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Acharya S, Neupane G, Seals A, Kc M, Giustini D, Sharma S, Taylor YJ, Palakshappa D, Williamson JD, Moore JB, Bosworth HB, Pokharel Y. Self-Measured Blood Pressure-Guided Pharmacotherapy: A Systematic Review and Meta-Analysis of United States-Based Telemedicine Trials. Hypertension 2024; 81:648-657. [PMID: 38189139 DOI: 10.1161/hypertensionaha.123.22109] [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] [Subscribe] [Scholar Register] [Received: 09/20/2023] [Accepted: 12/25/2023] [Indexed: 01/09/2024]
Abstract
BACKGROUND The optimal approach to implementing telemedicine hypertension management in the United States is unknown. METHODS We examined telemedicine hypertension management versus the effect of usual clinic-based care on blood pressure (BP) and patient/clinician-related heterogeneity in a systematic review/meta-analysis. We searched United States-based randomized trials from Medline, Embase, CENTRAL, CINAHL, PsycINFO, Compendex, Web of Science Core Collection, Scopus, and 2 trial registries. We used trial-level differences in BP and its control rate at ≥6 months using random-effects models. We examined heterogeneity in univariable metaregression and in prespecified subgroups (clinicians leading pharmacotherapy [physician/nonphysician], self-management support [pharmacist/nurse], White versus non-White patient predominant trials [>50% patients/trial], diabetes predominant trials [≥25% patients/trial], and White patient predominant but not diabetes predominant trials versus both non-White and diabetes patient predominant trials]. RESULTS Thirteen, 11, and 7 trials were eligible for systolic and diastolic BP difference and BP control, respectively. Differences in systolic and diastolic BP and BP control rate were -7.3 mm Hg (95% CI, -9.4 to -5.2), -2.7 mm Hg (-4.0 to -1.5), and 10.1% (0.4%-19.9%), respectively, favoring telemedicine. Greater BP reduction occurred in trials where nonphysicians led pharmacotherapy, pharmacists provided self-management support, White patient predominant trials, and White patient predominant but not diabetes predominant trials, with no difference by diabetes predominant trials. CONCLUSIONS Telemedicine hypertension management is more effective than clinic-based care in the United States, particularly when nonphysicians lead pharmacotherapy and pharmacists provide self-management support. Non-White patient predominant trials achieved less BP reduction. Equity-conscious, locally informed adaptation of telemedicine interventions is needed before wider implementation.
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Affiliation(s)
- Sameer Acharya
- Department of Internal Medicine, Cayuga Medical Center, Ithaca, NY (S.A.)
- Department of Internal Medicine, Atrium Health Wake Forest Baptist, Winston-Salem, NC (A.S., D.P., J.D.W., Y.P.)
| | - Gagan Neupane
- Department of Internal Medicine, Florida Atlantic University, Boca Raton (G.N.)
| | | | - Madhav Kc
- School of Medicine, Yale University, New Haven, CT (M.K.)
| | - Dean Giustini
- The University of British Columbia, Vancouver, Canada (D.G.)
| | - Sharan Sharma
- SCL Health Heart and Vascular: Sisters of Charity of Leavenworth Health Heart and Vascular Institute, Brighton, CO (S.S.)
| | - Yhenneko J Taylor
- Center for Health System Sciences, Atrium Health, Charlotte, NC (Y.J.T., Y.P.)
| | - Deepak Palakshappa
- Department of Internal Medicine, Atrium Health Wake Forest Baptist, Winston-Salem, NC (A.S., D.P., J.D.W., Y.P.)
| | - Jeff D Williamson
- Department of Internal Medicine, Atrium Health Wake Forest Baptist, Winston-Salem, NC (A.S., D.P., J.D.W., Y.P.)
| | - Justin B Moore
- Department of Implementation Science, Wake Forest University School of Medicine, Winston-Salem, NC (J.B.M.)
| | - Hayden B Bosworth
- Department of Population Health Sciences, Duke University, Durham, NC (H.B.B.)
| | - Yashashwi Pokharel
- Department of Internal Medicine, Atrium Health Wake Forest Baptist, Winston-Salem, NC (A.S., D.P., J.D.W., Y.P.)
- Center for Health System Sciences, Atrium Health, Charlotte, NC (Y.J.T., Y.P.)
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Gilbert O, Patel P, Ponir C, Drazner MH, Phillips A, Ivanov A, Seals A, Reza N, Rose-Jones L, Chien CV. Interest in Advanced Heart Failure and Transplant Cardiology Fellowship: A National Survey of Cardiology Fellows. JACC Heart Fail 2024; 12:412-414. [PMID: 37921800 PMCID: PMC10923165 DOI: 10.1016/j.jchf.2023.09.016] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/20/2023] [Accepted: 09/26/2023] [Indexed: 11/04/2023]
Affiliation(s)
- Olivia Gilbert
- Wake Forest University School of Medicine, Internal Medicine, Section of Cardiovascular Medicine, Advanced Heart Failure, Heart Transplant, and Mechanical Circulatory Support, Medical Center Boulevard, Winston-Salem, North Carolina 27157, USA
| | - Priyesh Patel
- Wake Forest University School of Medicine, Internal Medicine, Section of Cardiovascular Medicine, Advanced Heart Failure, Heart Transplant, and Mechanical Circulatory Support, Medical Center Boulevard, Winston-Salem, North Carolina 27157, USA
| | - Cynthia Ponir
- Wake Forest University School of Medicine, Internal Medicine, Section of Cardiovascular Medicine, Advanced Heart Failure, Heart Transplant, and Mechanical Circulatory Support, Medical Center Boulevard, Winston-Salem, North Carolina 27157, USA
| | - Mark H. Drazner
- Wake Forest University School of Medicine, Internal Medicine, Section of Cardiovascular Medicine, Advanced Heart Failure, Heart Transplant, and Mechanical Circulatory Support, Medical Center Boulevard, Winston-Salem, North Carolina 27157, USA
| | - Andrews Phillips
- Wake Forest University School of Medicine, Internal Medicine, Section of Cardiovascular Medicine, Advanced Heart Failure, Heart Transplant, and Mechanical Circulatory Support, Medical Center Boulevard, Winston-Salem, North Carolina 27157, USA
| | - Alexander Ivanov
- Wake Forest University School of Medicine, Internal Medicine, Section of Cardiovascular Medicine, Advanced Heart Failure, Heart Transplant, and Mechanical Circulatory Support, Medical Center Boulevard, Winston-Salem, North Carolina 27157, USA
| | - Austin Seals
- Wake Forest University School of Medicine, Internal Medicine, Section of Cardiovascular Medicine, Advanced Heart Failure, Heart Transplant, and Mechanical Circulatory Support, Medical Center Boulevard, Winston-Salem, North Carolina 27157, USA
| | - Nosheen Reza
- Wake Forest University School of Medicine, Internal Medicine, Section of Cardiovascular Medicine, Advanced Heart Failure, Heart Transplant, and Mechanical Circulatory Support, Medical Center Boulevard, Winston-Salem, North Carolina 27157, USA
| | - Lisa Rose-Jones
- Wake Forest University School of Medicine, Internal Medicine, Section of Cardiovascular Medicine, Advanced Heart Failure, Heart Transplant, and Mechanical Circulatory Support, Medical Center Boulevard, Winston-Salem, North Carolina 27157, USA
| | - Christopher V. Chien
- Wake Forest University School of Medicine, Internal Medicine, Section of Cardiovascular Medicine, Advanced Heart Failure, Heart Transplant, and Mechanical Circulatory Support, Medical Center Boulevard, Winston-Salem, North Carolina 27157, USA
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Ponir C, Seals A, Caldarera T, Ip EH, German CA, Taylor Y, Moore JB, Bosworth HB, Shapiro MD, Pokharel Y. Specialty preference for cardiovascular prevention practice in the Southeast US and role of a preventive cardiologist. Postgrad Med J 2023; 100:42-49. [PMID: 37857510 DOI: 10.1093/postmj/qgad082] [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] [Subscribe] [Scholar Register] [Received: 06/19/2023] [Revised: 08/11/2023] [Accepted: 09/01/2023] [Indexed: 10/21/2023]
Abstract
INTRODUCTION Cardiovascular disease (CVD) prevention is practiced concurrently by providers from several specialties. Our goal was to understand providers' preference of specialties in CVD prevention practice and the role of preventive cardiologists. MATERIALS AND METHODS Between 11 October 2021 and 1 March 2022, we surveyed providers from internal medicine, family medicine, endocrinology, and cardiology specialties to examine their preference of specialties in managing various domains of CVD prevention. We examined categorical variables using Chi square test and continuous variables using t or analysis of variance test. RESULTS Of 956 invitees, 263 from 21 health systems and 9 states responded. Majority of respondents were women (54.5%), practicing physicians (72.5%), specializing in cardiology (43.6%), and working at academic centers (51.3%). Respondents favored all specialties to prescribe statins (43.2%), ezetimibe (37.8%), sodium-glucose cotransporter-2 (SGLT2) inhibitors (30.5%), and aspirin in primary prevention (36.3%). Only 7.9% and 9.5% selected cardiologists and preventive cardiologists, respectively, to prescribe SGLT2 inhibitors. Most preferred specialists (i.e. cardiology and endocrinology) to manage advanced lipid disorders, refractory hypertension, and premature coronary heart disease. The most common conditions selected for preventive cardiologists to manage were genetic lipid disorders (17%), cardiovascular risk assessment (15%), dyslipidemia (13%), and refractory/resistant hypertension (12%). CONCLUSIONS For CVD prevention practice, providers favored all specialties to manage common conditions, specialists to manage complex conditions, and preventive cardiologists to manage advanced lipid disorders. Cardiologists were least preferred to prescribe SGLT2 inhibitor. Future research should explore reasons for selected CVD prevention practice preferences to optimize care coordination and for effective use of limited expertise.
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Affiliation(s)
- Cynthia Ponir
- Department of Internal Medicine, Atrium Health Wake Forest Baptist, Winston-Salem, NC 27157, United States
| | - Austin Seals
- Section of Cardiovascular Medicine, Department of Internal Medicine, Atrium Health Wake Forest Baptist, Winston-Salem, NC 27157, United States
| | - Trevor Caldarera
- Department of Internal Medicine, Atrium Health Wake Forest Baptist, Winston-Salem, NC 27157, United States
| | - Edward H Ip
- Department of Biostatistics & Data Science, Department of Social Sciences and Health policy, Translational Science Institute, Atrium Health Wake Forest Baptist, Winston-Salem, NC 27157, United States
| | - Charles A German
- Section of Cardiology, Department of Internal Medicine, University of Chicago, Chicago, IL 60637, United States
| | - Yhenneko Taylor
- Center for Outcomes Research and Evaluation, Atrium Health, Charlotte, NC 28203, United States
| | - Justin B Moore
- Department of Implementation Science, Wake Forest University School of Medicine, Winston-Salem, NC 27101, United States
- Department of Epidemiology & Prevention, Wake Forest University School of Medicine, Winston-Salem, NC 27101, United States
| | - Hayden B Bosworth
- Population Health Sciences, Duke University, Durham, NC 27701, United States
| | - Michael D Shapiro
- Section of Cardiovascular Medicine, Department of Internal Medicine, Atrium Health Wake Forest Baptist, Winston-Salem, NC 27157, United States
| | - Yashashwi Pokharel
- Section of Cardiovascular Medicine, Department of Internal Medicine, Atrium Health Wake Forest Baptist, Winston-Salem, NC 27157, United States
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Ponir C, Annabathula R, Caldarera T, Penmetsa M, Seals A, Saha A, Moore JB, Bosworth HB, Ip EH, Shapiro MD, Pokharel Y. Availability of Specialty Services for Cardiovascular Prevention Practice in the Southeastern United States. South Med J 2023; 116:848-856. [PMID: 37913802 DOI: 10.14423/smj.0000000000001617] [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] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2023]
Abstract
OBJECTIVES A comprehensive cardiovascular disease (CVD) prevention approach should address patients' medical, behavioral, and psychological issues. The aim of this study was to understand the clinician-reported availability of a pertinent CVD preventive workforce across various specialties using a survey study in the southeastern United States, an area with a disproportionate burden of CVD and commonly known as the Stroke Belt. METHODS We surveyed physicians, advanced practice providers (APPs), and pharmacists in internal medicine, family medicine, endocrinology, and cardiology regarding available specialists in CVD preventive practice. We examined categorical variables using the χ2 test and continuous variables using the t test/analysis of variance. RESULTS A total of 263 clinicians from 21 health systems participated (27.6% response rate, 91.5% from North Carolina). Most were women (54.5%) and physicians (72.5%) specializing in cardiology (43.6%) and working at academic centers (51.3%). Overall, most clinicians stated having adequate specialist services to manage hypertension (86.6%), diabetes mellitus (90.1%), and dyslipidemia (84%), with >50% stating having adequate specialist services for obesity, smoking cessation, diet/nutrition, and exercise counseling. Many reported working with an APP (69%) or a pharmacist (56.5%). Specialist services for exercise therapy, psychology, behavioral counseling, and preventive cardiology were less available. When examined across the four specialties, the majority reported having adequate specialist services for hypertension, diabetes mellitus, obesity, dyslipidemia, and diet/nutrition counseling. Providers from all four specialties were less likely to work with exercise therapists, psychologists, behavioral counselors, and preventive cardiologists. CONCLUSIONS A majority of providers expressed having adequate specialists for hypertension, diabetes mellitus, dyslipidemia, obesity, smoking cessation, diet/nutrition, and exercise counseling. Most worked together with APPs and pharmacists but less frequently with exercise therapists, psychologists, behavioral counselors, and preventive cardiologists. Further research should explore approaches to use and expand less commonly available specialists for optimal CVD preventive care.
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Affiliation(s)
- Cynthia Ponir
- From the Department of Internal Medicine, Atrium Health Wake Forest Baptist, Winston-Salem, North Carolina
| | - Rahul Annabathula
- From the Department of Internal Medicine, Atrium Health Wake Forest Baptist, Winston-Salem, North Carolina
| | - Trevor Caldarera
- From the Department of Internal Medicine, Atrium Health Wake Forest Baptist, Winston-Salem, North Carolina
| | - Megha Penmetsa
- Division of Cardiovascular Disease, Department of Medicine, Carilion Clinic, Roanoke, Virginia
| | - Austin Seals
- Section of Cardiovascular Medicine, Department of Internal Medicine, Atrium Health Wake Forest Baptist, Winston-Salem, North Carolina
| | - Animita Saha
- Atrium Health Internal Medicine, Carolinas Medical Center, Charlotte, North Carolina
| | | | | | - Edward H Ip
- Departments of Biostatistics and Data Science and Social Sciences and Health Policy, Translational Science Institute, Atrium Health Wake Forest Baptist, Winston-Salem, North Carolina
| | - Michael D Shapiro
- Section of Cardiovascular Medicine, Department of Internal Medicine, Atrium Health Wake Forest Baptist, Winston-Salem, North Carolina
| | - Yashashwi Pokharel
- Section of Cardiovascular Medicine, Department of Internal Medicine, Atrium Health Wake Forest Baptist, Winston-Salem, North Carolina
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Acharya S, Neupane G, Seals A, Madhav KC, Giustini D, Sharma S, Taylor YJ, Palakshappa D, Williamson JD, Moore JB, Bosworth HB, Pokharel Y. Heterogeneity of the Effect of Telemedicine Hypertension Management Approach on Blood Pressure: A Systematic Review and Meta-analysis of US-based Clinical Trials. medRxiv 2023:2023.09.14.23295587. [PMID: 37745417 PMCID: PMC10516092 DOI: 10.1101/2023.09.14.23295587] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 09/26/2023]
Abstract
Background Telemedicine management of hypertension (TM-HTN) uses home blood pressure (BP) to guide pharmacotherapy and telemedicine-based self-management support (SMS). Optimal approach to implementing TM-HTN in the US is unknown. Methods We conducted a systematic review and a meta-analysis to examine the effect of TM-HTN vs. usual clinic-based care on BP and assessed heterogeneity by patient- and clinician-related factors. We searched US-based randomized clinical trials among adults from Medline, Embase, CENTRAL, CINAHL, PsycInfo, and Compendex, Web of Science Core Collection, Scopus, and two trial registries to 7/7/2023. Two authors extracted, and a third author confirmed data. We used trial-level differences in systolic BP (SBP), diastolic BP (DBP) and BP control rate at ≥6 months using random-effects models. We examined heterogeneity of effect in univariable meta-regression and in pre-specified subgroups [clinicians leading pharmacotherapy (physician vs. non-physician), SMS (pharmacist vs. nurse), White vs. non-White patient predominant trials (>50% patients/trial), diabetes predominant trials (≥25% patients/trial) and in trials that have majority of both non-White patients and patients with diabetes vs. White patient predominant but not diabetes predominant trials. Results Thirteen, 11 and 7 trials were eligible for SBP, DBP and BP control, respectively. Differences in SBP, DBP and BP control rate were -7.3 mmHg (95% CI: - 9.4, -5.2), -2.7 mmHg (-4.0, -1.5) and 10.1% (0.4%, 19.9%), respectively, favoring TM-HTN. More BP reduction occurred in trials with non-physician vs. physician led pharmacotherapy (9.3/4.0 mmHg vs. 4.9/1.1 mmHg, P<0.01 for both SBP/DBP), pharmacist vs. nurses provided SMS (9.3/4.1 mmHg vs. 5.6/1.0 mmHg, P=0.01 for SBP, P<0.01 for DBP), and White vs. non-White patient predominant trials (9.3/4.0 mmHg vs. 4.4/1.1 mmHg, P<0.01 for both SBP/DBP), with no difference by diabetes predominant trials. Lower BP reduction occurred in both diabetes and non-White patient predominant trials vs. White patient predominant but not diabetes predominant trials (4.5/0.9 mmHg vs. 9.5/4.2 mmHg, P<0.01 for both SBP/DBP). Conclusions TM-HTN is more effective than clinic-based care in the US, particularly when non-physician led pharmacotherapy and pharmacist provided SMS. Non-White patient predominant trials seemed to achieve lesser BP reduction. Equity conscious, locally informed adaptation of TM-HTN is needed before wider implementation. Clinical Perspective What Is New?: In this systematic review and meta-analysis of US-based clinical trials, we found that telemedicine management of hypertension (TM-HTN) was more effective in reducing and controlling blood pressure (BP) compared with clinic based hypertension (HTN) care.The BP reduction was more evident when pharmacotherapy was led by non-physician compared with physicians and HTN self-management support was provided by clinical pharmacists compared with nurses,Non-White patient predominant trials achieved lesser BP reductions than White patient predominant trials.What Are the Clinical Implications?: Before wider implementation of TM-HTN intervention in the US, locally informed adaptation, such as optimizing the team-based HTN care approach, can provide more effective BP control.Without equity focused tailoring, TM-HTN intervention implemented as such can exacerbate inequities in BP control among non-White patients in the US.
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Caldarera T, Ponir C, Seals A, Penmetsa M, Ip E, German CA, Virani SS, Saha A, Bosworth HB, Moore JB, Shapiro MD, Pokharel Y. Clinicians' self-reported efficacy in cardiovascular prevention practice in the southeastern United States. Future Cardiol 2023; 19:593-604. [PMID: 37916575 DOI: 10.2217/fca-2023-0040] [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] [Subscribe] [Scholar Register] [Indexed: 11/03/2023] Open
Abstract
Aim: We assessed self-reported efficacy in cardiovascular prevention practice among internal medicine, family medicine, endocrinology and cardiology clinicians. Patients & methods: We emailed a 21-item questionnaire to 956 physicians, nurse practitioners, physician assistants and pharmacists. Results: 264 clinicians responded (median age: 39 years, 55% women, 47.9% specialists). Most expressed high self-efficacy in lifestyle counselling, prescribing statins, metformin, and aspirin in primary prevention, but low self-efficacy in managing specialized conditions like elevated lipoprotein(a). Compared with specialists, PCPs expressed lower self-efficacy in managing advanced lipid disorders and higher self-efficacy in prescribing sodium-glucose cotransporter-2 inhibitors and glucagon-like peptide-1 receptor agonists. Conclusion: Self-efficacy in cardiovascular prevention varied across specialties. Future research should explore relevant provider, clinic and system level factors to optimize cardiovascular prevention.
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Affiliation(s)
- Trevor Caldarera
- Department of Internal Medicine, Wake Forest University School of Medicine, Winston-Salem, NC 27101, USA
| | - Cynthia Ponir
- Department of Internal Medicine, Wake Forest University School of Medicine, Winston-Salem, NC 27101, USA
| | - Austin Seals
- Section of Cardiovascular Medicine, Department of Internal Medicine, Wake Forest University School of Medicine, Winston-Salem, NC, USA 27101
| | - Megha Penmetsa
- Division of Cardiovascular Disease, Department of Medicine, Carilion Clinic, Roanoke, VA 24014, USA
| | - Edward Ip
- Department of Biostatistics & Data Science, Division of Public Health Sciences, Wake Forest University School of Medicine, Winston-Salem, NC 27101, USA
| | - Charles A German
- Section of Cardiology, Department of Medicine, University of Chicago, Chicago, IL 60637, USA
| | - Salim S Virani
- Department of Medicine, The Aga Khan University, Karachi, 74800, Pakistan
- Department of Internal Medicine, Division of Cardiology, Baylor College of Medicine, Houston, TX 77030, USA
| | - Animita Saha
- Department of Internal Medicine, Atrium Health, Charlotte, NC 28207, USA
| | - Hayden B Bosworth
- Department of Population Health Science, Duke University School of Medicine, Durham, NC 27710, USA
| | - Justin B Moore
- Department of Implementation Science, Division of Public Health Sciences, Wake Forest University School of Medicine, Winston-Salem, NC 27101, USA
- Department of Epidemiology & Prevention, Division of Public Health Sciences, Wake Forest University School of Medicine, Winston-Salem, NC 27101, USA
| | - Michael D Shapiro
- Section of Cardiovascular Medicine, Department of Internal Medicine, Wake Forest University School of Medicine, Winston-Salem, NC, USA 27101
| | - Yashashwi Pokharel
- Section of Cardiovascular Medicine, Department of Internal Medicine, Wake Forest University School of Medicine, Winston-Salem, NC, USA 27101
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Wang SK, Suresh V, Elashker A, Ajja R, Seals A, Acharya S, Williamson JD, Moore J, Bosworth H, Pokharel Y. IDENTIFYING IMPLEMENTATION TACTICS USED IN CLINICAL TRIALS OF TELEMEDICINE MANAGEMENT OF HYPERTENSION TO ENHANCE TRANSLATION INTO PRACTICE. J Am Coll Cardiol 2023. [DOI: 10.1016/s0735-1097(23)02325-2] [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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Acharya S, Neupane G, Seals A, Sharma S, Taylor Y, Palakshappa D, Williamson JD, Bosworth H, Moore J, Pokharel Y. INFORMING RESEARCH TO PRACTICE TRANSLATION OF TELEMEDICINE MANAGEMENT OF HYPERTENSION: A SYSTEMATIC REVIEW AND META-ANALYSIS OF CLINICAL TRIALS. J Am Coll Cardiol 2023. [DOI: 10.1016/s0735-1097(23)02198-8] [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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Ha ET, Ivanov A, Yeboah J, Seals A, Peterson SJ, Parikh M, Aronow WS, Frishman WH. Relation of Left Ventricular Hypertrophy Subtype to Long-Term Mortality in Those With Subclinical Cardiovascular Disease (from the Multiethnic Study of Atherosclerosis [MESA]). Am J Cardiol 2022; 175:131-138. [PMID: 35550820 DOI: 10.1016/j.amjcard.2022.03.058] [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] [Received: 01/29/2022] [Revised: 03/22/2022] [Accepted: 03/28/2022] [Indexed: 11/01/2022]
Abstract
The clinical and biochemical profile of differing Left ventricular hypertrophy phenotypes and its effect on long-term outcomes is ill-defined. The study investigated the differences in risk profiles and prognostic effect of concentric (CH) and eccentric hypertrophy (EH) on long-term adverse outcomes in a contemporary, ethnically diverse cohort. We analyzed follow-up data over 15 years from the Multiethnic Study of Atherosclerosis study. A total of 4,979 participants with cardiac magnetic resonance performed at baseline enrollment were included. Descriptive statistics, Kaplan-Meier curves, and regression models were applied. Independent variables associated with CH were black and Hispanic race/ethnicity, systolic blood pressure, and metabolic syndrome. Independent variables associated with EH were systolic blood pressure and urine creatinine, whereas serum creatinine had an inverse association. The primary end point of all-cause death (n = 1,137, 22.8%) occurred in 21.7%, 47.4%, and 56.6% of participants with no, CH, or EH, respectively (p- < 0.001). Age (hazard ratio [HR] per year = 1.10 [1.09 to 1.11], p <0.001), male gender (HR = 1.48 [1.29 to 1.69], p <0.001), black race (HR = 1.17 [1.005 to 1.36], p = 0.04), fasting glucose (HR = 1.005 [1.003 to 1.007], p <0.001), baseline creatinine (HR per mg/100 ml = 1.29 [1.15 to 1.46], p <0.001), left ventricular ejection fraction (HR per 1% = 0.98 [0.98 to 0.99], p = 0.005), IL-6 (HR per pg/ml = 1.17 [1.12 to 1.22], p <0.001), CH (HR = 1.84 [1.41 to 2.41], p <0.001), and EH (HR = 2.58 [1.77 to 3.76], p <0.001) were significant predictors of all-cause mortality. In conclusion, CH and EH are 2 distinct clinical phenotypes of left ventricular hypertrophy with differing gender and racial predisposition, both of which are associated with worse long-term adverse outcomes.
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Affiliation(s)
- Edward T Ha
- Department of Internal Medicine and Cardiology, NewYork-Presbyterian Brooklyn Methodist Hospital, Brooklyn, New York
| | - Alexander Ivanov
- Department of Cardiology, Atrium Health Wake Forest Baptist Health, Winston-Salem, North Carolina.
| | - Joseph Yeboah
- Department of Cardiology, Atrium Health Wake Forest Baptist Health, Winston-Salem, North Carolina
| | - Austin Seals
- Department of Cardiology, Atrium Health Wake Forest Baptist Health, Winston-Salem, North Carolina
| | - Stephen J Peterson
- Department of Internal Medicine and Cardiology, NewYork-Presbyterian Brooklyn Methodist Hospital, Brooklyn, New York; Department of Medicine, Weill Cornell Medical College, New York, New York
| | - Manish Parikh
- Department of Internal Medicine and Cardiology, NewYork-Presbyterian Brooklyn Methodist Hospital, Brooklyn, New York; Department of Medicine, Weill Cornell Medical College, New York, New York
| | - Wilbert S Aronow
- Department of Internal Medicine, New York Medical College, Valhalla, New York
| | - William H Frishman
- Department of Internal Medicine, New York Medical College, Valhalla, New York
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Ye F, Pu M, Rodriguez C, Callahan K, Seals A, Vasu S, Jao G. Risk Factors Associated with One Year Mortality from the Time of Cardiac Amyloid Diagnosis. J Heart Lung Transplant 2022. [DOI: 10.1016/j.healun.2022.01.1686] [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] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
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Brumberger ZL, Branch ME, Klein MW, Seals A, Shapiro MD, Vasu S. Cardiotoxicity risk factors with immune checkpoint inhibitors. Cardiooncology 2022; 8:3. [PMID: 35277208 PMCID: PMC8915459 DOI: 10.1186/s40959-022-00130-5] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [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: 06/10/2021] [Accepted: 02/21/2022] [Indexed: 12/18/2022]
Abstract
Background Checkpoint-inhibitor immunotherapies have had a profound effect in the treatment of cancer by inhibiting down-regulation of T-cell response to malignancy. The cardiotoxic potential of these agents was first described in murine models and, more recently, in numerous clinical case reports of pericarditis, myocarditis, pericardial effusion, cardiomyopathy, and new arrhythmias. The objective of our study was to determine the frequency of and associated risk factors for cardiotoxic events in patients treated with immune checkpoint inhibitors. Methods Medical records of patients who underwent immunotherapy with durvalumab, ipilimumab, nivolumab, and pembrolizumab at Wake Forest Baptist Health were reviewed. We collected retrospective data regarding sex, cancer type, age, and cardiovascular disease risk factors and medications. We aimed to identify new diagnoses of heart failure, atrial fibrillation, ventricular fibrillation/tachycardia, myocarditis, and pericarditis after therapy onset. To assess the relationship between CVD risk factors and the number of cardiac events, a multivariate model was applied using generalized linear regression. Incidence rate ratios were calculated for every covariate along with the adjusted P-value. We applied a multivariate model using logistic regression to assess the relationship between CVD risk factors and mortality. Odds ratios were calculated for every covariate along with the adjusted P-value. Adjusted P-values were calculated using multivariable regression adjusting for other covariates. Results Review of 538 medical records revealed the following events: 3 ventricular fibrillation/tachycardia, 12 pericarditis, 11 atrial fibrillation with rapid ventricular rate, 0 myocarditis, 8 heart failure. Significant risk factors included female gender, African American race, and tobacco use with IRR 3.34 (95% CI 1.421, 7.849; P = 0.006), IRR 3.39 (95% CI 1.141, 10.055; P = 0.028), and IRR 4.21 (95% CI 1.289, 13.763; P = 0.017) respectively. Conclusions Our study revealed 34 significant events, most frequent being pericarditis (2.2%) and atrial fibrillation (2.0%) with strongest risk factors being female gender, African American race, and tobacco use. Patients who meet this demographic, particularly those with planned pembrolizumab treatment, may benefit from early referral to a cardio-oncologist. Further investigation is warranted on the relationship between CTLA-4 and PD-L1 expression and cardiac adverse events with ICIs, particularly for these subpopulations.
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Affiliation(s)
- Zachary L Brumberger
- Department of Internal Medicine, Wake Forest University School of Medicine, 1 Medical Center Boulevard, Winston-Salem, NC, 27157, USA
| | - Mary E Branch
- Department of Internal Medicine, Section On Cardiovascular Medicine, Wake Forest University School of Medicine, 1 Medical Center Boulevard, Winston-Salem, NC, 27157, USA
| | - Max W Klein
- Department of Internal Medicine, Wake Forest University School of Medicine, 1 Medical Center Boulevard, Winston-Salem, NC, 27157, USA.
| | - Austin Seals
- Department of Internal Medicine, Section On Cardiovascular Medicine, Wake Forest University School of Medicine, 1 Medical Center Boulevard, Winston-Salem, NC, 27157, USA
| | - Michael D Shapiro
- Department of Internal Medicine, Section On Cardiovascular Medicine, Wake Forest University School of Medicine, 1 Medical Center Boulevard, Winston-Salem, NC, 27157, USA
| | - Sujethra Vasu
- Department of Internal Medicine, Section On Cardiovascular Medicine, Wake Forest University School of Medicine, 1 Medical Center Boulevard, Winston-Salem, NC, 27157, USA
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Cioci A, Seals A, Upadhya B, Chein C, Gilbert O. THE IMPACT OF TELEHEALTH ON OUTCOMES IN CARDIOVASCULAR PATIENTS. J Am Coll Cardiol 2022. [PMCID: PMC8972611 DOI: 10.1016/s0735-1097(22)02983-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
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Chandrasekhar M, Jacob J, Seals A, Jao G, Pu M. IDENTIFICATION OF CARDIAC AMYLOIDOSIS USING MYOCARDIAL STRAIN IMAGING IN HYPERTROPHIC CARDIAC SUBSTRATES. J Am Coll Cardiol 2021. [DOI: 10.1016/s0735-1097(21)04663-5] [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: 11/27/2022]
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Smalling RW, Bode C, Kalbfleisch J, Sen S, Limbourg P, Forycki F, Habib G, Feldman R, Hohnloser S, Seals A. More rapid, complete, and stable coronary thrombolysis with bolus administration of reteplase compared with alteplase infusion in acute myocardial infarction. RAPID Investigators. Circulation 1995; 91:2725-32. [PMID: 7758177 DOI: 10.1161/01.cir.91.11.2725] [Citation(s) in RCA: 155] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/27/2023]
Abstract
BACKGROUND Early restoration and maintenance of normal (TIMI 3) blood flow during acute myocardial infarction is critical for optimal preservation of left ventricular function and survival. Recombinant plasminogen activator (r-PA, reteplase) is a nonglycosylated deletion mutant of wild-type tissue-type plasminogen activator (TPA) that has been shown to achieve more rapid and complete thrombolysis compared with other plasminogen activators in animal models. METHODS AND RESULTS The RAPID Trial was designed to test the hypothesis that bolus administration of one or more dosage regimens of r-PA was superior to standard-dose alteplase (TPA) in achieving infarct-related artery patency 90 minutes after initiation of treatment. Six hundred six patients with acute myocardial infarction were randomized to one of four treatment arms: (1) TPA 100 mg i.v. over 3 hours, (2) r-PA as a 15-MU single bolus, (3) r-PA as a 10-MU bolus followed by 5 MU 30 minutes later, or (4) r-PA as a 10-MU bolus followed by 10 MU 30 minutes later. Coronary arteriography was performed at 30, 60, and 90 minutes after initiation of treatment and at hospital discharge. The 10 + 10-MU r-PA group achieved better 90-minute and 5- to 14-day TIMI 3 flow (63% [CI, 55% to 71%] versus 49% [41% to 57%], P = .019, and 88% [82% to 94%] versus 71% [63% to 79%], P < .001, respectively) than the TPA group. The TIMI 3 flow in the 10 + 10-MU r-PA group at 60 minutes was equivalent to that in the TPA group at 90 minutes (51 versus 49%). Global ejection fraction and regional wall motion in the 10 + 10-MU r-PA group were superior to those of the TPA group at hospital discharge (53 +/- 1.3% versus 49 +/- 1.3%, P = .034; -2.19 +/- 0.12 versus -2.61 +/- 0.13 SD per chord, P = .02, respectively). The 15-MU and 10 + 5-MU r-PA patency and left ventricular function results were similar to those of the TPA and inferior to those of the 10 + 10-MU r-PA group. Bleeding complications were similar between the groups. CONCLUSIONS r-PA given as a double bolus of 10 + 10 MU achieves more rapid, complete, and sustained thrombolysis of the infarct-related artery than standard-dose TPA, without an apparent increased risk of complications. This was associated with improved global and regional left ventricular function at hospital discharge.
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Affiliation(s)
- R W Smalling
- Division of Cardiology, University of Texas Medical School at Houston 77030, USA
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