boston MA USA
| | | | - Andrew L Beam
- Harvard T.H. Chan School of Public Health Boston MA USA
| | | | - Murray A Mittleman
- Harvard T.H. Chan School of Public Health Boston MA USA
- Beth Israel Deaconess Medical Center Boston MA USA
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Berman AN, Shiyovich A, Biery DW, Cardoso RN, Weber BN, Petranovic M, Besser SA, Hainer J, Wasfy JH, Turchin A, Di Carli MF, Blankstein R, Huck DM. Natural language processing to phenotype coronary computed tomography angiography: Development, validation, and initial results of a large multi-institution cohort. J Cardiovasc Comput Tomogr 2024:S1934-5925(24)00062-5. [PMID: 38458851 DOI: 10.1016/j.jcct.2024.03.003] [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] [Received: 02/20/2024] [Revised: 02/27/2024] [Accepted: 03/01/2024] [Indexed: 03/10/2024]
Affiliation(s)
- Adam N Berman
- Division of Cardiovascular Medicine, Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Arthur Shiyovich
- Division of Cardiovascular Medicine, Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - David W Biery
- Division of Cardiovascular Medicine, Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Rhanderson N Cardoso
- Division of Cardiovascular Medicine, Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Brittany N Weber
- Division of Cardiovascular Medicine, Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Milena Petranovic
- Department of Radiology, Division of Thoracic Imaging and Intervention, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Stephanie A Besser
- Division of Cardiovascular Medicine, Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Jon Hainer
- Department of Radiology, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Jason H Wasfy
- Cardiology Division, Department of Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Alexander Turchin
- Division of Endocrinology, Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Marcelo F Di Carli
- Division of Cardiovascular Medicine, Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA; Department of Radiology, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Ron Blankstein
- Division of Cardiovascular Medicine, Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA; Department of Radiology, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Daniel M Huck
- Division of Cardiovascular Medicine, Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA; Department of Radiology, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA.
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Berman AN, Biery DW, Besser SA, Singh A, Shiyovich A, Weber BN, Huck DM, Divakaran S, Hainer J, Kaur G, Blaha MJ, Cannon CP, Plutzky J, Januzzi JL, Booth JN, López JAG, Kent ST, Nasir K, Di Carli MF, Bhatt DL, Blankstein R. Lipoprotein(a) and Major Adverse Cardiovascular Events in Patients With or Without Baseline Atherosclerotic Cardiovascular Disease. J Am Coll Cardiol 2024; 83:873-886. [PMID: 38418000 DOI: 10.1016/j.jacc.2023.12.031] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/19/2023] [Revised: 12/14/2023] [Accepted: 12/22/2023] [Indexed: 03/01/2024]
Abstract
BACKGROUND Lipoprotein(a) [Lp(a)] is associated with an increased risk of atherosclerotic cardiovascular disease (ASCVD). However, whether the optimal Lp(a) threshold for risk assessment should differ based on baseline ASCVD status is unknown. OBJECTIVES The purpose of this study was to assess the association between Lp(a) and major adverse cardiovascular events (MACE) among patients with and without baseline ASCVD. METHODS We studied a retrospective cohort of patients with Lp(a) measured at 2 medical centers in Boston, Massachusetts, from 2000 to 2019. To assess the association of Lp(a) with incident MACE (nonfatal myocardial infarction [MI], nonfatal stroke, coronary revascularization, or cardiovascular mortality), Lp(a) percentile groups were generated with the reference group set at the first to 50th Lp(a) percentiles. Cox proportional hazards modeling was used to assess the association of Lp(a) percentile group with MACE. RESULTS Overall, 16,419 individuals were analyzed with a median follow-up of 11.9 years. Among the 10,181 (62%) patients with baseline ASCVD, individuals in the 71st to 90th percentile group had a 21% increased hazard of MACE (adjusted HR: 1.21; P < 0.001), which was similar to that of individuals in the 91st to 100th group (adjusted HR: 1.26; P < 0.001). Among the 6,238 individuals without established ASCVD, there was a continuously higher hazard of MACE with increasing Lp(a), and individuals in the 91st to 100th Lp(a) percentile group had the highest relative risk with an adjusted HR of 1.93 (P < 0.001). CONCLUSIONS In a large, contemporary U.S. cohort, elevated Lp(a) is independently associated with long-term MACE among individuals with and without baseline ASCVD. Our results suggest that the threshold for risk assessment may be different in primary vs secondary prevention cohorts.
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Affiliation(s)
- Adam N Berman
- Division of Cardiovascular Medicine, Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA. https://twitter.com/adambermanMD
| | - David W Biery
- Division of Cardiovascular Medicine, Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Stephanie A Besser
- Division of Cardiovascular Medicine, Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Avinainder Singh
- Division of Cardiovascular Medicine, Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Arthur Shiyovich
- Division of Cardiovascular Medicine, Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Brittany N Weber
- Division of Cardiovascular Medicine, Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Daniel M Huck
- Division of Cardiovascular Medicine, Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Sanjay Divakaran
- Division of Cardiovascular Medicine, Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Jon Hainer
- Department of Radiology, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Gurleen Kaur
- Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Michael J Blaha
- Johns Hopkins Ciccarone Center for the Prevention of Heart Disease, Baltimore, Maryland, USA
| | - Christopher P Cannon
- Division of Cardiovascular Medicine, Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Jorge Plutzky
- Division of Cardiovascular Medicine, Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - James L Januzzi
- Cardiology Division, Massachusetts General Hospital, Harvard Medical School, Baim Institute for Clinical Research, Boston, Massachusetts, USA
| | - John N Booth
- Center for Observational Research, Amgen Inc, Thousand Oaks, California, USA
| | | | - Shia T Kent
- Center for Observational Research, Amgen Inc, Thousand Oaks, California, USA
| | - Khurram Nasir
- Department of Cardiovascular Medicine, Division of Cardiovascular Prevention and Wellness, Houston Methodist DeBakey Heart and Vascular Center, Houston, Texas, USA
| | - Marcelo F Di Carli
- Division of Cardiovascular Medicine, Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA; Department of Radiology, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Deepak L Bhatt
- Mount Sinai Fuster Heart Hospital, Icahn School of Medicine at Mount Sinai Health System, New York, New York, USA. https://twitter.com/DLBHATTMD
| | - Ron Blankstein
- Division of Cardiovascular Medicine, Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA; Department of Radiology, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA.
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Slavin SD, Berman AN, Gaba P, Hoshi RA, Mittleman MA. Influenza vaccination and use of lipid lowering therapies in adults with atherosclerotic cardiovascular disease: An analysis of the Behavioral Risk Factor Surveillance System (BRFSS). Am Heart J 2024; 268:1-8. [PMID: 37956919 PMCID: PMC10841584 DOI: 10.1016/j.ahj.2023.11.007] [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] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/01/2023] [Revised: 10/24/2023] [Accepted: 11/04/2023] [Indexed: 11/21/2023]
Abstract
BACKGROUND Influenza vaccination and lipid lowering therapy (LLT) are evidence-based interventions with substantial benefit for individuals with established atherosclerotic cardiovascular disease (ASCVD). However, levels of influenza immunization and LLT use are low, possibly due to pervasive fear-based misinformation uniquely targeting vaccines and LLT. Whether being unvaccinated for influenza predicts lower utilization of LLT is unknown. OBJECTIVES We tested the hypothesis that American adults with ASCVD who are unvaccinated for influenza have lower use of LLT even after accounting for traditional factors associated with underuse of preventive therapies. METHODS We pooled 2017, 2019, and 2021 survey data from the Behavioral Risk Factor Surveillance System (BRFSS), and selected respondents aged 40 to 75 years with self-reported ASCVD. We used logistic regression models adjusted for potential confounders to examine the association between influenza vaccination and self-reported LLT use. We performed a sensitivity analysis with multiple imputation to account for missing data. All analyses accounted for complex survey weighting. RESULTS Of 66,923 participants with ASCVD, 55% reported influenza vaccination in the last year and 76% reported using LLT. Being unvaccinated for influenza was associated with lower odds of LLT use (OR 0.54; 95% CI 0.50, 0.58; P< .001). In a multivariable regression model adjusting for demographics and comorbidities, this association remained statistically significant (aOR 0.58, 95% CI 0.52, 0.64, P < .001). After additional adjustment for preventive care engagement, health care access, and use patterns of other cardiovascular medications this association persisted (aOR 0.66; 95% CI 0.60, 0.74; P < .001). There were no significant differences across subgroups, including those with and without hyperlipidemia. CONCLUSIONS Unvaccinated status for influenza was independently associated with 34% lower odds of LLT use among American adults with ASCVD after adjustment for traditional factors linked to underuse of preventive therapies. This finding identifies a population with excess modifiable ASCVD risk, and supports investigation into nontraditional mechanisms driving underuse of preventive therapies, including fear-based misinformation.
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Affiliation(s)
- Samuel D Slavin
- Division of Cardiovascular Medicine, Brigham and Women's Hospital, Boston, MA; Harvard Medical School, Boston, MA; Division of Epidemiology, Harvard Chan School of Public Health, Boston, MA.
| | - Adam N Berman
- Division of Cardiovascular Medicine, Brigham and Women's Hospital, Boston, MA; Harvard Medical School, Boston, MA
| | - Prakriti Gaba
- Division of Cardiovascular Medicine, Brigham and Women's Hospital, Boston, MA; Harvard Medical School, Boston, MA
| | - Rosangela A Hoshi
- Division of Cardiovascular Medicine, Brigham and Women's Hospital, Boston, MA; Harvard Medical School, Boston, MA
| | - Murray A Mittleman
- Harvard Medical School, Boston, MA; Beth Israel Deaconess Medical Center, Boston, MA; Division of Epidemiology, Harvard Chan School of Public Health, Boston, MA
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Abdelrahman K, Shiyovich A, Huck DM, Berman AN, Weber B, Gupta S, Cardoso R, Blankstein R. Artificial Intelligence in Coronary Artery Calcium Scoring Detection and Quantification. Diagnostics (Basel) 2024; 14:125. [PMID: 38248002 PMCID: PMC10814920 DOI: 10.3390/diagnostics14020125] [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] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2023] [Revised: 12/25/2023] [Accepted: 12/27/2023] [Indexed: 01/23/2024] Open
Abstract
Coronary artery calcium (CAC) is a marker of coronary atherosclerosis, and the presence and severity of CAC have been shown to be powerful predictors of future cardiovascular events. Due to its value in risk discrimination and reclassification beyond traditional risk factors, CAC has been supported by recent guidelines, particularly for the purposes of informing shared decision-making regarding the use of preventive therapies. In addition to dedicated ECG-gated CAC scans, the presence and severity of CAC can also be accurately estimated on non-contrast chest computed tomography scans performed for other clinical indications. However, the presence of such "incidental" CAC is rarely reported. Advances in artificial intelligence have now enabled automatic CAC scoring for both cardiac and non-cardiac CT scans. Various AI approaches, from rule-based models to machine learning algorithms and deep learning, have been applied to automate CAC scoring. Convolutional neural networks, a deep learning technique, have had the most successful approach, with high agreement with manual scoring demonstrated in multiple studies. Such automated CAC measurements may enable wider and more accurate detection of CAC from non-gated CT studies, thus improving the efficiency of healthcare systems to identify and treat previously undiagnosed coronary artery disease.
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Affiliation(s)
| | | | | | | | | | | | | | - Ron Blankstein
- Departments of Medicine (Cardiovascular Division) and Radiology, Brigham and Women’s Hospital, Harvard Medical School, Boston, MA 02115, USA
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Berman AN, Ginder C, Sporn ZA, Tanguturi V, Hidrue MK, Shirkey LB, Zhao Y, Blankstein R, Turchin A, Wasfy JH. Natural Language Processing for the Ascertainment and Phenotyping of Left Ventricular Hypertrophy and Hypertrophic Cardiomyopathy on Echocardiogram Reports. Am J Cardiol 2023; 206:247-253. [PMID: 37714095 DOI: 10.1016/j.amjcard.2023.08.109] [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] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/14/2023] [Revised: 08/17/2023] [Accepted: 08/20/2023] [Indexed: 09/17/2023]
Abstract
Extracting and accurately phenotyping electronic health documentation is critical for medical research and clinical care. We sought to develop a highly accurate and open-source natural language processing (NLP) module to ascertain and phenotype left ventricular hypertrophy (LVH) and hypertrophic cardiomyopathy (HCM) diagnoses from echocardiogram reports within a diverse hospital network. After the initial development on 17,250 echocardiogram reports, 700 unique reports from 6 hospitals were randomly selected from data repositories within the Mass General Brigham healthcare system and manually adjudicated by physicians for 10 subtypes of LVH and diagnoses of HCM. Using an open-source NLP system, the module was formally tested on 300 training set reports and validated on 400 reports. The sensitivity, specificity, positive predictive value, and negative predictive value were calculated to assess the discriminative accuracy of the NLP module. The NLP demonstrated robust performance across the 10 LVH subtypes, with the overall sensitivity and specificity exceeding 96%. In addition, the NLP module demonstrated excellent performance in detecting HCM diagnoses, with sensitivity and specificity exceeding 93%. In conclusion, we designed a highly accurate NLP module to determine the presence of LVH and HCM on echocardiogram reports. Our work demonstrates the feasibility and accuracy of NLP to detect diagnoses on imaging reports, even when described in free text. This module has been placed in the public domain to advance research, trial recruitment, and population health management for patients with LVH-associated conditions.
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Affiliation(s)
- Adam N Berman
- Division of Cardiovascular Medicine, Department of Medicine, Brigham and Women's Hospital
| | - Curtis Ginder
- Division of Cardiovascular Medicine, Department of Medicine, Brigham and Women's Hospital
| | | | - Varsha Tanguturi
- Cardiology Division, Department of Medicine, Massachusetts General Hospital
| | - Michael K Hidrue
- Division of Performance Analysis and Improvement, Massachusetts General Physicians Organization, Massachusetts General Hospital
| | - Linnea B Shirkey
- Division of Performance Analysis and Improvement, Massachusetts General Physicians Organization, Massachusetts General Hospital
| | - Yunong Zhao
- Cardiology Division, Department of Medicine, Massachusetts General Hospital
| | - Ron Blankstein
- Division of Cardiovascular Medicine, Department of Medicine, Brigham and Women's Hospital
| | - Alexander Turchin
- Division of Endocrinology, Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Jason H Wasfy
- Cardiology Division, Department of Medicine, Massachusetts General Hospital.
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Berman AN, Ginder C, Wang XS, Borden L, Hidrue MK, Searl Como JM, Daly D, Sun YP, Curry WT, Del Carmen M, Morrow DA, Scirica B, Choudhry NK, Januzzi JL, Wasfy JH. A pragmatic clinical trial assessing the effect of a targeted notification and clinical support pathway on the diagnostic evaluation and treatment of individuals with left ventricular hypertrophy (NOTIFY-LVH). Am Heart J 2023; 265:40-49. [PMID: 37454754 DOI: 10.1016/j.ahj.2023.06.014] [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] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/14/2023] [Revised: 06/19/2023] [Accepted: 06/28/2023] [Indexed: 07/18/2023]
Abstract
BACKGROUND Electronic health records contain vast amounts of cardiovascular data, including potential clues suggesting unrecognized conditions. One important example is the identification of left ventricular hypertrophy (LVH) on echocardiography. If the underlying causes are untreated, individuals are at increased risk of developing clinically significant pathology. As the most common cause of LVH, hypertension accounts for more cardiovascular deaths than any other modifiable risk factor. Contemporary healthcare systems have suboptimal mechanisms for detecting and effectively implementing hypertension treatment before downstream consequences develop. Thus, there is an urgent need to validate alternative intervention strategies for individuals with preexisting-but potentially unrecognized-LVH. METHODS Through a randomized pragmatic trial within a large integrated healthcare system, we will study the impact of a centralized clinical support pathway on the diagnosis and treatment of hypertension and other LVH-associated diseases in individuals with echocardiographic evidence of concentric LVH. Approximately 600 individuals who are not treated for hypertension and who do not have a known cardiomyopathy will be randomized. The intervention will be directed by population health coordinators who will notify longitudinal clinicians and offer to assist with the diagnostic evaluation of LVH. Our hypothesis is that an intervention that alerts clinicians to the presence of LVH will increase the detection and treatment of hypertension and the diagnosis of alternative causes of thickened myocardium. The primary outcome is the initiation of an antihypertensive medication. Secondary outcomes include new hypertension diagnoses and new cardiomyopathy diagnoses. The trial began in March 2023 and outcomes will be assessed 12 months from the start of follow-up. CONCLUSION The NOTIFY-LVH trial will assess the efficacy of a centralized intervention to improve the detection and treatment of hypertension and LVH-associated diseases. Additionally, it will serve as a proof-of-concept for how to effectively utilize previously collected electronic health data to improve the recognition and management of a broad range of chronic cardiovascular conditions. TRIAL REGISTRATION NCT05713916.
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Affiliation(s)
- Adam N Berman
- Division of Cardiovascular Medicine, Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA; Massachusetts General Physicians Organization, Boston, MA
| | - Curtis Ginder
- Division of Cardiovascular Medicine, Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA
| | - Xianghong S Wang
- Division of Performance Analysis and Improvement, Massachusetts General Physicians Organization, Boston, MA
| | - Linnea Borden
- Massachusetts General Physicians Organization, Boston, MA
| | - Michael K Hidrue
- Division of Performance Analysis and Improvement, Massachusetts General Physicians Organization, Boston, MA
| | | | - Danielle Daly
- Massachusetts General Physicians Organization, Boston, MA
| | - Yee-Ping Sun
- Division of Cardiovascular Medicine, Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA
| | - William T Curry
- Massachusetts General Physicians Organization, Boston, MA; Department of Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA
| | - Marcela Del Carmen
- Massachusetts General Physicians Organization, Boston, MA; Department of Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA
| | - David A Morrow
- Division of Cardiovascular Medicine, Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA
| | - Benjamin Scirica
- Division of Cardiovascular Medicine, Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA
| | - Niteesh K Choudhry
- Department of Medicine, Center for Healthcare Delivery Sciences, Brigham and Women's Hospital, Harvard Medical School, Boston, MA
| | - James L Januzzi
- Cardiology Division, Department of Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, MA; Heart Failure and Biomarker Trials, Baim Institute for Clinical Research, Boston, MA
| | - Jason H Wasfy
- Massachusetts General Physicians Organization, Boston, MA; Cardiology Division, Department of Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, MA.
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Wasfy JH, Achanta A, Hidrue MK, Urbut S, Axtell AL, Berman AN, Zhao Y, Chen J, Gustus S, Picard MH. Association between implanted cardioverter-defibrillators and mortality for patients with left ventricular ejection fraction between 30% and 35. Open Heart 2023; 10:e002289. [PMID: 37625819 PMCID: PMC10462974 DOI: 10.1136/openhrt-2023-002289] [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] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/14/2023] [Accepted: 06/30/2023] [Indexed: 08/27/2023] Open
Abstract
BACKGROUND Consensus guidelines support the use of implanted cardioverter-defibrillators (ICD) for primary prevention of sudden cardiac death in patients with either non-ischaemic or ischaemic cardiomyopathy with left ventricular ejection fraction (LVEF) ≤35%. However, evidence from trials for efficacy specifically for patients with LVEF near 35% is weak. Past trials are underpowered for this population and future trials are unlikely to be performed. METHODS Patients with lowest LVEF between 30% and 35% without an ICD prior to the lowest-LVEF echo (defined as 'time zero') were identified by querying echocardiography data from 28 November 2001 to 9 July 2020 at the Massachusetts General Hospital linked to ICD treatment status. To assess the association between ICD and mortality, propensity score matching followed by Cox proportional hazards models considering treatment status as a time-dependent covariate was used. A secondary analysis was performed for LVEF 36%-40%. RESULTS Initially, 526 440 echocardiograms representing 266 601 unique patients were identified. After inclusion and exclusion criteria were applied, 6109 patients remained for the analytical cohort. In bivariate unadjusted comparisons, patients who received ICDs were substantially more often male (79.8% vs 65.4%, p<0.0001), more often white (87.5% vs 83.7%, p<0.046) and more often had a history of ventricular tachycardia (74.5% vs 19.1%, p<0.0001) and myocardial infarction (56.1% vs 38.2%, p<0.0001). In the propensity matched sample, after accounting for time-dependence, there was no association between ICD and mortality (HR 0.93, 95% CI 0.75 to 1.15, p=0.482). CONCLUSIONS ICD therapy was not associated with reduced mortality near the conventional LVEF threshold of 35%. Although this treatment design cannot definitively demonstrate lack of efficacy, our results are concordant with available prior trial data. A definitive, well-powered trial is needed to answer the important clinical question of primary prevention ICD efficacy between LVEF 30% and 35%.
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Affiliation(s)
- Jason H Wasfy
- Cardiology Division, Department of Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Aditya Achanta
- Department of Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Michael K Hidrue
- Office of the Chief Medical Officer, Mass General Brigham, Boston, Massachusetts, USA
| | - Sarah Urbut
- Cardiology Division, Department of Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Andrea L Axtell
- Department of Surgery, Harvard Medical School, Boston, Massachusetts, USA
| | - Adam N Berman
- Division of Cardiovascular Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Yunong Zhao
- Cardiology Division, Department of Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Julian Chen
- Cardiology Division, Department of Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Sarah Gustus
- Cardiology Division, Department of Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Michael H Picard
- Cardiology Division, Department of Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA
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Shiyovich A, Berman AN, Besser SA, Biery DW, Huck DM, Weber B, Cannon C, Januzzi JL, Booth JN, Nasir K, Di Carli MF, López JAG, Kent ST, Bhatt DL, Blankstein R. Cardiovascular outcomes in patients with coronary artery disease and elevated lipoprotein(a): implications for the OCEAN(a)-outcomes trial population. Eur Heart J Open 2023; 3:oead077. [PMID: 37641636 PMCID: PMC10460541 DOI: 10.1093/ehjopen/oead077] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 07/10/2023] [Revised: 07/19/2023] [Accepted: 08/09/2023] [Indexed: 08/31/2023]
Abstract
Aims The ongoing Olpasiran Trials of Cardiovascular Events and Lipoprotein(a) Reduction [OCEAN(a)]-Outcomes trial is evaluating whether Lp(a) lowering can reduce the incidence of cardiovascular events among patients with prior myocardial infarction (MI) or percutaneous coronary intervention (PCI) and elevated Lp(a) (≥200 nmol/L). The purpose of this study is to evaluate the association of elevated Lp(a) with cardiovascular outcomes in an observational cohort resembling the OCEAN(a)-Outcomes trial main enrolment criteria. Methods and results This study included patients aged 18-85 years with Lp(a) measured as part of their clinical care between 2000 and 2019. While patients were required to have a history of MI, or PCI, those with severe kidney dysfunction or a malignant neoplasm were excluded. Elevated Lp(a) was defined as ≥200 nmol/L consistent with the OCEAN(a)-Outcomes trial. The primary outcome was a composite of coronary heart disease death, MI, or coronary revascularization. Natural language processing algorithms, billing and ICD codes, and laboratory data were employed to identify outcomes and covariates. A total of 3142 patients met the eligibility criteria, the median age was 61 (IQR: 52-73) years, 28.6% were women, and 12.3% had elevated Lp(a). Over a median follow-up of 12.2 years (IQR: 6.2-14.3), the primary composite outcome occurred more frequently in patients with versus without elevated Lp(a) [46.0 vs. 38.0%, unadjHR = 1.30 (95% CI: 1.09-1.53), P = 0.003]. Following adjustment for measured confounders, elevated Lp(a) remained independently associated with the primary outcome [adjHR = 1.33 (95% CI: 1.12-1.58), P = 0.001]. Conclusion In an observational cohort resembling the main OCEAN(a)-Outcomes Trial enrolment criteria, patients with an Lp(a) ≥200 nmol/L had a higher risk of cardiovascular outcomes.
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Affiliation(s)
- Arthur Shiyovich
- Division of Cardiovascular Medicine, Department of Medicine, Brigham and Women’s Hospital, Harvard Medical School, Boston, MA 02115, USA
| | - Adam N Berman
- Division of Cardiovascular Medicine, Department of Medicine, Brigham and Women’s Hospital, Harvard Medical School, Boston, MA 02115, USA
| | - Stephanie A Besser
- Division of Cardiovascular Medicine, Department of Medicine, Brigham and Women’s Hospital, Harvard Medical School, Boston, MA 02115, USA
| | - David W Biery
- Division of Cardiovascular Medicine, Department of Medicine, Brigham and Women’s Hospital, Harvard Medical School, Boston, MA 02115, USA
| | - Daniel M Huck
- Division of Cardiovascular Medicine, Department of Medicine, Brigham and Women’s Hospital, Harvard Medical School, Boston, MA 02115, USA
- Department of Radiology, Brigham and Women’s Hospital, Harvard Medical School, Boston, MA 02115, USA
| | - Brittany Weber
- Division of Cardiovascular Medicine, Department of Medicine, Brigham and Women’s Hospital, Harvard Medical School, Boston, MA 02115, USA
| | - Christopher Cannon
- Division of Cardiovascular Medicine, Department of Medicine, Brigham and Women’s Hospital, Harvard Medical School, Boston, MA 02115, USA
| | - James L Januzzi
- Cardiology Division, Massachusetts General Hospital, Harvard Medical School, and Baim Institute for Clinical Research, Boston, MA 02115, USA
| | - John N Booth
- Center for Observational Research, Amgen Inc., Thousand Oaks, CA 91320, USA
| | - Khurram Nasir
- Department of Cardiovascular Medicine, Division of Cardiovascular Prevention and Wellness, Houston Methodist DeBakey Heart and Vascular Center, Houston, TX 77030, USA
| | - Marcelo F Di Carli
- Division of Cardiovascular Medicine, Department of Medicine, Brigham and Women’s Hospital, Harvard Medical School, Boston, MA 02115, USA
- Department of Radiology, Brigham and Women’s Hospital, Harvard Medical School, Boston, MA 02115, USA
| | | | - Shia T Kent
- Center for Observational Research, Amgen Inc., Thousand Oaks, CA 91320, USA
| | - Deepak L Bhatt
- Division of Cardiovascular Medicine, Department of Medicine, Brigham and Women’s Hospital, Harvard Medical School, Boston, MA 02115, USA
- Mount Sinai Heart, Icahn School of Medicine at Mount Sinai Health System, New York, NY 10029, USA
| | - Ron Blankstein
- Division of Cardiovascular Medicine, Department of Medicine, Brigham and Women’s Hospital, Harvard Medical School, Boston, MA 02115, USA
- Department of Radiology, Brigham and Women’s Hospital, Harvard Medical School, Boston, MA 02115, USA
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11
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Daly DJ, Essien UR, Del Carmen MG, Scirica B, Berman AN, Searl Como J, Wasfy JH. Race, ethnicity, sex, and socioeconomic disparities in anticoagulation for atrial fibrillation: A narrative review of contemporary literature. J Natl Med Assoc 2023; 115:290-297. [PMID: 36882341 DOI: 10.1016/j.jnma.2023.02.008] [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] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/16/2022] [Revised: 01/27/2023] [Accepted: 02/10/2023] [Indexed: 03/07/2023]
Abstract
Atrial fibrillation (AF) is the most prevalent arrhythmia in the United States and is responsible for 1 in 7 ischemic strokes. While anticoagulation is effective at preventing strokes, prior work has highlighted significant disparities in anticoagulation prescribing. Furthermore, racial, ethnic, sex, and socioeconomic disparities in AF outcomes have been described. As such, we aimed to review recent data on disparities with respect to anticoagulation for AF published between January 2018 and February 2021. The search string consisted of 7 phrases that combined AF, anticoagulation, and disparities involving sex, race, ethnicity, income, socioeconomic status (SES), and access to care and identified 13 relevant articles. The aggregate data demonstrated that Black patients were less likely to be prescribed anticoagulation than patients of other racial/ethnic groups. Additionally, Black patients were more likely to be prescribed warfarin instead of direct oral anticoagulants (DOACs) despite evidence that DOACs are safer and better tolerated. Lower-income patients and patients with less education were also less likely to receive DOACs. Some studies found that women were less likely to be anticoagulated than men even when their estimated stroke risk was higher, although other studies did not show sex-based differences. Building upon prior work, our study demonstrates that racial and ethnic disparities have persisted in the management of AF. Additionally, we our work highlights that there are significant disparities in anticoagulation management for AF associated with sex, income, and education. More work is needed to identify mechanisms for these disparities and identify potential solutions to achieve pharmacoequity.
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Affiliation(s)
- Danielle J Daly
- Population Health Management, Performance Analysis and Improvement Unit, Massachusetts General Hospital, Boston, MA.
| | - Utibe R Essien
- Center for Health Equity Research and Promotion, VA Pittsburgh Healthcare System, Pittsburgh, PA; Division of General Internal Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA
| | - Marcela G Del Carmen
- Harvard T.H. Chan School of Public Health, Boston, MA;; Center for Surgery and Public Health, Brigham and Women's Hospital, Boston, Massachusetts, USA;; Division of Gynecologic Oncology, Department of Obstetrics and Gynecology and Reproductive Biology, Massachusetts General Hospital, Boston, MA, USA;; Massachusetts General Physicians Organization, Boston, MA; Harvard Medical School, Boston, MA
| | - Benjamin Scirica
- Harvard Medical School, Boston, MA; Division of Cardiovascular Medicine, Brigham and Women's Hospital, Boston, MA
| | - Adam N Berman
- Division of Cardiovascular Medicine, Brigham and Women's Hospital, Boston, MA
| | - Jennifer Searl Como
- Population Health Management, Performance Analysis and Improvement Unit, Massachusetts General Hospital, Boston, MA
| | - Jason H Wasfy
- Massachusetts General Physicians Organization, Boston, MA; Cardiology Division, Department of Medicine, Massachusetts General Hospital, Boston, MA
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12
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Kaur G, Berman AN, Biery D, Wu W, Besser SA, Weber B, Carli MFD, Bhatt DL, Blankstein R. SEX DIFFERENCES IN THE ASSOCIATION BETWEEN LIPOPROTEIN(A) AND CARDIOVASCULAR OUTCOMES: THE MASS GENERAL BRIGHAM LP(A) REGISTRY. J Am Coll Cardiol 2023. [DOI: 10.1016/s0735-1097(23)02079-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 03/06/2023]
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13
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Hsieh G, Biery D, Berman AN, Besser S, Danik JS, Sun YP, Nasir K, Hung JW, Blaha MJ, Bhatt DL, O'Gara PT, Carli MFD, Blankstein R. ASSOCIATION OF LIPOPROTEIN(A) WITH PROGRESSION AND PROGNOSIS OF CALCIFIC AORTIC STENOSIS: THE MASS GENERAL BRIGHAM LP(A) REGISTRY. J Am Coll Cardiol 2023. [DOI: 10.1016/s0735-1097(23)01847-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 03/06/2023]
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Slavin SD, Berman AN, Gaba P, Hoshi RA, Mittleman MA. Abstract P629: Influenza Vaccine Uptake is Associated With Cholesterol Treatment Adherence: An Analysis of the Behavioral Risk Factor Surveillance System Survey. Circulation 2023. [DOI: 10.1161/circ.147.suppl_1.p629] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [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] [Indexed: 03/15/2023]
Abstract
Introduction:
Misinformation, distrust, and other sociocultural factors that influence vaccine uptake may also influence adherence to cholesterol treatment.
Hypothesis:
Among American adults with hyperlipidemia, individuals who receive influenza vaccination are more likely to report use of cholesterol lowering medication.
Methods:
We pooled 2017 and 2019 survey data from the Behavioral Risk Factor Surveillance System (BRFSS). Our sample included all respondents aged 40 to 75 years with self-reported high cholesterol. We used logistic regression models adjusted for potential confounders to examine the association between influenza vaccine uptake and use of cholesterol medication. We also evaluated whether the association was different among those with and without established atherosclerotic cardiovascular disease (ASCVD). All analyses accounted for survey weighting.
Results:
Of 228,338 (weighted = 107,893,277) participants with hyperlipidemia, 51% reported influenza vaccination and 61% reported taking cholesterol medication. Vaccine uptake was associated with cholesterol medication use (OR 2.08, 95% CI 2.00-2.16, p <0.001). Although slightly attenuated, this association persisted after adjustment for socio-demographics, access to care, comorbidities, and adherence to hypertension treatment (OR 1.53, 95% CI 1.42-1.65, p-value <0.001). The association was similar in those with ASCVD (OR 1.63, 95% CI 1.32-2.03, p-value <0.001) and those without ASCVD (OR 1.52, 95% CI 1.40-1.64, p-value <0.001), p-value for interaction = 0.89.
Conclusions:
Influenza vaccine uptake is associated with cholesterol medication use among American adults with high cholesterol, including those with ASCVD. The sociocultural factors affecting vaccine avoidance, such as misinformation and distrust, merit investigation as potential targets of cardiovascular prevention efforts.
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Siddiqi HK, Defilippis EM, Biery DW, Singh A, Wu WY, Divakaran S, Berman AN, Rizk T, Januzzi JL, Bohula E, Stewart G, Carli MDI, Bhatt DL, Blankstein R. Mortality and Heart Failure Hospitalization Among Young Adults With and Without Cardiogenic Shock After Acute Myocardial Infarction. J Card Fail 2023; 29:18-29. [PMID: 36130688 PMCID: PMC10403806 DOI: 10.1016/j.cardfail.2022.08.012] [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] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/25/2022] [Revised: 08/15/2022] [Accepted: 08/22/2022] [Indexed: 01/17/2023]
Abstract
OBJECTIVES To investigate risk factors and outcomes of cardiogenic shock complicating acute myocardial infarction (AMI-CS) in young patients with AMI. BACKGROUND AMI-CS is associated with high morbidity and mortality rates. Data regarding AMI-CS in younger individuals are limited. METHODS AND RESULTS Consecutive patients with type 1 AMI aged 18-50 years admitted to 2 large tertiary-care academic centers were included, and they were adjudicated as having cardiogenic shock (CS) by physician review of electronic medical records using the Society for Cardiovascular Angiography and Interventions CS classification system. Outcomes included all-cause mortality (ACM), cardiovascular mortality (CVM) and 1-year hospitalization for heart failure (HHF). In addition to using the full population, matching was also used to define a comparator group in the non-CS cohort. Among 2097 patients (mean age 44 ± 5.1 years, 74% white, 19% female), AMI-CS was present in 148 (7%). Independent risk factors of AMI-CS included ST-segment elevation myocardial infarction, left main disease, out-of-hospital cardiac arrest, female sex, peripheral vascular disease, and diabetes. Over median follow-up of 11.2 years, young patients with AMI-CS had a significantly higher risk of ACM (adjusted HR 2.84, 95% CI 1.68-4.81; P < 0.001), CVM (adjusted HR 4.01, 95% CI 2.17-7.71; P < 0.001), and 1-year HHF (adjusted HR 5.99, 95% CI 2.04-17.61; P = 0.001) compared with matched non-AMI-CS patients. Over the course of the study, there was an increase in the incidence of AMI-CS among young patients with MI as well as rising mortality rates for patients with both AMI-CS and non-AMI-CS. CONCLUSIONS Of young patients with AMI, 7% developed AMI-CS, which was associated with a significantly elevated risk of mortality and HHF.
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Affiliation(s)
- Hasan K Siddiqi
- Cardiovascular Division, Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts; Cardiovascular Division, Department of Medicine, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Ersilia M Defilippis
- New York Presbyterian-Columbia University Irving Medical Center, New York, New York
| | - David W Biery
- Cardiovascular Division, Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
| | | | - Wanda Y Wu
- Cardiovascular Division, Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Sanjay Divakaran
- Cardiovascular Division, Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Adam N Berman
- Cardiovascular Division, Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Theresa Rizk
- Cardiovascular Division, Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
| | - James L Januzzi
- Cardiovascular Division, Department of Medicine, Massachusetts General Hospital, Boston, Massachusetts
| | - Erin Bohula
- Cardiovascular Division, Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Garrick Stewart
- Cardiovascular Division, Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Marcelo DI Carli
- Cardiovascular Division, Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts; Department of Radiology, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Deepak L Bhatt
- Cardiovascular Division, Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Ron Blankstein
- Cardiovascular Division, Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts; Department of Radiology, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts.
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16
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Sporn ZA, Berman AN, Daly D, Wasfy JH. Improving guideline-based anticoagulation in atrial fibrillation: A systematic literature review of prospective trials. Heart Rhythm 2023; 20:69-75. [PMID: 36122695 DOI: 10.1016/j.hrthm.2022.09.011] [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] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/13/2022] [Revised: 09/07/2022] [Accepted: 09/12/2022] [Indexed: 01/12/2023]
Abstract
BACKGROUND Guidelines for anticoagulation in patients with atrial fibrillation (AF) aim to decrease the risk of ischemic stroke. However, there is a gap in actual practice between patients who have an indication for anticoagulation and those who are actually prescribed anticoagulation. OBJECTIVE We sought to evaluate the efficacy of prior population-based interventions aimed at decreasing this AF anticoagulation gap. METHODS This study was prospectively registered in the International Prospective Register of Systematic Reviews database (CRD42021287875). A systematic literature review was conducted to obtain all prospective individually randomized and cluster randomized trials by searching 4 electronic databases: PubMed, Google Scholar, Web of Science, and Medline. RESULTS After a review of 1474 studies, 20 trials were included in this systematic literature review. Forty-five percent were effective in decreasing the AF anticoagulation gap. Trial interventions that improved anticoagulation prescribing included 6 trials of electronic risk assessment or decision support, 1 trial of provider education, 2 trials of new protocol or pathway, and 2 trials of patient education. Six of 15 ambulatory trials, 2 of 4 inpatient trials, and 1 trial that spanned inpatient and outpatient settings improved anticoagulation prescribing rates. Interventions focused on patient education, provider education, and electronic risk assessment or decision support increased absolute appropriate anticoagulation prescribing by 8.3%, 4.9%, and 2.0%, respectively. CONCLUSION Interventions aimed at improving anticoagulation prescribing patterns in AF can be effective, although there is heterogeneity in outcomes across intervention type. The most effective interventions appeared to target patient education, provider education, and electronic risk assessment or decision support.
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Affiliation(s)
- Zachary A Sporn
- Department of Medicine, Massachusetts General Hospital, Boston, Massachusetts.
| | - Adam N Berman
- Cardiovascular Division, Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Danielle Daly
- Population Health Management, Performance Analysis and Improvement, Massachusetts General Physicians Organization, Massachusetts General Hospital, Boston, Massachusetts
| | - Jason H Wasfy
- Population Health Management, Performance Analysis and Improvement, Massachusetts General Physicians Organization, Massachusetts General Hospital, Boston, Massachusetts; Cardiology Division, Department of Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts
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17
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Berman AN, Wasfy JH. Translating Clinical Guidelines Into Care Delivery Innovation: The Importance of Rigorous Methods for Generating Evidence. J Am Heart Assoc 2022; 11:e026677. [PMID: 35766287 PMCID: PMC9333392 DOI: 10.1161/jaha.122.026677] [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] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Affiliation(s)
- Adam N Berman
- Division of Cardiovascular Medicine, Department of Medicine, Brigham and Women's Hospital Harvard Medical School Boston MA
| | - Jason H Wasfy
- Cardiology Division, Department of Medicine, Massachusetts General Hospital Harvard Medical School Boston MA
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18
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Wu WY, Biery DW, Berman AN, Hsieh G, Divakaran S, Gupta S, Steigner ML, Aghayev A, Skali H, Polk DM, Plutzky J, Cannon CP, Di Carli MF, Blankstein R. Impact of coronary artery calcium testing on patient management. J Cardiovasc Comput Tomogr 2021; 16:303-308. [PMID: 34998708 DOI: 10.1016/j.jcct.2021.12.006] [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] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/31/2021] [Revised: 11/19/2021] [Accepted: 12/14/2021] [Indexed: 10/19/2022]
Abstract
BACKGROUND Coronary artery calcium (CAC) scoring can identify individuals who may benefit from aggressive prevention therapies. However, there is a paucity of contemporary data on the impact of CAC testing on patient management. METHODS Retrospective cohort study of adults who underwent CAC testing at Brigham and Women's Hospital between 2015 and 2019. Information on baseline medications, follow-up medications, lifestyle modification, and downstream cardiovascular testing within one-year post-CAC were obtained from electronic health records. RESULTS Of the 839 patients with available baseline and follow-up data, 376 (45%) had a CAC = 0, 289 (34%) had CAC = 1-99, and 174 (21%) had CAC≥100. The mean age at time of CAC testing was 59 ± 9.7 years. Patients with higher CAC scores were more likely to be male, have diabetes and hypertension, and have higher low-density lipoprotein cholesterol and lower high-density lipoprotein cholesterol. A non-zero CAC score was associated with initiation of aspirin (41% increase, p < 0.001), anti-hypertensives (9% increase, p = 0.031), and lipid-lowering therapies (114% increase, p < 0.001), whereas CAC = 0 was not. Among individuals with CAC≥100, 75% were started on new or more intense lipid-lowering therapy. Higher calcium scores correlated with increased physician recommendations for diet (p = 0.008) and exercise (p = 0.004). The proportion of cardiovascular downstream testing following CAC was 9.1%, and the majority of patients who underwent additional testing post-CAC had CAC scores ≥100. CONCLUSION Approximately half of individuals referred for CAC testing had evidence of calcified coronary plaque, and of those who had significant calcifications (CAC≥100), nearly 90% were prescribed lipid-lowering therapies post-CAC. Rates of downstream non-invasive testing were low and such testing was mostly performed in patients who had at least moderate CAC.
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Affiliation(s)
- Wanda Y Wu
- Cardiovascular Division, Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA; Boston University School of Medicine, Boston, MA, USA
| | - David W Biery
- Cardiovascular Division, Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Adam N Berman
- Cardiovascular Division, Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Grace Hsieh
- Cardiovascular Division, Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA; Department of Radiology, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Sanjay Divakaran
- Cardiovascular Division, Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Sumit Gupta
- Department of Radiology, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Michael L Steigner
- Department of Radiology, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Ayaz Aghayev
- Department of Radiology, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Hicham Skali
- Cardiovascular Division, Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Donna M Polk
- Cardiovascular Division, Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Jorge Plutzky
- Cardiovascular Division, Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Christopher P Cannon
- Cardiovascular Division, Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Marcelo F Di Carli
- Cardiovascular Division, Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA; Department of Radiology, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Ron Blankstein
- Cardiovascular Division, Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA; Department of Radiology, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA.
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Berman AN, DeFilippis EM, Blankstein R. Role of Income-Lifting Social Programs in Reducing Years of Life Lost to Myocardial Infarction and Sudden Death-Reply. JAMA Cardiol 2021; 7:230-231. [PMID: 34910076 DOI: 10.1001/jamacardio.2021.5130] [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: 11/14/2022]
Affiliation(s)
- Adam N Berman
- Department of Medicine (Cardiovascular Division), Brigham and Women's Hospital, Boston, Massachusetts
| | - Ersilia M DeFilippis
- Department of Medicine, Columbia University Irving Medical Center, New York, New York
| | - Ron Blankstein
- Department of Medicine (Cardiovascular Division), Brigham and Women's Hospital, Boston, Massachusetts
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20
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Berman AN, Biery DW, Ginder C, Hulme OL, Marcusa D, Leiva O, Wu WY, Cardin N, Hainer J, Bhatt DL, Di Carli MF, Turchin A, Blankstein R. Natural language processing for the assessment of cardiovascular disease comorbidities: The cardio-Canary comorbidity project. Clin Cardiol 2021; 44:1296-1304. [PMID: 34347314 PMCID: PMC8428009 DOI: 10.1002/clc.23687] [Citation(s) in RCA: 1] [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] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/10/2021] [Accepted: 06/24/2021] [Indexed: 12/02/2022] Open
Abstract
Objective: Accurate ascertainment of comorbidities is paramount in clinical research. While manual adjudication is labor‐intensive and expensive, the adoption of electronic health records enables computational analysis of free‐text documentation using natural language processing (NLP) tools. Hypothesis: We sought to develop highly accurate NLP modules to assess for the presence of five key cardiovascular comorbidities in a large electronic health record system. Methods: One‐thousand clinical notes were randomly selected from a cardiovascular registry at Mass General Brigham. Trained physicians manually adjudicated these notes for the following five diagnostic comorbidities: hypertension, dyslipidemia, diabetes, coronary artery disease, and stroke/transient ischemic attack. Using the open‐source Canary NLP system, five separate NLP modules were designed based on 800 “training‐set” notes and validated on 200 “test‐set” notes. Results: Across the five NLP modules, the sentence‐level and note‐level sensitivity, specificity, and positive predictive value was always greater than 85% and was most often greater than 90%. Accuracy tended to be highest for conditions with greater diagnostic clarity (e.g. diabetes and hypertension) and slightly lower for conditions whose greater diagnostic challenges (e.g. myocardial infarction and embolic stroke) may lead to less definitive documentation. Conclusion: We designed five open‐source and highly accurate NLP modules that can be used to assess for the presence of important cardiovascular comorbidities in free‐text health records. These modules have been placed in the public domain and can be used for clinical research, trial recruitment and population management at any institution as well as serve as the basis for further development of cardiovascular NLP tools.
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Affiliation(s)
- Adam N Berman
- Cardiovascular Division, Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - David W Biery
- Cardiovascular Division, Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Curtis Ginder
- Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Olivia L Hulme
- Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Daniel Marcusa
- Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Orly Leiva
- Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Wanda Y Wu
- Cardiovascular Division, Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Nicholas Cardin
- Division of Endocrinology, Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Jon Hainer
- Department of Radiology, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Deepak L Bhatt
- Cardiovascular Division, Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Marcelo F Di Carli
- Cardiovascular Division, Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA.,Department of Radiology, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Alexander Turchin
- Division of Endocrinology, Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Ron Blankstein
- Cardiovascular Division, Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA.,Department of Radiology, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA
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21
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Berman AN, Biery DW, Ginder C, Singh A, Baek J, Wadhera RK, Wu WY, Divakaran S, DeFilippis EM, Hainer J, Cannon CP, Plutzky J, Polk DM, Nasir K, Di Carli MF, Ash AS, Bhatt DL, Blankstein R. Association of Socioeconomic Disadvantage With Long-term Mortality After Myocardial Infarction: The Mass General Brigham YOUNG-MI Registry. JAMA Cardiol 2021; 6:880-888. [PMID: 34009238 DOI: 10.1001/jamacardio.2021.0487] [Citation(s) in RCA: 31] [Impact Index Per Article: 10.3] [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] [Indexed: 12/14/2022]
Abstract
Importance Socioeconomic disadvantage is associated with poor health outcomes. However, whether socioeconomic factors are associated with post-myocardial infarction (MI) outcomes in younger patient populations is unknown. Objective To evaluate the association of neighborhood-level socioeconomic disadvantage with long-term outcomes among patients who experienced an MI at a young age. Design, Setting, and Participants This cohort study analyzed patients in the Mass General Brigham YOUNG-MI Registry (at Brigham and Women's Hospital and Massachusetts General Hospital in Boston, Massachusetts) who experienced an MI at or before 50 years of age between January 1, 2000, and April 30, 2016. Each patient's home address was mapped to the Area Deprivation Index (ADI) to capture higher rates of socioeconomic disadvantage. The median follow-up duration was 11.3 years. The dates of analysis were May 1, 2020, to June 30, 2020. Exposures Patients were assigned an ADI ranking according to their home address and then stratified into 3 groups (least disadvantaged group, middle group, and most disadvantaged group). Main Outcomes and Measures The outcomes of interest were all-cause and cardiovascular mortality. Cause of death was adjudicated from national registries and electronic medical records. Cox proportional hazards regression modeling was used to evaluate the association of ADI with all-cause and cardiovascular mortality. Results The cohort consisted of 2097 patients, of whom 2002 (95.5%) with an ADI ranking were included (median [interquartile range] age, 45 [42-48] years; 1607 male individuals [80.3%]). Patients in the most disadvantaged neighborhoods were more likely to be Black or Hispanic, have public insurance or no insurance, and have higher rates of traditional cardiovascular risk factors such as hypertension and diabetes. Among the 1964 patients who survived to hospital discharge, 74 (13.6%) in the most disadvantaged group compared with 88 (12.6%) in the middle group and 41 (5.7%) in the least disadvantaged group died. Even after adjusting for a comprehensive set of clinical covariates, higher neighborhood disadvantage was associated with a 32% higher all-cause mortality (hazard ratio, 1.32; 95% CI, 1.10-1.60; P = .004) and a 57% higher cardiovascular mortality (hazard ratio, 1.57; 95% CI, 1.17-2.10; P = .003). Conclusions and Relevance This study found that, among patients who experienced an MI at or before age 50 years, socioeconomic disadvantage was associated with higher all-cause and cardiovascular mortality even after adjusting for clinical comorbidities. These findings suggest that neighborhood and socioeconomic factors have an important role in long-term post-MI survival.
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Affiliation(s)
- Adam N Berman
- Division of Cardiovascular Medicine, Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
| | - David W Biery
- Division of Cardiovascular Medicine, Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Curtis Ginder
- Division of Cardiovascular Medicine, Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Avinainder Singh
- Department of Medicine, Yale University School of Medicine, New Haven, Connecticut
| | - Jonggyu Baek
- Division of Biostatistics and Health Services Research, University of Massachusetts Medical School, Worcester
| | - Rishi K Wadhera
- Richard A. and Susan F. Smith Center for Outcomes Research in Cardiology, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts
| | - Wanda Y Wu
- Division of Cardiovascular Medicine, Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Sanjay Divakaran
- Division of Cardiovascular Medicine, Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Ersilia M DeFilippis
- Cardiovascular Division, New York Presbyterian-Columbia University Irving Medical Center, New York
| | - Jon Hainer
- Department of Radiology, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Christopher P Cannon
- Division of Cardiovascular Medicine, Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Jorge Plutzky
- Division of Cardiovascular Medicine, Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Donna M Polk
- Division of Cardiovascular Medicine, Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Khurram Nasir
- Department of Cardiology, Houston Methodist Hospital, Houston, Texas
| | - Marcelo F Di Carli
- Division of Cardiovascular Medicine, Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts.,Department of Radiology, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Arlene S Ash
- Division of Biostatistics and Health Services Research, University of Massachusetts Medical School, Worcester
| | - Deepak L Bhatt
- Division of Cardiovascular Medicine, Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Ron Blankstein
- Division of Cardiovascular Medicine, Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts.,Department of Radiology, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
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22
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Berman AN, Biery DW, Singh A, Wu WY, Divakaran S, DeFilippis EM, Hainer J, Blaha MJ, Cannon C, Polk DM, Plutzky J, Natarajan P, Nasir K, Di Carli MF, Bhatt DL, Blankstein R. Atherosclerotic cardiovascular disease risk and elevated lipoprotein(a) among young adults with myocardial infarction: The Partners YOUNG-MI Registry. Eur J Prev Cardiol 2021; 28:e12-e14. [PMID: 32539451 DOI: 10.1177/2047487320931296] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [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: 11/16/2022]
Affiliation(s)
- Adam N Berman
- Cardiovascular Division, Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, USA
| | - David W Biery
- Cardiovascular Division, Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, USA
| | | | - Wanda Y Wu
- Cardiovascular Division, Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, USA
| | - Sanjay Divakaran
- Cardiovascular Division, Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, USA
| | | | - Jon Hainer
- Department of Radiology, Brigham and Women's Hospital, Harvard Medical School, USA
| | - Michael J Blaha
- Johns Hopkins Ciccarone Center for the Prevention of Heart Disease, USA
| | - Christopher Cannon
- Cardiovascular Division, Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, USA
| | - Donna M Polk
- Cardiovascular Division, Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, USA
| | - Jorge Plutzky
- Cardiovascular Division, Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, USA
| | - Pradeep Natarajan
- Cardiology Division, Massachusetts General Hospital, Harvard Medical School, USA
| | - Khurram Nasir
- Department of Cardiology, Houston Methodist Hospital, USA
| | - Marcelo F Di Carli
- Cardiovascular Division, Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, USA.,Department of Radiology, Brigham and Women's Hospital, Harvard Medical School, USA
| | - Deepak L Bhatt
- Cardiovascular Division, Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, USA
| | - Ron Blankstein
- Cardiovascular Division, Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, USA.,Department of Radiology, Brigham and Women's Hospital, Harvard Medical School, USA
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23
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Divakaran S, Biery DW, Berman AN, Singh A, Hainer J, Wu WY, Di Carli MF, Bhatt DL, Nohria A, Blankstein R. Long-Term Outcomes Following Myocardial Infarction in Young Adult Survivors of Hodgkin Lymphoma: The YOUNG-MI Registry. JACC CardioOncol 2021; 3:319-321. [PMID: 34396341 PMCID: PMC8352268 DOI: 10.1016/j.jaccao.2021.04.001] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 01/02/2023]
Affiliation(s)
- Sanjay Divakaran
- Cardiovascular Division and Cardiovascular Imaging Program, Brigham and Women’s Hospital, 75 Francis Street, 70FR-5-5140, Boston, Massachusetts 02115, USA @SanjayDivakaran@BrighamWomens
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24
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DeFilippis EM, Collins BL, Singh A, Biery DW, Fatima A, Qamar A, Berman AN, Gupta A, Cawley M, Wood MJ, Klein J, Hainer J, Gulati M, Taqueti VR, Di Carli MF, Nasir K, Bhatt DL, Blankstein R. Women who experience a myocardial infarction at a young age have worse outcomes compared with men: the Mass General Brigham YOUNG-MI registry. Eur Heart J 2021; 41:4127-4137. [PMID: 33049774 DOI: 10.1093/eurheartj/ehaa662] [Citation(s) in RCA: 53] [Impact Index Per Article: 17.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/09/2019] [Revised: 04/08/2020] [Accepted: 07/29/2020] [Indexed: 12/14/2022] Open
Abstract
AIMS There are sex differences in presentation, treatment, and outcomes of myocardial infarction (MI) but less is known about these differences in a younger patient population. The objective of this study was to investigate sex differences among individuals who experience their first MI at a young age. METHODS AND RESULTS Consecutive patients presenting to two large academic medical centres with a Type 1 MI at ≤50 years of age between 2000 and 2016 were included. Cause of death was adjudicated using electronic health records and death certificates. In total, 2097 individuals (404 female, 19%) had an MI (mean age 44 ± 5.1 years, 73% white). Risk factor profiles were similar between men and women, although women were more likely to have diabetes (23.7% vs. 18.9%, P = 0.028). Women were less likely to undergo invasive coronary angiography (93.5% vs. 96.7%, P = 0.003) and coronary revascularization (82.1% vs. 92.6%, P < 0.001). Women were significantly more likely to have MI with non-obstructive coronary disease on angiography (10.2% vs. 4.2%, P < 0.001). They were less likely to be discharged with aspirin (92.2% vs. 95.0%, P = 0.027), beta-blockers (86.6% vs. 90.3%, P = 0.033), angiotensin-converting enzyme inhibitors/angiotensin-receptor blockers (53.4% vs. 63.7%, P < 0.001), and statins (82.4% vs. 88.4%, P < 0.001). There was no significant difference in in-hospital mortality; however, women who survived to hospital discharge experienced a higher all-cause mortality rate (adjusted HR = 1.63, P = 0.01; median follow-up 11.2 years) with no significant difference in cardiovascular mortality (adjusted HR = 1.14, P = 0.61). CONCLUSIONS Women who experienced their first MI under the age of 50 were less likely to undergo coronary revascularization or be treated with guideline-directed medical therapies. Women who survived hospitalization experienced similar cardiovascular mortality with significantly higher all-cause mortality than men. A better understanding of the mechanisms underlying these differences is warranted.
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Affiliation(s)
- Ersilia M DeFilippis
- Cardiovascular Division, Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, 75 Francis Street, Boston 02115, MA, USA.,New York Presbyterian-Columbia University Irving Medical Center, New York City, New York, NY, USA
| | - Bradley L Collins
- Cardiovascular Division, Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, 75 Francis Street, Boston 02115, MA, USA.,New York Presbyterian-Columbia University Irving Medical Center, New York City, New York, NY, USA
| | - Avinainder Singh
- Cardiovascular Division, Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, 75 Francis Street, Boston 02115, MA, USA.,Yale University School of Medicine, New Haven, CT, USA
| | - David W Biery
- Cardiovascular Division, Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, 75 Francis Street, Boston 02115, MA, USA
| | - Amber Fatima
- Department of Medicine, Tufts Medical Center, Boston, MA, USA
| | - Arman Qamar
- Cardiovascular Division, Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, 75 Francis Street, Boston 02115, MA, USA
| | - Adam N Berman
- Cardiovascular Division, Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, 75 Francis Street, Boston 02115, MA, USA
| | - Ankur Gupta
- Cardiovascular Division, Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, 75 Francis Street, Boston 02115, MA, USA.,Department of Radiology, Brigham and Women's Hospital, Harvard Medical School, 75 Francis Street, Boston 02115, MA, USA
| | - Mary Cawley
- Cardiovascular Division, Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, 75 Francis Street, Boston 02115, MA, USA
| | - Malissa J Wood
- Massachusetts General Hospital Heart Center, Harvard Medical School, Boston, MA, USA
| | - Josh Klein
- Department of Radiology, Brigham and Women's Hospital, Harvard Medical School, 75 Francis Street, Boston 02115, MA, USA
| | - Jon Hainer
- Department of Radiology, Brigham and Women's Hospital, Harvard Medical School, 75 Francis Street, Boston 02115, MA, USA
| | - Martha Gulati
- Cardiovascular Division, Department of Medicine, UA College of Medicine, Phoenix, AZ, USA
| | - Viviany R Taqueti
- Department of Radiology, Brigham and Women's Hospital, Harvard Medical School, 75 Francis Street, Boston 02115, MA, USA
| | - Marcelo F Di Carli
- Cardiovascular Division, Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, 75 Francis Street, Boston 02115, MA, USA.,Department of Radiology, Brigham and Women's Hospital, Harvard Medical School, 75 Francis Street, Boston 02115, MA, USA
| | - Khurram Nasir
- Division of Cardiovascular Disease Prevention and Wellness, Houston Methodist De Bakey Heart and Vascular Center, Houston, TX, USA
| | - Deepak L Bhatt
- Cardiovascular Division, Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, 75 Francis Street, Boston 02115, MA, USA
| | - Ron Blankstein
- Cardiovascular Division, Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, 75 Francis Street, Boston 02115, MA, USA.,Department of Radiology, Brigham and Women's Hospital, Harvard Medical School, 75 Francis Street, Boston 02115, MA, USA
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25
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Weber B, Biery DW, Singh A, Divakaran S, Berman AN, Wu WY, Brown JM, Hainer J, Nasir K, Liao K, Bhatt DL, Di Carli MF, Blankstein R. Association of inflammatory disease and long-term outcomes among young adults with myocardial infarction: the Mass General Brigham YOUNG-MI Registry. Eur J Prev Cardiol 2021; 29:352-359. [PMID: 33784740 DOI: 10.1093/eurjpc/zwaa154] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/08/2020] [Revised: 11/16/2020] [Accepted: 12/17/2020] [Indexed: 01/30/2023]
Abstract
AIMS Autoimmune systemic inflammatory diseases (SIDs) are associated with an increased risk of cardiovascular (CV) disease, particularly myocardial infarction (MI). However, there are limited data on the prevalence and effects of SID among adults who experience an MI at a young age. We sought to determine the prevalence and prognostic implications of SID among adults who experienced an MI at a young age. METHODS AND RESULTS The YOUNG-MI registry is a retrospective cohort study from two large academic centres, which includes patients who experienced a first MI at 50 years of age or younger. SID was ascertained through physician review of the electronic medical record (EMR). Incidence of death was ascertained through the EMR and national databases. The cohort consisted of 2097 individuals, with 53 (2.5%) possessing a diagnosis of SID. Patients with SID were more likely to be female (36% vs. 19%, P = 0.004) and have hypertension (62% vs. 46%, P = 0.025). Over a median follow-up of 11.2 years, patients with SID experienced an higher risk of all-cause mortality compared with either the full cohort of non-SID patients [hazard ratio (HR) = 1.95, 95% confidence interval (CI) (1.07-3.57), P = 0.030], or a matched cohort based on age, gender, and CV risk factors [HR = 2.68, 95% CI (1.18-6.07), P = 0.018]. CONCLUSIONS Among patients who experienced a first MI at a young age, 2.5% had evidence of SID, and these individuals had higher rates of long-term all-cause mortality. Our findings suggest that the presence of SID is associated with worse long-term survival after premature MI.
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Affiliation(s)
- Brittany Weber
- Division of Cardiovascular Medicine, Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, 75 Francis Street, Boston, MA 02115, USA.,Cardiovascular Imaging Program, Departments of Medicine and Radiology, Brigham and Women's Hospital, Harvard Medical School, 75 Francis Street, Boston, MA 02115, USA
| | - David W Biery
- Division of Cardiovascular Medicine, Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, 75 Francis Street, Boston, MA 02115, USA
| | - Avinainder Singh
- Department of Medicine, Yale University School of Medicine, 333 Cedar St, New Haven, CT 06510, USA
| | - Sanjay Divakaran
- Division of Cardiovascular Medicine, Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, 75 Francis Street, Boston, MA 02115, USA.,Cardiovascular Imaging Program, Departments of Medicine and Radiology, Brigham and Women's Hospital, Harvard Medical School, 75 Francis Street, Boston, MA 02115, USA
| | - Adam N Berman
- Division of Cardiovascular Medicine, Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, 75 Francis Street, Boston, MA 02115, USA
| | - Wanda Y Wu
- Division of Cardiovascular Medicine, Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, 75 Francis Street, Boston, MA 02115, USA
| | - Jenifer M Brown
- Division of Cardiovascular Medicine, Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, 75 Francis Street, Boston, MA 02115, USA.,Cardiovascular Imaging Program, Departments of Medicine and Radiology, Brigham and Women's Hospital, Harvard Medical School, 75 Francis Street, Boston, MA 02115, USA
| | - Jon Hainer
- Cardiovascular Imaging Program, Departments of Medicine and Radiology, Brigham and Women's Hospital, Harvard Medical School, 75 Francis Street, Boston, MA 02115, USA
| | - Khurram Nasir
- Division of Cardiovascular Prevention and Wellness, Department of Medicine, Houston Methodist DeBakey Heart & Vascular Center, Houston, 6550 Fannin St, Houston, TX 77030, USA
| | - Katherine Liao
- Division of Rheumatology, Inflammation, and Immunity, Department of Medicine, Brigham and Women's Hospital Harvard Medical School, 75 Francis Street, Boston, MA 02115, USA
| | - Deepak L Bhatt
- Division of Cardiovascular Medicine, Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, 75 Francis Street, Boston, MA 02115, USA
| | - Marcelo F Di Carli
- Division of Cardiovascular Medicine, Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, 75 Francis Street, Boston, MA 02115, USA.,Cardiovascular Imaging Program, Departments of Medicine and Radiology, Brigham and Women's Hospital, Harvard Medical School, 75 Francis Street, Boston, MA 02115, USA
| | - Ron Blankstein
- Division of Cardiovascular Medicine, Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, 75 Francis Street, Boston, MA 02115, USA.,Cardiovascular Imaging Program, Departments of Medicine and Radiology, Brigham and Women's Hospital, Harvard Medical School, 75 Francis Street, Boston, MA 02115, USA
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26
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Berman AN, Biery DW, Ginder C, Hulme OL, Marcusa D, Leiva O, Wu WY, Singh A, Divakaran S, Hainer J, Turchin A, Januzzi JL, Natarajan P, Cannon CP, Di Carli MF, Bhatt DL, Blankstein R. Study of lipoprotein(a) and its impact on atherosclerotic cardiovascular disease: Design and rationale of the Mass General Brigham Lp(a) Registry. Clin Cardiol 2020; 43:1209-1215. [PMID: 32893370 PMCID: PMC7661644 DOI: 10.1002/clc.23456] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/10/2020] [Revised: 08/20/2020] [Accepted: 08/22/2020] [Indexed: 12/24/2022] Open
Abstract
Lipoprotein(a) [Lp(a)] is independently associated with atherosclerotic cardiovascular disease and calcific aortic valve stenosis. Elevated Lp(a) affects approximately one in five individuals and meaningfully contributes to the residual cardiovascular risk in individuals with otherwise well-controlled risk factors. With targeted therapies in the therapeutic pipeline, there is a need to further characterize the clinical phenotypes and outcomes of individuals with elevated levels of this unique biomarker. The Mass General Brigham Lp(a) Registry will be built from the longitudinal electronic health record of two large academic medical centers in Boston, Massachusetts, to develop a detailed cohort of patients who have had their Lp(a) measured. In combination with structured data sources, clinical documentation will be analyzed using natural language processing techniques to accurately characterize baseline characteristics. Important outcome measures including all-cause mortality, cardiovascular mortality, and cardiovascular events will be available for analysis. Approximately 30 000 patients who have had their Lp(a) tested within the Mass General Brigham system from January 2000 to July 2019 will be included in the registry. This large Lp(a) cohort will provide meaningful observational data regarding the differential risk associated with Lp(a) values and cardiovascular disease. With a new frontier of targeted Lp(a) therapies on the horizon, the Mass General Brigham Lp(a) Registry will help provide a deeper understanding of Lp(a)'s role in long term cardiovascular outcomes.
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Affiliation(s)
- Adam N. Berman
- Cardiovascular Division, Department of MedicineBrigham and Women's Hospital, Harvard Medical SchoolBostonMassachusettsUSA
| | - David W. Biery
- Cardiovascular Division, Department of MedicineBrigham and Women's Hospital, Harvard Medical SchoolBostonMassachusettsUSA
| | - Curtis Ginder
- Department of MedicineBrigham and Women's Hospital, Harvard Medical SchoolBostonMassachusettsUSA
| | - Olivia L. Hulme
- Department of MedicineBrigham and Women's Hospital, Harvard Medical SchoolBostonMassachusettsUSA
| | - Daniel Marcusa
- Department of MedicineBrigham and Women's Hospital, Harvard Medical SchoolBostonMassachusettsUSA
| | - Orly Leiva
- Department of MedicineBrigham and Women's Hospital, Harvard Medical SchoolBostonMassachusettsUSA
| | - Wanda Y. Wu
- Cardiovascular Division, Department of MedicineBrigham and Women's Hospital, Harvard Medical SchoolBostonMassachusettsUSA
| | - Avinainder Singh
- Department of MedicineYale University School of MedicineNew HavenConnecticutUSA
| | - Sanjay Divakaran
- Cardiovascular Division, Department of MedicineBrigham and Women's Hospital, Harvard Medical SchoolBostonMassachusettsUSA
| | - Jon Hainer
- Department of RadiologyBrigham and Women's Hospital, Harvard Medical SchoolBostonMassachusettsUSA
| | - Alexander Turchin
- Division of Endocrinology, Department of MedicineBrigham and Women's Hospital, Harvard Medical SchoolBostonMassachusettsUSA
| | - James L. Januzzi
- Cardiology DivisionMassachusetts General Hospital, Harvard Medical SchoolBostonMassachusettsUSA
| | - Pradeep Natarajan
- Cardiology DivisionMassachusetts General Hospital, Harvard Medical SchoolBostonMassachusettsUSA
| | - Christopher P. Cannon
- Cardiovascular Division, Department of MedicineBrigham and Women's Hospital, Harvard Medical SchoolBostonMassachusettsUSA
| | - Marcelo F. Di Carli
- Cardiovascular Division, Department of MedicineBrigham and Women's Hospital, Harvard Medical SchoolBostonMassachusettsUSA
- Department of RadiologyBrigham and Women's Hospital, Harvard Medical SchoolBostonMassachusettsUSA
| | - Deepak L. Bhatt
- Cardiovascular Division, Department of MedicineBrigham and Women's Hospital, Harvard Medical SchoolBostonMassachusettsUSA
| | - Ron Blankstein
- Cardiovascular Division, Department of MedicineBrigham and Women's Hospital, Harvard Medical SchoolBostonMassachusettsUSA
- Department of RadiologyBrigham and Women's Hospital, Harvard Medical SchoolBostonMassachusettsUSA
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27
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Biery DW, Berman AN, Singh A, Divakaran S, DeFilippis EM, Collins BL, Gupta A, Fatima A, Qamar A, Klein J, Hainer J, Blaha MJ, Di Carli MF, Nasir K, Bhatt DL, Blankstein R. Association of Smoking Cessation and Survival Among Young Adults With Myocardial Infarction in the Partners YOUNG-MI Registry. JAMA Netw Open 2020; 3:e209649. [PMID: 32639567 PMCID: PMC7344383 DOI: 10.1001/jamanetworkopen.2020.9649] [Citation(s) in RCA: 25] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/18/2022] Open
Abstract
IMPORTANCE Despite significant progress in primary prevention, the rate of myocardial infarction (MI) continues to increase in young adults. OBJECTIVES To identify the prevalence of tobacco use and to examine the association of both smoking and smoking cessation with survival in a cohort of adults who experienced an initial MI at a young age. DESIGN, SETTING, AND PARTICIPANTS The Partners YOUNG-MI registry is a retrospective cohort study from 2 large academic centers in Boston, Massachusetts, that includes patients who experienced an initial MI at 50 years or younger. Smoking status at the time of presentation and at 1 year after MI was determined from electronic medical records. Participants were 2072 individuals who experienced an MI at 50 years or younger between January 2000 and April 2016. The dates of analysis were October to December 2019. MAIN OUTCOMES AND MEASURES Deaths were ascertained from the Social Security Administration Death Master File, the Massachusetts Department of Vital Statistics, and the National Death Index. Cause of death was adjudicated independently by 2 cardiologists. Propensity score-adjusted Cox proportional hazards modeling was used to evaluate the association between smoking cessation and both all-cause and cardiovascular mortality. RESULTS Among the 2072 individuals (median age, 45 years [interquartile range, 42-48 years]; 1669 [80.6%] men), 1088 (52.5%) were smokers at the time of their index hospitalization. Of these, 910 patients were further classified into either the cessation group (343 [37.7%]) or the persistent smoking group (567 [62.3%]) at 1 year after MI. Over a median follow-up of 11.2 years (interquartile range, 7.3-14.2 years), individuals who quit smoking had a statistically significantly lower rate of all-cause mortality (hazard ratio [HR], 0.35; 95% CI, 0.19-0.63; P < .001) and cardiovascular mortality (HR, 0.29; 95% CI, 0.11-0.79; P = .02). These values remained statistically significant after propensity score adjustment (HR, 0.30 [95% CI, 0.16-0.56; P < .001] for all-cause mortality and 0.19 [95% CI, 0.06-0.56; P = .003] for cardiovascular mortality). CONCLUSIONS AND RELEVANCE In this cohort study, approximately half of individuals who experienced an MI at 50 years or younger were active smokers. Among them, smoking cessation within 1 year after MI was associated with more than 50% lower all-cause and cardiovascular mortality.
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Affiliation(s)
- David W. Biery
- Division of Cardiovascular Medicine, Department of Medicine, Brigham and Women’s Hospital, Harvard Medical School, Boston, Massachusetts
| | - Adam N. Berman
- Division of Cardiovascular Medicine, Department of Medicine, Brigham and Women’s Hospital, Harvard Medical School, Boston, Massachusetts
| | - Avinainder Singh
- Division of Cardiovascular Medicine, Department of Medicine, Brigham and Women’s Hospital, Harvard Medical School, Boston, Massachusetts
- Division of Cardiology, Department of Medicine, Yale University School of Medicine, New Haven, Connecticut
| | - Sanjay Divakaran
- Division of Cardiovascular Medicine, Department of Medicine, Brigham and Women’s Hospital, Harvard Medical School, Boston, Massachusetts
| | | | - Bradley L. Collins
- New York Presbyterian/Columbia University Irving Medical Center, New York, New York
| | - Ankur Gupta
- Division of Cardiovascular Medicine, Department of Medicine, Brigham and Women’s Hospital, Harvard Medical School, Boston, Massachusetts
- Department of Radiology, Brigham and Women’s Hospital, Harvard Medical School, Boston, Massachusetts
| | - Amber Fatima
- Department of Medicine, Tufts Medical Center, Boston, Massachusetts
| | - Arman Qamar
- Division of Cardiovascular Medicine, Department of Medicine, Brigham and Women’s Hospital, Harvard Medical School, Boston, Massachusetts
| | - Josh Klein
- Department of Radiology, Brigham and Women’s Hospital, Harvard Medical School, Boston, Massachusetts
| | - Jon Hainer
- Department of Radiology, Brigham and Women’s Hospital, Harvard Medical School, Boston, Massachusetts
| | - Michael J. Blaha
- The Johns Hopkins Ciccarone Center for the Prevention of Cardiovascular Disease, Baltimore, Maryland
| | - Marcelo F. Di Carli
- Division of Cardiovascular Medicine, Department of Medicine, Brigham and Women’s Hospital, Harvard Medical School, Boston, Massachusetts
- Department of Radiology, Brigham and Women’s Hospital, Harvard Medical School, Boston, Massachusetts
| | - Khurram Nasir
- Division of Cardiology, Department of Medicine, Yale University School of Medicine, New Haven, Connecticut
- Center for Outcomes Research, Houston Methodist, Houston, Texas
| | - Deepak L. Bhatt
- Division of Cardiovascular Medicine, Department of Medicine, Brigham and Women’s Hospital, Harvard Medical School, Boston, Massachusetts
| | - Ron Blankstein
- Division of Cardiovascular Medicine, Department of Medicine, Brigham and Women’s Hospital, Harvard Medical School, Boston, Massachusetts
- Department of Radiology, Brigham and Women’s Hospital, Harvard Medical School, Boston, Massachusetts
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Wu WY, Biery DW, Singh A, Divakaran S, Berman AN, Ayuba G, DeFilippis EM, Nasir K, Januzzi JL, Di Carli MF, Bhatt DL, Blankstein R. Recovery of Left Ventricular Systolic Function and Clinical Outcomes in Young Adults With Myocardial Infarction. J Am Coll Cardiol 2020; 75:2804-2815. [PMID: 32498808 PMCID: PMC7392115 DOI: 10.1016/j.jacc.2020.03.074] [Citation(s) in RCA: 24] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/15/2020] [Revised: 03/10/2020] [Accepted: 03/16/2020] [Indexed: 12/20/2022]
Abstract
BACKGROUND Left ventricular ejection fraction (EF) recovery is associated with better long-term outcomes after myocardial infarction (MI). However, the association between long-term outcomes and EF recovery among young MI patients has not been investigated. OBJECTIVES This study sought to evaluate the prevalence of left ventricular systolic dysfunction among patients who experience their first MI at a young age and to compare outcomes between those who recovered their EF versus those who did not. METHODS The YOUNG-MI registry is a retrospective cohort study of patients who experienced an MI at ≤50 years of age. EF at the time of MI and within 180 days post-MI were determined from all available medical records. The primary outcomes were all-cause and cardiovascular mortality. RESULTS There were 1,724 patients with baseline EF data: 503 (29%) had EF <50%, whereas 1,221 (71%) had a normal baseline EF. Patients with lower EF were more likely to have experienced ST-segment elevation MI, have higher troponin values, and have more severe angiographic coronary artery disease. Among patients with abnormal baseline EF, information on follow-up EF was available for 216, of whom 90 (42%) recovered their EF to ≥50%. Patients who experienced EF recovery had less severe angiographic disease, lower alcohol use, and a lower burden of comorbidities. Over a median follow-up of 11.1 years, EF recovery was associated with an ∼8-fold reduction in all-cause mortality (adjusted hazard ratio: 0.12; p = 0.001) and a ∼10-fold reduction in cardiovascular mortality (adjusted hazard ratio: 0.10; p = 0.025). CONCLUSIONS Nearly one-third of young patients presented with left ventricular dysfunction post-MI. Among them, EF recovery occurred in more than 40% and was independently associated with a substantial decrease in all-cause and cardiovascular mortality.
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Affiliation(s)
- Wanda Y Wu
- Cardiovascular Division, Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts; Boston University School of Medicine, Boston, Massachusetts
| | - David W Biery
- Cardiovascular Division, Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
| | | | - Sanjay Divakaran
- Cardiovascular Division, Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Adam N Berman
- Cardiovascular Division, Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Gloria Ayuba
- Cardiovascular Division, Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Ersilia M DeFilippis
- NewYork-Presbyterian/Columbia University Irving Medical Center, New York, New York
| | | | - James L Januzzi
- Cardiology Division, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts
| | - Marcelo F Di Carli
- Cardiovascular Division, Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts; Department of Radiology, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Deepak L Bhatt
- Cardiovascular Division, Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts. https://twitter.com/DLBHATTMD
| | - Ron Blankstein
- Cardiovascular Division, Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts; Department of Radiology, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts.
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29
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Eberly LA, Richterman A, Beckett AG, Wispelwey B, Marsh RH, Cleveland Manchanda EC, Chang CY, Glynn RJ, Brooks KC, Boxer R, Kakoza R, Goldsmith J, Loscalzo J, Morse M, Lewis EF, Abel S, Adams A, Anaya J, Andrews EH, Atkinson B, Avutu V, Bachorik A, Badri O, Bailey M, Baird K, Bakshi S, Balaban D, Barshop K, Baumrin E, Bayomy O, Beamesderfer J, Becker N, Berg DD, Berman AN, Blum SM, Boardman AP, Boden K, Bonacci RA, Brown S, Campbell K, Case S, Cetrone E, Charrow A, Chiang D, Clark D, Cohen AJ, Cooper A, Cordova T, Cuneo CN, de Feria AA, Deffenbacher K, DeFilippis EM, DeGregorio G, Deutsch AJ, Diephuis B, Divakaran S, Dorschner P, Downing N, Drescher C, D'Silva KM, Dunbar P, Duong D, Earp S, Eckhardt C, Elman SA, England R, Everett K, Fedotova N, Feingold-Link T, Ferreira M, Fisher H, Foo P, Foote M, Franco I, Gilliland T, Greb J, Greco K, Grewal S, Grin B, Growdon ME, Guercio B, Hahn CK, Hasselfeld B, Haydu EJ, Hermes Z, Hildick-Smith G, Holcomb Z, Holroyd K, Horton L, Huang G, Jablonski S, Jacobs D, Jain N, Japa S, Joseph R, Kalashnikova M, Kalwani N, Kang D, Karan A, Katz JT, Kellner D, Kidia K, Kim JH, Knowles SM, Kolbe L, Kore I, Koullias Y, Kuye I, Lang J, Lawlor M, Lechner MG, Lee K, Lee S, Lee Z, Limaye N, Lin-Beckford S, Lipsyc M, Little J, Loewenthal J, Logaraj R, Lopez DM, Loriaux D, Lu Y, Ma K, Marukian N, Matias W, Mayers JR, McConnell I, McLaughlin M, Meade C, Meador C, Mehta A, Messenger E, Michaelidis C, Mirsky J, Mitten E, Mueller A, Mullur J, Munir A, Murphy E, Nagami E, Natarajan A, Nsahlai M, Nze C, Okwara N, Olds P, Paez R, Pardo M, Patel S, Petersen A, Phelan L, Pimenta E, Pipilas D, Plovanich M, Pong D, Powers BW, Rao A, Ramirez Batlle H, Ramsis M, Reichardt A, Reiger S, Rengarajan M, Rico S, Rome BN, Rosales R, Rotenstein L, Roy A, Royston S, Rozansky H, Rudder M, Ryan CE, Salgado S, Sanchez P, Schulte J, Sekar A, Semenkovich N, Shannon E, Shaw N, Shorten AB, Shrauner W, Sinnenberg L, Smithy JW, Snyder G, Sreekrishnan A, Stabenau H, Stavrou E, Stergachis A, Stern R, Stone A, Tabrizi S, Tanyos S, Thomas C, Thun H, Torres-Lockhart K, Tran A, Treasure C, Tsai FD, Tsaur S, Tschirhart E, Tuwatananurak J, Venkateswaran RV, Vishnevetsky A, Wahl L, Wall A, Wallace F, Walsh E, Wang P, Ward HB, Warner LN, Weeks LD, Weiskopf K, Wengrod J, Williams JN, Winkler M, Wong JL, Worster D, Wright A, Wunsch C, Wynter JS, Yarbrough C, Yau WY, Yazdi D, Yeh J, Yialamas MA, Yozamp N, Zambrotta M, Zon R. Identification of Racial Inequities in Access to Specialized Inpatient Heart Failure Care at an Academic Medical Center. Circ Heart Fail 2019; 12:e006214. [PMID: 31658831 DOI: 10.1161/circheartfailure.119.006214] [Citation(s) in RCA: 91] [Impact Index Per Article: 18.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND Racial inequities for patients with heart failure (HF) have been widely documented. HF patients who receive cardiology care during a hospital admission have better outcomes. It is unknown whether there are differences in admission to a cardiology or general medicine service by race. This study examined the relationship between race and admission service, and its effect on 30-day readmission and mortality Methods: We performed a retrospective cohort study from September 2008 to November 2017 at a single large urban academic referral center of all patients self-referred to the emergency department and admitted to either the cardiology or general medicine service with a principal diagnosis of HF, who self-identified as white, black, or Latinx. We used multivariable generalized estimating equation models to assess the relationship between race and admission to the cardiology service. We used Cox regression to assess the association between race, admission service, and 30-day readmission and mortality. RESULTS Among 1967 unique patients (66.7% white, 23.6% black, and 9.7% Latinx), black and Latinx patients had lower rates of admission to the cardiology service than white patients (adjusted rate ratio, 0.91; 95% CI, 0.84-0.98, for black; adjusted rate ratio, 0.83; 95% CI, 0.72-0.97 for Latinx). Female sex and age >75 years were also independently associated with lower rates of admission to the cardiology service. Admission to the cardiology service was independently associated with decreased readmission within 30 days, independent of race. CONCLUSIONS Black and Latinx patients were less likely to be admitted to cardiology for HF care. This inequity may, in part, drive racial inequities in HF outcomes.
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Affiliation(s)
- Lauren A Eberly
- University of Pennsylvania, Department of Medicine, Division of Cardiovascular Medicine, Philadelphia, PA (L.A.E.)
| | - Aaron Richterman
- Department of Medicine (A.R., A.G.B., B.W., K.C.B., R.K., J.L., M.M.), Brigham and Women's Hospital, Boston, MA
| | - Anne G Beckett
- Department of Medicine (A.R., A.G.B., B.W., K.C.B., R.K., J.L., M.M.), Brigham and Women's Hospital, Boston, MA
| | - Bram Wispelwey
- Department of Medicine (A.R., A.G.B., B.W., K.C.B., R.K., J.L., M.M.), Brigham and Women's Hospital, Boston, MA
| | - Regan H Marsh
- Department of Emergency Medicine (R.H.M., E.C.C.M., C.Y.C), Brigham and Women's Hospital, Boston, MA
| | | | - Cindy Y Chang
- Department of Emergency Medicine (R.H.M., E.C.C.M., C.Y.C), Brigham and Women's Hospital, Boston, MA.,Harvard Medical School, Boston, MA (C.Y.C)
| | - Robert J Glynn
- Division of Preventive Medicine, Department of Medicine (R.J.G.), Brigham and Women's Hospital, Boston, MA.,Department of Biostatistics, Harvard T.H. Chan School of Public Health, Boston, MA (R.J.G)
| | - Katherine C Brooks
- Department of Medicine (A.R., A.G.B., B.W., K.C.B., R.K., J.L., M.M.), Brigham and Women's Hospital, Boston, MA
| | - Robert Boxer
- Division of General Internal Medicine, Department of Medicine (R.B.), Brigham and Women's Hospital, Boston, MA
| | - Rose Kakoza
- Department of Medicine (A.R., A.G.B., B.W., K.C.B., R.K., J.L., M.M.), Brigham and Women's Hospital, Boston, MA
| | - Jennifer Goldsmith
- Division of Global Health Equity, Department of Medicine (J.G., M.M.), Brigham and Women's Hospital, Boston, MA
| | - Joseph Loscalzo
- Department of Medicine (A.R., A.G.B., B.W., K.C.B., R.K., J.L., M.M.), Brigham and Women's Hospital, Boston, MA
| | - Michelle Morse
- Department of Medicine (A.R., A.G.B., B.W., K.C.B., R.K., J.L., M.M.), Brigham and Women's Hospital, Boston, MA.,Division of Global Health Equity, Department of Medicine (J.G., M.M.), Brigham and Women's Hospital, Boston, MA
| | - Eldrin F Lewis
- Division of Cardiovascular Medicine, and Department of Medicine (E.F..L.), Brigham and Women's Hospital, Boston, MA
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Affiliation(s)
- Adam N. Berman
- Cardiovascular Division, Department of Medicine, Brigham and Women’s Hospital, Harvard Medical School, Boston, Massachusetts
- Department of Radiology, Brigham and Women’s Hospital, Harvard Medical School, Boston, Massachusetts
| | - Ron Blankstein
- Cardiovascular Division, Department of Medicine, Brigham and Women’s Hospital, Harvard Medical School, Boston, Massachusetts
- Department of Radiology, Brigham and Women’s Hospital, Harvard Medical School, Boston, Massachusetts
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Abstract
Primary prevention of incident atherosclerotic cardiovascular disease (ASCVD) as well as decreasing the risk of future events in those with established atherosclerosis is critical from a public health perspective. Management of dyslipidemias constitutes a key target in decreasing the risk of developing ASCVD events. While there have been great strides in the treatment of dyslipidemia over the last three decades, there are important recent developments and ongoing research that will expand the available therapeutic options and enable further cardiovascular risk reduction. PURPOSE OF REVIEW: The purpose of this paper is to review new developments relating to the primary prevention and management of ASCVD with a specific focus on optimizing the treatment of dyslipidemias. RECENT FINDINGS: In the realm of ASCVD risk prediction, mounting evidence over the last decade has demonstrated that coronary artery calcium testing is superior to any serum biomarker in the prediction of future ASCVD events and in discriminating future cardiovascular risk. As such, it has been incorporated into the most recent ACC/AHA primary prevention guideline to help guide management decisions in select patients. In terms of the management of dyslipidemias, PCSK9 inhibitors lower LDL-C by 50-70% and provide an additional 15% reduction in key cardiovascular events in high-risk patients with known ASCVD, as demonstrated in the ODYSSEY and FOURIER trials. Cholesteryl ester transfer protein (CETP) inhibitors, which significantly increase HDL-C levels, demonstrated mixed results in large clinical trials and have helped reframe HDL-C as a risk marker rather than a modifiable risk factor. In regard to the management of triglycerides, the REDUCE-IT trial demonstrated a nearly 5% absolute reduction in key cardiovascular events with a highly purified fish-oil derivative named icosapent ethyl in high-risk patients already on statin therapy. Finally, in regard to lipoprotein(a)-which is a strong risk factor for ASCVD-there are exciting developments in the therapeutic pipeline which reduce circulating lipoprotein(a) levels by nearly 90%. The management of dyslipidemias continues to be an exciting field with several ongoing cardiovascular outcomes trials, improvement in risk prediction models, and new therapeutic agents in the pipeline that will further mitigate residual cardiovascular risk in both primary and secondary prevention patients.
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Affiliation(s)
- Adam N Berman
- Departments of Medicine (Cardiovascular Division) and Radiology, Brigham and Women's Hospital, Harvard Medical School, 75 Francis Street, Boston, MA, 02115, USA
| | - Ron Blankstein
- Departments of Medicine (Cardiovascular Division) and Radiology, Brigham and Women's Hospital, Harvard Medical School, 75 Francis Street, Boston, MA, 02115, USA.
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