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Anderson JL, Knowlton KU, Thomas May H, Le VT, Lappe DL, Cripps S, Schwab L, Bair TL, Muhlestein JB. IMPACT OF ACTIVE VERSUS PASSIVE STATIN SELECTION FOR PRIMARY PREVENTION OF ATHEROSCLEROTIC CARDIOVASCULAR DISEASE (ASCVD): A REPORT FROM THE CORCAL VANGUARD TRIAL. J Am Coll Cardiol 2023. [DOI: 10.1016/s0735-1097(23)01743-6] [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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Muhlestein JB, Knowlton KU, Le VT, Lappe DL, May HT, Min DB, Johnson KM, Cripps ST, Schwab LH, Braun SB, Bair TL, Anderson JL. Coronary Artery Calcium Versus Pooled Cohort Equations Score for Primary Prevention Guidance: Randomized Feasibility Trial. JACC Cardiovasc Imaging 2021; 15:843-855. [PMID: 34922872 DOI: 10.1016/j.jcmg.2021.11.006] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [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: 06/24/2021] [Revised: 11/03/2021] [Accepted: 11/05/2021] [Indexed: 01/03/2023]
Abstract
OBJECTIVES This study sought to determine the feasibility of performing an extensive randomized outcomes trial comparing a coronary artery calcium (CAC)- versus a pooled cohort equations (PCE) risk score-based strategy for initiating statin therapy for primary atherosclerotic cardiovascular disease (ASCVD) prevention. BACKGROUND Statin therapy is standard for the primary prevention of ASCVD in subjects at increased risk. National guidelines recommend using the American College of Cardiology/American Heart Association PCE risk score to guide a statin recommendation. Whether guidance by a CAC score is equivalent or superior is unknown. METHODS CorCal (Effectiveness of a Proactive Cardiovascular Primary Prevention Strategy, With or Without the Use of Coronary Calcium Screening, in Preventing Future Major Adverse Cardiac Events) was a randomized trial consenting 601 patients without known ASCVD, diabetes, or prior statin therapy recruited from primary care clinics and randomized to CAC- (n = 302) or PCE guidance (n = 299) of statin initiation for primary prevention. Enrolled subjects and their physicians made final treatment decisions. Primary outcomes compared the proportion of statin recommendations received and subject adherence over 1 year between CAC- and PCE-arm subjects. Modeled medical costs, adverse effects, and low-density lipoprotein-cholesterol (LDL-C) were additional measures of interest. RESULTS Subjects were well matched, and 540 (89.9%) completed entry testing and received a protocol-based recommendation. A statin was recommended in 101 (35.9%) CAC- and 124 (47.9%) PCE-arm subjects (P = 0.005). Compared to PCE-based recommendations, CAC-arm subjects were reclassified from statin to no statin in 36.0% and from no statin to statin in 5.6% of cases, resulting in a total reclassification of 20.6%. Physicians accepted the study-dictated recommendation to start a statin in 88.1% of CAC- vs 75.0% of PCE-arm subjects (P = 0.01). Patient-reported adherence to this recommendation at 3 months was 62.2% vs 42.2%, respectively (P = 0.009). At 1 year, statin adherence remained superior, LDL-C levels were lower, estimated costs were similar or reduced in CAC subjects, and few events occurred. CONCLUSIONS CAC guidance may be a more efficient, personalized, cost-effective, and motivating approach to statin initiation and maintenance in primary prevention. This feasibility phase of CorCal should be regarded as hypothesis-generating with respect to cardiovascular outcomes, which is being addressed in a large, longer-term outcomes trial. (Effectiveness of a Proactive Cardiovascular Primary Prevention Strategy, With or Without the Use of Coronary Calcium Screening, in Preventing Future Major Adverse Cardiac Events [CorCal]; NCT03439267).
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Affiliation(s)
- Joseph B Muhlestein
- Intermountain Medical Center Heart Institute, Murray, Utah, USA; University of Utah School of Medicine, Salt Lake City, Utah, USA.
| | - Kirk U Knowlton
- Intermountain Medical Center Heart Institute, Murray, Utah, USA; University of Utah School of Medicine, Salt Lake City, Utah, USA
| | - Viet T Le
- Intermountain Medical Center Heart Institute, Murray, Utah, USA; Rocky Mountain University of Health Professions, Masters of Physician Assistant Studies Program, Provo, Utah, USA
| | - Donald L Lappe
- Intermountain Medical Center Heart Institute, Murray, Utah, USA; University of Utah School of Medicine, Salt Lake City, Utah, USA
| | - Heidi T May
- Intermountain Medical Center Heart Institute, Murray, Utah, USA
| | - David B Min
- Intermountain Medical Center Heart Institute, Murray, Utah, USA
| | - Kevin M Johnson
- Intermountain Medical Center Heart Institute, Murray, Utah, USA
| | | | - Lesley H Schwab
- Intermountain Medical Center Heart Institute, Murray, Utah, USA
| | - Shelbi B Braun
- Intermountain Medical Center Heart Institute, Murray, Utah, USA
| | - Tami L Bair
- Intermountain Medical Center Heart Institute, Murray, Utah, USA
| | - Jeffrey L Anderson
- Intermountain Medical Center Heart Institute, Murray, Utah, USA; University of Utah School of Medicine, Salt Lake City, Utah, USA
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Barker T, May HT, Doty JR, Lappe DL, Knowlton KU, Carlquist J, Konery K, Inglet S, Chisum B, Galenko O, Anderson JL, Muhlestein JB. Vitamin D supplementation protects against reductions in plasma 25-hydroxyvitamin D induced by open-heart surgery: Assess-d trial. Physiol Rep 2021; 9:e14747. [PMID: 33580636 PMCID: PMC7881347 DOI: 10.14814/phy2.14747] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [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: 11/24/2020] [Revised: 01/14/2021] [Accepted: 01/15/2021] [Indexed: 12/28/2022] Open
Abstract
Low vitamin D (serum or plasma 25‐hydroxyvitamin D (25(OH)D)) is a global pandemic and associates with a greater prevalence in all‐cause and cardiovascular mortality and morbidity. Open‐heart surgery is a form of acute stress that decreases circulating 25(OH)D concentrations and exacerbates the preponderance of low vitamin D in a patient population already characterized by low levels. Although supplemental vitamin D increases 25(OH)D, it is unknown if supplemental vitamin D can overcome the decreases in circulating 25(OH)D induced by open‐heart surgery. We sought to identify if supplemental vitamin D protects against the acute decrease in plasma 25(OH)D propagated by open‐heart surgery during perioperative care. Participants undergoing open‐heart surgery were randomly assigned (double‐blind) to one of two groups: (a) vitamin D (n = 75; cholecalciferol, 50,000 IU/dose) or (b) placebo (n = 75). Participants received supplements on three separate occasions: orally the evening before surgery and either orally or per nasogastric tube on postoperative days 1 and 2. Plasma 25(OH)D concentrations were measured at baseline (the day before surgery and before the first supplement bolus), after surgery on postoperative days 1, 2, 3, and 4, at hospital discharge (5–8 days after surgery), and at an elective outpatient follow‐up visit at 6 months. Supplemental vitamin D abolished the acute decrease in 25(OH)D induced by open‐heart surgery during postoperative care. Moreover, plasma 25(OH)D gradually increased from baseline to day 3 and remained significantly increased thereafter but plateaued to discharge with supplemental vitamin D. We conclude that perioperative vitamin D supplementation protects against the immediate decrease in plasma 25(OH)D induced by open‐heart surgery. ClinicalTrials.gov Identifier: NCT02460211.
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Affiliation(s)
- Tyler Barker
- Precision Genomics, Intermountain Healthcare, St. George, Utah, USA.,Nutrition and Integrative Physiology, University of Utah, Salt Lake City, Utah, USA
| | - Heidi T May
- Heart Institute, Intermountain Healthcare, Salt Lake City, Utah, USA
| | - John R Doty
- Heart Institute, Intermountain Healthcare, Salt Lake City, Utah, USA.,School of Medicine, University of Utah, Salt Lake City, Utah, USA
| | - Donald L Lappe
- Heart Institute, Intermountain Healthcare, Salt Lake City, Utah, USA.,School of Medicine, University of Utah, Salt Lake City, Utah, USA
| | - Kirk U Knowlton
- Heart Institute, Intermountain Healthcare, Salt Lake City, Utah, USA.,School of Medicine, University of Utah, Salt Lake City, Utah, USA
| | - John Carlquist
- Heart Institute, Intermountain Healthcare, Salt Lake City, Utah, USA
| | - Kristin Konery
- Heart Institute, Intermountain Healthcare, Salt Lake City, Utah, USA
| | - Shannon Inglet
- Heart Institute, Intermountain Healthcare, Salt Lake City, Utah, USA
| | - Ben Chisum
- Heart Institute, Intermountain Healthcare, Salt Lake City, Utah, USA
| | - Oxana Galenko
- Heart Institute, Intermountain Healthcare, Salt Lake City, Utah, USA
| | - Jeffrey L Anderson
- Heart Institute, Intermountain Healthcare, Salt Lake City, Utah, USA.,School of Medicine, University of Utah, Salt Lake City, Utah, USA
| | - Joseph B Muhlestein
- Heart Institute, Intermountain Healthcare, Salt Lake City, Utah, USA.,School of Medicine, University of Utah, Salt Lake City, Utah, USA
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Graves KG, May HT, Jacobs V, Knowlton KU, Muhlestein JB, Lappe DL, Anderson JL, Horne BD, Bunch TJ. CHA 2DS 2-VASc scores and Intermountain Mortality Risk Scores for the joint risk stratification of dementia among patients with atrial fibrillation. Heart Rhythm 2020; 16:3-9. [PMID: 30611392 DOI: 10.1016/j.hrthm.2018.10.018] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [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: 07/23/2018] [Indexed: 10/27/2022]
Abstract
BACKGROUND High CHA2DS2-VASc scores in atrial fibrillation (AF) patients are generally associated with increased risks of stroke and dementia. At lower CHA2DS2-VASc scores, there remains an unquantifiable cranial injury risk, necessitating an improved risk assessment method within these lower-risk groups. OBJECTIVE The purpose of this study was to determine whether sex-specific Intermountain Mortality Risk Scores (IMRS), a dynamic measures of systemic health that comprises commonly performed blood tests, can stratify dementia risk overall and among CHA2DS2-VASc score strata in AF patients. METHODS Female (n = 34,083) and male (n = 39,998) AF patients with no history of dementia were studied. CHA2DS2-VASc scores were assessed at the time of AF diagnosis and were stratified into scores of 0-1, 2, and ≥3. Within each CHA2DS2-VASc score stratum, patients were further stratified by IMRS categories of low, moderate, and high. Multivariable Cox hazard regression was used to determine dementia risk. RESULTS High-risk IMRS patients were generally older and had higher rates of hypertension, diabetes, heart failure, and prior stroke. Higher CHA2DS2-VASc score strata (≥3 vs ≤1: women, hazard ratio [HR] 7.77, 95% confidence interval [CI] 5.94-10.17, P < .001; men: HR 4.75, 95% CI 4.15-5.44, P < .001) and IMRS categories (high vs low: women, HR 3.09, 95% CI 2.71-3.51, P < .001; men, HR 2.70, 95% CI 2.39-3.06, P < .001) were predictive of dementia. When stratified by CHA2DS2-VASc scores, IMRS further identified risk in each stratum. CONCLUSION Both CHA2DS2-VASc scores and IMRS were independently associated with dementia incidence among AF patients. IMRS further stratified dementia risk among CHA2DS2-VASc score strata, particularly among those with lower CHA2DS2-VASc scores.
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Affiliation(s)
- Kevin G Graves
- Intermountain Heart Institute, Intermountain Medical Center, University of Utah, Salt Lake City, Utah; Department of Biomedical Informatics, University of Utah, Salt Lake City, Utah
| | - Heidi T May
- Intermountain Heart Institute, Intermountain Medical Center, University of Utah, Salt Lake City, Utah
| | - Victoria Jacobs
- Intermountain Heart Institute, Intermountain Medical Center, University of Utah, Salt Lake City, Utah
| | - Kirk U Knowlton
- Intermountain Heart Institute, Intermountain Medical Center, University of Utah, Salt Lake City, Utah
| | - Joseph B Muhlestein
- Intermountain Heart Institute, Intermountain Medical Center, University of Utah, Salt Lake City, Utah; Cardiology Division, Department of Internal Medicine, University of Utah, Salt Lake City, Utah
| | - Donald L Lappe
- Intermountain Heart Institute, Intermountain Medical Center, University of Utah, Salt Lake City, Utah; Cardiology Division, Department of Internal Medicine, University of Utah, Salt Lake City, Utah
| | - Jeffrey L Anderson
- Intermountain Heart Institute, Intermountain Medical Center, University of Utah, Salt Lake City, Utah; Cardiology Division, Department of Internal Medicine, University of Utah, Salt Lake City, Utah
| | - Benjamin D Horne
- Intermountain Heart Institute, Intermountain Medical Center, University of Utah, Salt Lake City, Utah; Department of Biomedical Informatics, University of Utah, Salt Lake City, Utah
| | - T Jared Bunch
- Intermountain Heart Institute, Intermountain Medical Center, University of Utah, Salt Lake City, Utah; Stanford University, Department of Internal Medicine, Palo Alto, California.
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Anderson JL, Le VT, Min DB, Biswas S, Minder CM, McCubrey RO, Knight S, Horne BD, Mason S, Lappe DL, Muhlestein JB, Knowlton KU. Comparison of Three Atherosclerotic Cardiovascular Disease Risk Scores With and Without Coronary Calcium for Predicting Revascularization and Major Adverse Coronary Events in Symptomatic Patients Undergoing Positron Emission Tomography-Stress Testing. Am J Cardiol 2020; 125:341-348. [PMID: 31806210 DOI: 10.1016/j.amjcard.2019.10.044] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/24/2019] [Revised: 10/16/2019] [Accepted: 10/28/2019] [Indexed: 11/19/2022]
Abstract
Atherosclerotic cardiovascular disease (ASCVD) is the most important cause of morbidity and mortality nationally and internationally. Improving ASCVD risk prediction is a high clinical priority. We sought to determine which of 3 ASCVD risk scores best predicts the need for revascularization and incident major adverse coronary events (MACE) in symptomatic patients at low-to-intermediate primary ASCVD risk referred for regadenoson-stress positron emission tomography (PET). Risk scores included the standard ASCVD pooled cohort equation (PCE), the multiethnic study of atherosclerosis (MESA) risk equation, and the coronary artery calcium score (CACS), obtained by PET. All qualifying patients in our institution at primary ASCVD risk referred for PET-stress tests in whom PCE, MESA, and CAC scores could be calculated were studied. CACS categories were: 0, 1 to 10, 11 to 299, 300 to 999, and 1000+. MESA and PCE scores were divided into quartiles. Logistic regression modeling was used to predict clinical/PET-driven early revascularization (within 90 days) and 1-year MACE (death, myocardial infarction, or any-time revascularization). A total of 981 patients (54% men, age 67 ± 10 years) qualified and were studied. Scores including CAC (MESA, CACS) performed better than PCE for predicting overall 1-year MACE (MESA p <0.001, CACS p = 0.012 vs PCE), which was driven by early revascularization. In conclusion, in a large population of patients at primary ASCVD risk referred for PET-stress testing, risk scores including CAC (CACS, MESA), which better predicted early revascularization and 1-year MACE, may be particularly useful in primary coronary risk assessment when considering whom to refer for PET-stress testing.
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Affiliation(s)
- Jeffrey L Anderson
- Intermountain Medical Center, Intermountain Heart Institute, Salt Lake City, Utah; University of Utah, School of Medicine, Salt Lake City, Utah.
| | - Viet T Le
- Rocky Mountain University of Health Professions, Provo, Utah
| | - David B Min
- Intermountain Medical Center, Intermountain Heart Institute, Salt Lake City, Utah
| | - Santanu Biswas
- Intermountain Medical Center, Intermountain Heart Institute, Salt Lake City, Utah
| | - C Michael Minder
- Intermountain Medical Center, Intermountain Heart Institute, Salt Lake City, Utah
| | - Raymond O McCubrey
- Intermountain Medical Center, Intermountain Heart Institute, Salt Lake City, Utah
| | - Stacey Knight
- Intermountain Medical Center, Intermountain Heart Institute, Salt Lake City, Utah; University of Utah, School of Medicine, Salt Lake City, Utah
| | - Benjamin D Horne
- Intermountain Medical Center, Intermountain Heart Institute, Salt Lake City, Utah; University of Utah, School of Medicine, Salt Lake City, Utah
| | - Steve Mason
- Intermountain Medical Center, Intermountain Heart Institute, Salt Lake City, Utah
| | - Donald L Lappe
- Intermountain Medical Center, Intermountain Heart Institute, Salt Lake City, Utah; University of Utah, School of Medicine, Salt Lake City, Utah
| | - Joseph B Muhlestein
- Intermountain Medical Center, Intermountain Heart Institute, Salt Lake City, Utah; University of Utah, School of Medicine, Salt Lake City, Utah
| | - Kirk U Knowlton
- Intermountain Medical Center, Intermountain Heart Institute, Salt Lake City, Utah; University of Utah, School of Medicine, Salt Lake City, Utah
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Anderson JL, Jacobs V, May HT, Bair TL, Benowitz BA, Lappe DL, Muhlestein JB, Knowlton KU, Bunch TJ. Free thyroxine within the normal reference range predicts risk of atrial fibrillation. J Cardiovasc Electrophysiol 2019; 31:18-29. [DOI: 10.1111/jce.14183] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [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: 03/29/2019] [Revised: 07/11/2019] [Accepted: 07/14/2019] [Indexed: 12/15/2022]
Affiliation(s)
- Jeffrey L. Anderson
- Intermountain Medical CenterIntermountain Heart Institute Salt Lake City Utah
- School of MedicineUniversity of Utah Salt Lake City Utah
| | - Victoria Jacobs
- Intermountain Medical CenterIntermountain Heart Institute Salt Lake City Utah
| | - Heidi T. May
- Intermountain Medical CenterIntermountain Heart Institute Salt Lake City Utah
- School of MedicineUniversity of Utah Salt Lake City Utah
| | - Tami L. Bair
- Intermountain Medical CenterIntermountain Heart Institute Salt Lake City Utah
| | - Barry A. Benowitz
- School of MedicineUniversity of Utah Salt Lake City Utah
- EndocrinologyLDS Hospital Salt Lake City Utah
| | - Donald L. Lappe
- Intermountain Medical CenterIntermountain Heart Institute Salt Lake City Utah
| | - Joseph B. Muhlestein
- Intermountain Medical CenterIntermountain Heart Institute Salt Lake City Utah
- School of MedicineUniversity of Utah Salt Lake City Utah
| | - Kirk U. Knowlton
- Intermountain Medical CenterIntermountain Heart Institute Salt Lake City Utah
- School of MedicineUniversity of Utah Salt Lake City Utah
| | - T. Jared Bunch
- Intermountain Medical CenterIntermountain Heart Institute Salt Lake City Utah
- Department of MedicineStanford University Stanford California
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Anderson JL, Jacobs V, May HT, Bair TL, Benowitz BA, Lappe DL, Muhlestein JB, Knowlton KU. P1536Does free thyroxine (fT4) predict risk of atherosclerotic cardiovascular disease (ASCVD)? Eur Heart J 2019. [DOI: 10.1093/eurheartj/ehz748.0298] [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: 11/13/2022] Open
Abstract
Abstract
Background
Thyroid hormones are associated with arrhythmic risk, but their relationship to ASCVD is unclear. The Rotterdam Study* reported associations of higher fT4 and lower thyroid stimulating hormone (TSH) levels with ASCVD, including within the euthyroid range. Free T3 (fT3) was not assessed.
Methods
We tested whether fT4, fT3, and TSH levels were associated with ASCVD in Intermountain Healthcare. All patients >18 y old with an fT4 level in the electronic medical record database were included. The hormone reference ranges were divided into quartiles (Q), and associations with prevalent and incident ASCVD were assessed by multivariable regression and trend tests.
Results
A total of 212,202 patients (age = 64.4±11.2 y; 66.6% women) were included and followed for 6.1±4.4 y. Of these, 8.3%, 86.6%, and 5.1% had fT4 levels below, within, and above the reference range. CAD was prevalent in 18.9% of fT4 Q1 patients. The adjusted odds ratio (OR) for coronary artery disease (CAD) increased through (Q4/Q1 OR=1.36) and beyond (High/Q1 OR=1.71) the normal range, p-trend<0.001 (Table). Smaller incremental risks were noted for fT3 (Q4/Q1 OR=1.13; High/Q1 OR=1.25). The frequencies of incident MI (Q1=2.5%) and stroke (Q1=5.4%) were low and did not show a concentration-related risk gradient. Incident all-cause death (Q1=24.3%) increased slightly for Q4 and high fT4 (OR=1.05, 1.06) but not fT3; death also increased with low fT4 (OR=1.28). TSH showed no consistent gradient within the normal range for prevalent or incident events; however, mortality increased with both high and low TSH.
Thyroid Hormone Levels and Prevalent CAD Prevalent CAD (adjusted OR) Low Normal Q1 Normal Q2 Normal Q3 Normal Q4 High fT4 (n=212,202) OR=1.08, p=0.02 OR=1.00 referent OR=1.11, p<0.001 OR=1.21, p<0.001 OR=1.36, p<0.001 OR=1.71, p<0.001 fT3 (n=30,200) OR=1.12, p<0.001 OR=1.00 referent OR=0.98, p=0.61 OR=1.02, p=0.53 OR=1.13, p<0.001 OR=1.25, p<0.001 TSH (n=183,227) OR=1.39, p<0.001 OR=1.00 referent OR=0.93, p=0.42 OR=0.88, p=0.15 OR=0.92, p=0.35 OR=1.73, p<0.001 Reference Q 1–4 are: fT4: 0.75–0.90; 0.91–1.01; 2.02–1.14; 1.15–1.50 ng/dL; TSH: 0.54–1.30; 1.31–2.04; 2.05–3.68; 3.69–6.80 uIU/mL; fT3: 2.40–2.60; 2.70–2.80; 2.90–3.10; 3.20–4.20 pg/dL.
Conclusions
Consistent with the Rotterdam Study, we found an increase in prevalent CAD with increasing fT4 levels within and beyond the normal range and, uniquely, a more modest relationship with fT3. We could not confirm a normal-range relationship between hormone levels and incident events or between TSH and prevalent disease. The relationship of fT4 levels to ASCVD is intriguing, is deserving of further study, and may have important implications for ASCVD prevention.
*A Bano, et-al. Circ Res 2017; 121:1397–1400
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Affiliation(s)
- J L Anderson
- Intermountain Medical Center, University of Utah School of Medicine, Salt Lake City, United States of America
| | - V Jacobs
- Intermountain Medical Center, Salt Lake City, United States of America
| | - H T May
- Intermountain Medical Center, Salt Lake City, United States of America
| | - T L Bair
- Intermountain Medical Center, Salt Lake City, United States of America
| | - B A Benowitz
- Intermountain Medical Center, Salt Lake City, United States of America
| | - D L Lappe
- Intermountain Medical Center, Salt Lake City, United States of America
| | - J B Muhlestein
- Intermountain Medical Center, University of Utah School of Medicine, Salt Lake City, United States of America
| | - K U Knowlton
- Intermountain Medical Center, Salt Lake City, United States of America
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Muhlestein JB, May HT, Galenko O, Knowlton KU, Otvos JD, Connelly MA, Lappe DL, Anderson JL. GlycA and hsCRP are independent and additive predictors of future cardiovascular events among patients undergoing angiography: The intermountain heart collaborative study. Am Heart J 2018; 202:27-32. [PMID: 29803983 DOI: 10.1016/j.ahj.2018.04.003] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/05/2017] [Accepted: 04/02/2018] [Indexed: 12/26/2022]
Abstract
BACKGROUND GlycA is an inflammatory marker that is raised in patients with cardiometabolic diseases and associated with cardiovascular (CV) events. We sought to determine if GlycA adds independent value to hsCRP for CV risk prediction. METHODS Patients in the Intermountain Heart Collaborative Study who underwent coronary angiography and had plasma GlycA and hsCRP levels were studied (n = 2996). Patients were followed for 7.0 ± 2.8 years. GlycA and hsCRP were moderately correlated (r = 0.46, P < .0001). GlycA and hsCRP concentrations were stratified into high and low categories by their median values. Multivariable cox hazard regression was utilized to determine the associations of GlycA quartiles, as well as high and low categories of GlycA and hsCRP, with major adverse cardiovascular events (MACE) defined as the composite of death, myocardial infarction (MI), heart failure (HF) hospitalization, and stroke. RESULTS The highest GlycA quartile was associated with future MACE [HR: 1.43; 95% CI: 1.22-1.69; P < .0001]. Patients with high GlycA and high hsCRP had more diabetes, hyperlipidemia, hypertension, HF, renal failure and MI, but not coronary artery disease. High GlycA and hsCRP (H/H) versus low GlycA and hsCRP (L/L) was associated with MACE, death and HF hospitalization, but not MI or stroke. Combined MACE rates were 33.5%, 41.3%, 35.7% and 49.1% for L/L, L/H, H/L and H/H categories of GlycA/hsCRP, respectively (P-trend < .0001). The interaction between GlycA and hsCRP was significant for the outcome of death (P = .03). CONCLUSION In this study, levels of GlycA and hsCRP were independent and additive markers of risk for MACE, death and HF hospitalization.
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Affiliation(s)
- Joseph B Muhlestein
- Intermountain Medical Center, Murray, UT; University of Utah, Salt Lake City, UT.
| | | | | | - Kirk U Knowlton
- Intermountain Medical Center, Murray, UT; University of California San Diego, San Diego, CA
| | - James D Otvos
- Laboratory Corporation of America Holdings (LabCorp), Morrisville, NC
| | | | | | - Jeffrey L Anderson
- Intermountain Medical Center, Murray, UT; University of Utah, Salt Lake City, UT
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Knight S, Min DB, Le VT, Meredith KG, Dhar R, Biswas S, Jensen KR, Mason SM, Ethington JD, Lappe DL, Muhlestein JB, Anderson JL, Knowlton KU. Implementation of a cardiac PET stress program: comparison of outcomes to the preceding SPECT era. JCI Insight 2018; 3:120949. [PMID: 29720565 DOI: 10.1172/jci.insight.120949] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [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: 03/07/2018] [Accepted: 04/04/2018] [Indexed: 11/17/2022] Open
Abstract
BACKGROUND Cardiac positron emission testing (PET) is more accurate than single photon emission computed tomography (SPECT) at identifying coronary artery disease (CAD); however, the 2 modalities have not been thoroughly compared in a real-world setting. We conducted a retrospective analysis of 60-day catheterization outcomes and 1-year major adverse cardiovascular events (MACE) after the transition from a SPECT- to a PET-based myocardial perfusion imaging (MPI) program. METHODS MPI patients at Intermountain Medical Center from January 2011-December 2012 (the SPECT era, n = 6,777) and January 2014-December 2015 (the PET era, n = 7,817) were studied. Outcomes studied were 60-day coronary angiography, high-grade obstructive CAD, left main/severe 3-vessel disease, revascularization, and 1-year MACE-revascularization (MACE-revasc; death, myocardial infarction [MI], or revascularization >60 days). RESULTS Patients were 64 ± 13 years old; 54% were male and 90% were of European descent; and 57% represented a screening population (no prior MI, revascularization, or CAD). During the PET era, compared with the SPECT era, a higher percentage of patients underwent coronary angiography (13.2% vs. 9.7%, P < 0.0001), had high-grade obstructive CAD (10.5% vs. 6.9%, P < 0.0001), had left main or severe 3-vessel disease (3.0% vs. 2.3%, P = 0.012), and had coronary revascularization (56.7% vs. 47.1%, P = 0.0001). Similar catheterization outcomes were seen when restricted to the screening population. There was no difference in 1-year MACE-revasc (PET [5.8%] vs. SPECT [5.3%], P = 0.31). CONCLUSIONS The PET-based MPI program resulted in improved identification of patients with high-grade obstructive CAD, as well as a larger percentage of revascularization, thus resulting in fewer patients undergoing coronary angiography without revascularization. FUNDING This observational study was funded using internal departmental funds.
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Affiliation(s)
- Stacey Knight
- Intermountain Heart Institute, Intermountain Medical Center, Murray, Utah, USA.,Department of Internal Medicine, University of Utah, Salt Lake City, Utah, USA
| | - David B Min
- Intermountain Heart Institute, Intermountain Medical Center, Murray, Utah, USA
| | - Viet T Le
- Intermountain Heart Institute, Intermountain Medical Center, Murray, Utah, USA.,Rocky Mountain University of Health Professions Physician Assistant Program, Provo, Utah, USA
| | - Kent G Meredith
- Intermountain Heart Institute, Intermountain Medical Center, Murray, Utah, USA
| | - Ritesh Dhar
- Intermountain Heart Institute, Intermountain Medical Center, Murray, Utah, USA
| | - Santanu Biswas
- Intermountain Heart Institute, Intermountain Medical Center, Murray, Utah, USA
| | - Kurt R Jensen
- Intermountain Heart Institute, Intermountain Medical Center, Murray, Utah, USA
| | - Steven M Mason
- Intermountain Heart Institute, Intermountain Medical Center, Murray, Utah, USA
| | | | - Donald L Lappe
- Intermountain Heart Institute, Intermountain Medical Center, Murray, Utah, USA.,Department of Internal Medicine, University of Utah, Salt Lake City, Utah, USA
| | - Joseph B Muhlestein
- Intermountain Heart Institute, Intermountain Medical Center, Murray, Utah, USA.,Department of Internal Medicine, University of Utah, Salt Lake City, Utah, USA
| | - Jeffrey L Anderson
- Intermountain Heart Institute, Intermountain Medical Center, Murray, Utah, USA.,Department of Internal Medicine, University of Utah, Salt Lake City, Utah, USA
| | - Kirk U Knowlton
- Intermountain Heart Institute, Intermountain Medical Center, Murray, Utah, USA
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Mason S, Osborn JS, Dhar R, Tonkin A, Ethington JD, Le V, Benuzillo J, Lappe DL, Knowlton KU, Bunch TJ, Anderson JL. Real world MRI experience with nonconditional and conditional cardiac rhythm devices after MagnaSafe. J Cardiovasc Electrophysiol 2017; 28:1468-1474. [DOI: 10.1111/jce.13351] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [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: 07/20/2017] [Revised: 08/10/2017] [Accepted: 08/14/2017] [Indexed: 11/27/2022]
Affiliation(s)
- Steve Mason
- Intermountain Medical Center Heart Institute; Salt Lake City UT USA
| | | | - Ritesh Dhar
- Intermountain Medical Center Heart Institute; Salt Lake City UT USA
| | - Allison Tonkin
- Intermountain Medical Center; Department of Radiology; Salt Lake City UT USA
| | | | - Viet Le
- Intermountain Medical Center Heart Institute; Salt Lake City UT USA
| | - Jose Benuzillo
- Intermountain Medical Center Heart Institute; Salt Lake City UT USA
| | - Donald L. Lappe
- Intermountain Medical Center Heart Institute; Salt Lake City UT USA
| | - Kirk U. Knowlton
- Intermountain Medical Center Heart Institute; Salt Lake City UT USA
- Department of Internal Medicine; University of Utah School of Medicine; Salt Lake City UT USA
| | - T. Jared Bunch
- Intermountain Medical Center Heart Institute; Salt Lake City UT USA
| | - Jeffrey L. Anderson
- Intermountain Medical Center Heart Institute; Salt Lake City UT USA
- Department of Internal Medicine; University of Utah School of Medicine; Salt Lake City UT USA
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11
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Muhlestein JB, Lappe DL, Anderson JL, Muhlestein JB, Budge D, May HT, Bennett ST, Bair TL, Horne BD. Both initial red cell distribution width (RDW) and change in RDW during heart failure hospitalization are associated with length of hospital stay and 30-day outcomes. Int J Lab Hematol 2017; 38:328-37. [PMID: 27121354 DOI: 10.1111/ijlh.12490] [Citation(s) in RCA: 31] [Impact Index Per Article: 4.4] [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: 11/24/2015] [Accepted: 02/12/2016] [Indexed: 01/12/2023]
Abstract
INTRODUCTION We examined the predictive ability of red cell distribution width (RDW) and the change in RDW during hospitalization (ΔRDW) for length of stay (LOS) and 30-day outcomes after heart failure (HF) inpatient stay. METHODS Electronic query of Intermountain Healthcare medical records identified patients (N = 6414) with a primary diagnosis of HF who were discharged between 2004 and 2013, had RDW measured within 24 h after admission, and had RDW tested at least once more during the same hospitalization. ΔRDW was defined as the last RDW within 24 h prior to discharge minus the first RDW. RESULTS Median LOS by initial RDW quartiles was Q1: 3.0, Q2: 3.1, Q3: 3.7, and Q4: 4.0 days (P-trend<0.001), and by ΔRDW quartiles was Q1: 4.1, Q2: 3.4, Q3: 3.6, and Q4: 4.7 days (P-trend<0.001). Both initial RDW (16.8 ± 2.8% vs. 16.3 ± 2.7%, P < 0.001) and ΔRDW (0.21 ± 1.09% vs. 0.14 ± 1.04%, P = 0.039) predicted 30-day readmission vs. no readmit. For 30-day decedents vs. survivors, initial RDW was 17.3 ± 3.0% vs. 16.3 ± 2.6% (P < 0.001), while ΔRDW was +0.20 ± 1.14% vs. +0.14 ± 1.04% (P = 0.15). CONCLUSIONS Greater initial RDW and ΔRDW during HF hospitalization were associated with 30-day mortality, longer LOS, and 30-day all-cause readmission, suggesting both ΔRDW and initial RDW may aid in personalizing prognosis and treatment.
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Affiliation(s)
- J B Muhlestein
- Intermountain Heart Institute, Salt Lake City, UT, USA.,University of Utah, Department of Internal Medicine, Salt Lake City, UT, USA
| | - D L Lappe
- Intermountain Heart Institute, Salt Lake City, UT, USA
| | - J L Anderson
- Intermountain Heart Institute, Salt Lake City, UT, USA.,University of Utah, Department of Internal Medicine, Salt Lake City, UT, USA
| | - J B Muhlestein
- Intermountain Heart Institute, Salt Lake City, UT, USA.,University of Utah, Department of Internal Medicine, Salt Lake City, UT, USA
| | - D Budge
- Intermountain Heart Institute, Salt Lake City, UT, USA
| | - H T May
- Intermountain Heart Institute, Salt Lake City, UT, USA
| | - S T Bennett
- Intermountain Central Laboratory, Intermountain Medical Center, Salt Lake City, UT, USA.,Department of Pathology, University of Utah, Salt Lake City, UT, USA
| | - T L Bair
- Intermountain Heart Institute, Salt Lake City, UT, USA
| | - B D Horne
- Intermountain Heart Institute, Salt Lake City, UT, USA.,Genetic Epidemiology Division, Department of Internal Medicine, University of Utah, Salt Lake City, UT, USA
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12
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Affiliation(s)
| | - Donald L Lappe
- Intermountain Medical Center Heart Institute, Murray, Utah
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13
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Kwan AC, May HT, Cater G, Sibley CT, Rosen BD, Lima JAC, Rodriguez K, Lappe DL, Muhlestein JB, Anderson JL, Bluemke DA. Coronary artery plaque volume and obesity in patients with diabetes: the factor-64 study. Radiology 2014; 272:690-9. [PMID: 24754493 DOI: 10.1148/radiol.14140611] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
PURPOSE To determine the relationship between coronary plaque detected with coronary computed tomographic (CT) angiography and clinical parameters and cardiovascular risk factors in asymptomatic patients with diabetes. MATERIALS AND METHODS All patients signed institutional review board-approved informed consent forms before enrollment. Two hundred twenty-four asymptomatic diabetic patients (121 men; mean patient age, 61.8 years; mean duration of diabetes, 10.4 years) underwent coronary CT angiography. Total coronary artery wall volume in all three vessels was measured by using semiautomated software. The coronary plaque volume index (PVI) was determined by dividing the wall volume by the coronary length. The relationship between the PVI and cardiovascular risk factors was determined with multivariable analysis. RESULTS The mean PVI (±standard deviation) was 11.2 mm(2) ± 2.7. The mean coronary artery calcium (CAC) score (determined with the Agatston method) was 382; 67% of total plaque was noncalcified. The PVI was related to age (standardized β = 0.32, P < .001), male sex (standardized β = 0.36, P < .001), body mass index (BMI) (standardized β = 0.26, P < .001), and duration of diabetes (standardized β = 0.14, P = .03). A greater percentage of soft plaque was present in younger individuals with a shorter disease duration (P = .02). The soft plaque percentage was directly related to BMI (P = .002). Patients with discrepancies between CAC score and PVI rank quartiles had a higher percentage of soft and fibrous plaque (18.7% ± 3.3 vs 17.4% ± 3.5 [P = .008] and 52.2% ± 7.2 vs 47.2% ± 8.8 [P < .0001], respectively). CONCLUSION In asymptomatic diabetic patients, BMI was the primary modifiable risk factor that was associated with total and soft coronary plaque as assessed with coronary CT angiography.
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Affiliation(s)
- Alan C Kwan
- From the Department of Radiology and Imaging Sciences, National Institutes of Health Clinical Center, 10 Center Dr, Building 10/1C355, Bethesda, MD 20892 (A.C.K., G.C., C.T.S., K.R., D.A.B.); Intermountain Heart Institute, Intermountain Medical Center, Salt Lake City, Utah (H.T.M., D.L.L., J.B.M., J.L.A.); Cardiology Division, Department of Medicine, Johns Hopkins University, Baltimore, Md (B.D.R., J.A.C.L.); and Cardiology Division, University of Utah, Salt Lake City, Utah (D.L.L., J.B.M., J.L.A.)
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14
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Bunch TJ, May HT, Bair TL, Weiss JP, Crandall BG, Osborn JS, Mallender C, Anderson JL, Muhlestein BJ, Lappe DL, Day JD. Atrial fibrillation ablation patients have long-term stroke rates similar to patients without atrial fibrillation regardless of CHADS2 score. Heart Rhythm 2013; 10:1272-7. [DOI: 10.1016/j.hrthm.2013.07.002] [Citation(s) in RCA: 90] [Impact Index Per Article: 8.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/02/2013] [Indexed: 10/26/2022]
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15
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Bunch TJ, Horne BD, Asirvatham SJ, Day JD, Crandall BG, Weiss JP, Osborn JS, Anderson JL, Muhlestein JB, Lappe DL, Pope CA. Atrial fibrillation hospitalization is not increased with short-term elevations in exposure to fine particulate air pollution. Pacing Clin Electrophysiol 2012; 34:1475-9. [PMID: 21895725 DOI: 10.1111/j.1540-8159.2011.03200.x] [Citation(s) in RCA: 33] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/01/2022]
Abstract
BACKGROUND Previous studies have observed that short-term exposure to elevated concentrations of particulate matter (PM) air pollution increases risk of acute ischemic heart disease events and heart failure hospitalization, alters cardiac autonomic function, and increases risk of arrhythmias. This study explored the potential associations between short-term elevations in PM exposure and atrial fibrillation (AF). METHODS AND RESULTS A case-crossover study design was used to explore associations between fine PM (PM2.5, particles with an aerodynamic diameter ≤2.5 μm) and 10,457 AF hospitalizations from 1993 to 2008 of patients who lived on Utah’s Wasatch Front. Patients were hospitalized at Intermountain Healthcare facilities with a primary diagnosis of AF. Concurrent day exposure and cumulative lagged exposures for up to 21 days were explored and the data were stratified by sex, age, and previous or subsequent admission for myocardial infarction. Although the estimated associations between PM2.5 and AF hospitalizations for the various lag structures and strata were consistently positive suggestive of risk, they were not statistically significant and they were extremely small compared to previously observed associations with ischemic heart disease events and heart failure hospitalizations. Further, we observed no additive risk between PM2.5 and AF hospitalization in those with respiratory disease or sleep apnea. CONCLUSIONS Unlike previously observed associations with ischemic heart disease events and heart failure hospitalizations using similar study design and approaches, this study found that hospitalization for AF was not significantly associated with elevations in short-term exposure to fine PM air pollution.
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Affiliation(s)
- T Jared Bunch
- Intermountain Heart Rhythm Specialists, Intermountain Medical Center, Murray, Utah 84107, USA.
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16
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Bunch TJ, May HT, Bair TL, Crandall BG, Weiss JP, Osborn JS, Anderson JL, Muhlestein JB, Horne BD, Lappe DL, Day JD. Trends in early and late mortality in patients undergoing coronary catheterization for myocardial infarction: implications on observation periods and risk factors to determine ICD candidacy. Heart Rhythm 2011; 8:1460-6. [DOI: 10.1016/j.hrthm.2011.03.052] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/07/2011] [Accepted: 03/23/2011] [Indexed: 10/18/2022]
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17
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Bunch TJ, Crandall BG, Weiss JP, May HT, Bair TL, Osborn JS, Anderson JL, Muhlestein JB, Horne BD, Lappe DL, Day JD. Patients Treated with Catheter Ablation for Atrial Fibrillation Have Long-Term Rates of Death, Stroke, and Dementia Similar to Patients Without Atrial Fibrillation. J Cardiovasc Electrophysiol 2011; 22:839-45. [PMID: 21410581 DOI: 10.1111/j.1540-8167.2011.02035.x] [Citation(s) in RCA: 285] [Impact Index Per Article: 21.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Affiliation(s)
- T Jared Bunch
- Intermountain Heart Rhythm Specialists Department of Cardiology, Intermountain Medical Center, Murray, Utah 84107, USA.
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18
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Zakaria KS, Sibley CT, Vavere AL, Bluemke DA, Ahmed R, Niinuma H, Lima JAC, Lappe DL, Anderson JL, Muhlestein JB. CORONARY CALCIUM SCORE AND CLINICAL RISK FACTORS FAIL TO PREDICT THE BURDEN OF CORONARY ATHEROSCLEROSIS IN ASYMPTOMATIC DIABETIC PATIENTS: THE FACTOR 64 STUDY. J Am Coll Cardiol 2010. [DOI: 10.1016/s0735-1097(10)60633-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: 10/19/2022]
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19
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Bunch TJ, Weiss JP, Crandall BG, May HT, Bair TL, Osborn JS, Anderson JL, Lappe DL, Muhlestein JB, Nelson J, Day JD. Long-Term Clinical Efficacy and Risk of Catheter Ablation for Atrial Fibrillation in Octogenarians. Pacing and Clinical Electrophysiology 2010; 33:146-52. [PMID: 19889181 DOI: 10.1111/j.1540-8159.2009.02604.x] [Citation(s) in RCA: 101] [Impact Index Per Article: 7.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Affiliation(s)
- T Jared Bunch
- Intermountain Heart Rhythm Specialists, Intermountain Medical Center, Eccles Outpatient Care Center, 5169 Cottonwood St., Murray, UT 84107, USA.
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20
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Smith MB, Christensen N, Wang S, Strohecker J, Day JD, Weiss JP, Crandall BG, Osborn JS, Anderson JL, Horne BD, Muhlestein JB, Lappe DL, Moss H, Oliver J, Viau K, Bunch TJ. Warfarin Knowledge in Patients with Atrial Fibrillation: Implications for Safety, Efficacy, and Education Strategies. Cardiology 2010; 116:61-9. [DOI: 10.1159/000314936] [Citation(s) in RCA: 45] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/21/2009] [Accepted: 03/01/2010] [Indexed: 11/19/2022]
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21
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Bunch TJ, Weiss JP, Crandall BG, May HT, Bair TL, Osborn JS, Anderson JL, Muhlestein JB, Horne BD, Lappe DL, Day JD. Atrial fibrillation is independently associated with senile, vascular, and Alzheimer's dementia. Heart Rhythm 2009; 7:433-7. [PMID: 20122875 DOI: 10.1016/j.hrthm.2009.12.004] [Citation(s) in RCA: 274] [Impact Index Per Article: 18.3] [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] [Received: 09/03/2009] [Accepted: 12/03/2009] [Indexed: 12/31/2022]
Abstract
BACKGROUND The aging population has resulted in more patients living with cardiovascular disease, such as atrial fibrillation (AF). Recent focus has been placed on understanding the long-term consequences of chronic cardiovascular disease, such as a potential increased risk of dementia. OBJECTIVE This study sought to determine whether there is an association between AF and dementia and whether their coexistence is an independent marker of risk. METHODS A total of 37,025 consecutive patients from the large ongoing prospective Intermountain Heart Collaborative Study database were evaluated and followed up for a mean of 5 years for the development of AF and dementia. Dementia was sub-typed into vascular (VD), senile (SD), Alzheimer's (AD), and nonspecified (ND). RESULTS Of the 37,025 patients with a mean age of 60.6 +/- 17.9 years, 10,161 (27%) developed AF and 1,535 (4.1%) developed dementia (179 VD, 321 SD, 347 AD, 688 ND) during the 5-year follow-up. Patients with dementia were older and had higher rates of hypertension, coronary artery disease, renal failure, heart failure, and prior strokes. In age-based analysis, AF independently was significantly associated with all dementia types. The highest risk was in the younger group (<70). After dementia diagnosis, the presence of AF was associated with a marked increased risk of mortality (VD: hazard ratio [HR] = 1.38, P = .01; SD: HR = 1.41, P = .001; AD: HR = 1.45; ND: HR = 1.38, P <.0001). CONCLUSION AF was independently associated with all forms of dementia. Although dementia is strongly associated with aging, the highest risk of AD was in the younger group, in support of the observed association. The presence of AF also identified dementia patients at high risk of death.
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Affiliation(s)
- T Jared Bunch
- Intermountain Heart Rhythm Specialists, Intermountain Medical Center, Murray, Utah 84107, USA.
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22
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Bunch TJ, Day JD, Anderson JL, Horne BD, Muhlestein JB, Crandall BG, Weiss JP, Lappe DL, Asirvatham SJ. Frequency of helicobacter pylori seropositivity and C-reactive protein increase in atrial fibrillation in patients undergoing coronary angiography. Am J Cardiol 2008; 101:848-51. [PMID: 18328851 DOI: 10.1016/j.amjcard.2007.09.118] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/14/2007] [Revised: 09/26/2007] [Accepted: 09/26/2007] [Indexed: 11/16/2022]
Abstract
Atrial fibrillation (AF) is the most common rhythm disturbance seen in clinical practice. Evidence emerged that suggested inflammation was associated with risk of AF. Helicobacter pylori causes gastric and esophageal inflammation, as well as systemic and vascular inflammation. These local and systemic inflammatory effects may increase the risk of AF. Study patients were consecutive patients who underwent angiography for suspicion of coronary artery disease. Patients' AF status was determined by a search of hospital discharge summaries for diagnostic International Classification of Diseases, Ninth Revision codes for AF, assessment of previous electrocardiograms at the index and previous admissions to LDS Hospital (Salt Lake City, Utah), and search of the electrocardiographic database of LDS Hospital. In addition to routine laboratory studies, serum was analyzed to determine H pylori serostatus and index C-reactive protein (CRP) level. A total of 943 patients with known AF status were studied. Those with AF tended to be older (70.9 +/- 9.5 vs 63.9 +/- 10.7 years; p <0.001) and had a higher prevalence of congestive heart failure (28% vs 11%; p <0.001). In addition, patients with AF were more likely to be seropositive for H pylori in comparison to the seronegative group (65% vs 55%; p = 0.049). Mean CRP was similar between those with and without AF (2.2 +/- 2.7 vs 2.3 +/- 2.4 mg/dl; p = 0.79). There was no apparent association between H pylori serostatus and CRP. Multivariate predictors of AF included age (hazard ratio [HR] 1.07 per year, 95% confidence interval [CI] 1.04 to 1.10, p <0.0001) and heart failure (HR 2.87, 95% CI 1.59 to 5.18, p <0.0001). H pylori added to the model was marginally associated with AF (HR 1.53, 95% CI 0.95 to 2.47, p = 0.08) when not accounting for age. However, younger patients (<50 years) who were H pylori seropositive had a higher relative risk of AF (8%) versus those who were seronegative (0%). In comparison, older patients seropositive for H pylori had only a modest increased risk of AF (17.5% vs 15.4%; p = 0.11). In conclusion, these data showed a general association of H pylori and AF in patients with multiple cardiovascular risk factors. The association did not persist after accounting for other risk factors. Although older age was highly associated with AF risk in this population, H pylori was additive across 3 distinct age groups, with the highest risk conveyed in the younger cohort.
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Affiliation(s)
- T Jared Bunch
- Division of Cardiovascular Disease, Department of Internal Medicine, Mayo Clinic, Rochester, Minnesota, USA.
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23
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Day JD, Doshi RN, Belott P, Birgersdotter-Green U, Behboodikhah M, Ott P, Glatter KA, Tobias S, Frumin H, Lee BK, Merillat J, Wiener I, Wang S, Grogin H, Chun S, Patrawalla R, Crandall B, Osborn JS, Weiss JP, Lappe DL, Neuman S. Inductionless or Limited Shock Testing Is Possible in Most Patients With Implantable Cardioverter- Defibrillators/Cardiac Resynchronization Therapy Defibrillators. Circulation 2007; 115:2382-9. [PMID: 17470697 DOI: 10.1161/circulationaha.106.663112] [Citation(s) in RCA: 38] [Impact Index Per Article: 2.2] [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: 11/16/2022]
Abstract
Background—
Implantable cardioverter-defibrillators and cardiac resynchronization therapy defibrillators have relied on multiple ventricular fibrillation (VF) induction/defibrillation tests at implantation to ensure that the device can reliably sense, detect, and convert VF. The ASSURE Study (Arrhythmia Single Shock Defibrillation Threshold Testing Versus Upper Limit of Vulnerability: Risk Reduction Evaluation With Implantable Cardioverter-Defibrillator Implantations) is the first large, multicenter, prospective trial comparing vulnerability safety margin testing versus defibrillation safety margin testing with a single VF induction/defibrillation.
Methods and Results—
A total of 426 patients receiving an implantable cardioverter-defibrillator or cardiac resynchronization therapy defibrillator underwent vulnerability safety margin or defibrillation safety margin screening at 14 J in a randomized order. After this, patients underwent confirmatory testing, which required 2 VF conversions without failure at ≤21 J. Patients who passed their first 14-J and confirmatory tests, irrespective of the results of their second 14-J test, had their devices programmed to a 21-J shock for ventricular tachycardia (VT) or VF ≥200 bpm and were followed up for 1 year. Of 420 patients who underwent 14-J vulnerability safety margin screening, 322 (76.7%) passed. Of these, 317 (98.4%) also passed 21-J confirmatory tests. Of 416 patients who underwent 14-J defibrillation safety margin screening, 343 (82.5%) passed, and 338 (98.5%) also passed 21-J confirmatory tests. Most clinical VT/VF episodes (32 of 37, or 86%) were terminated by the first shock, with no difference in first shock success. In all observed cases in which the first shock was unsuccessful, subsequent shocks terminated VT/VF without complication.
Conclusions—
Although spontaneous episodes of fast VT/VF were limited, there was no difference in the odds of first shock efficacy between groups. Screening with vulnerability safety margin or defibrillation safety margin may allow for inductionless or limited shock testing in most patients.
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Affiliation(s)
- John D Day
- Utah Heart Clinic Arrhythmia Service, LDS Hospital, 324 10th Ave, #206, Salt Lake City, UT 84103, USA.
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24
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Meredith KG, Horne BD, Pearson RR, Maycock CA, Lappe DL, Anderson JL, Muhlestein JB. Comparison of effects of high (80 mg) versus low (20 mg) dose of simvastatin on C-reactive protein and lipoproteins in patients with angiographic evidence of coronary arterial narrowing. Am J Cardiol 2007; 99:149-53. [PMID: 17223409 DOI: 10.1016/j.amjcard.2006.07.079] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/02/2006] [Revised: 07/25/2006] [Accepted: 07/25/2006] [Indexed: 11/20/2022]
Abstract
Although previous studies have demonstrated that various "statins" decrease levels of high-sensitivity C-reactive protein (hs-CRP), the dose-response relation for lowering hs-CRP by the clinically important drug simvastatin compared with lipid lowering is unclear. A 16-week, randomized, double-blind study was performed in patients with stable coronary artery disease and high hs-CRP levels (>3 mg/L). Subjects were randomized to placebo, 20 mg of simvastatin, or 80 mg of simvastatin for 12 weeks. Those currently on a statin first underwent a 4-week washout. Of the 107 total patients randomized, 96 completed the trial, and 89 were able to be evaluated for efficacy. Changes in hs-CRP differed across simvastatin and placebo groups (change score +1.6 vs -0.6 mg/L, p = 0.004), but no dose response was observed when comparing 80 with 20 mg/day (-0.6 vs -0.5 mg/L, respectively). A strong dose response was observed for changes in total (p <0.01) and low-density lipoprotein (p <0.001) cholesterol. hs-CRP changes did not correlate with low-density lipoprotein changes. In conclusion, this randomized trial in patients with chronic stable coronary artery disease showed a strong dose response for simvastatin for total and low-density lipoprotein cholesterol lowering but not for hs-CRP.
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Affiliation(s)
- Kent G Meredith
- Cardiovascular Department, LDS Hospital, Division of Cardiology, University of Utah, Salt Lake City, Utah, USA
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25
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Bunch TJ, Nelson J, Foley T, Allison S, Crandall BG, Osborn JS, Weiss JP, Anderson JL, Nielsen P, Anderson L, Lappe DL, Day JD. Temporary esophageal stenting allows healing of esophageal perforations following atrial fibrillation ablation procedures. J Cardiovasc Electrophysiol 2006; 17:435-9. [PMID: 16643370 DOI: 10.1111/j.1540-8167.2006.00464.x] [Citation(s) in RCA: 105] [Impact Index Per Article: 5.8] [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: 11/28/2022]
Abstract
BACKGROUND Left atrial catheter ablation (LACA) has emerged as a successful method to eliminate atrial fibrillation (AF). Recent reports have described atrio-esophageal fistulas, often resulting in death, from this procedure. Temporary esophageal stenting is an established therapy for malignant esophageal disease. We describe the first case of successful temporary esophageal stenting for an esophageal perforation following LACA. CASE A 48-year-old man with symptomatic drug refractory lone AF underwent an uneventful LACA. Fifty-nine ablations with an 8-mm tip ablation catheter (30 seconds, 70 Watts, 55 degrees C), as guided by 3-D NavX mapping, were performed in the left atrium to isolate the pulmonary veins as well as a left atrial flutter and roof ablation line. In addition, complex atrial electrograms in AF and sites of vagal innervation were ablated. Two weeks later, he presented with sub-sternal chest pain, fever, and dysphagia. A chest CT showed a 3-mm esophageal perforation at the level of the left atrium with mediastinal soiling and no pericardial effusion. An urgent upper endoscopy with placement of a PolyFlex removable esophageal stent to seal off the esophago-mediastinal fistula was performed. After 3 weeks of i.v. antibiotics, naso-jejunal tube feedings, and esophageal stenting, the perforation resolved and the stent was removed. Over 18 months of follow-up, there have been no other complications, and he has returned to a physically active life and remains free from AF on previously ineffective anti-arrhythmic drugs. CONCLUSION Early diagnosis of esophageal perforations following LACA may allow temporary esophageal stenting with successful esophageal healing. Prompt chest CT scans with oral and i.v. contrast should be considered in any patient with sub-sternal chest pain or dysphagia following LACA.
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Affiliation(s)
- T Jared Bunch
- Division of Cardiovascular Disease, Department of Internal Medicine, Mayo Clinic, 200 First Street SW, Rochester, MN 55905, USA
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Day JD, Nelson J, Foley T, Allison S, Crandall BG, Osborn JS, Weiss JP, Anderson JL, Miyawaki K, Anderson L, Lappe DL. Temporary esophageal stenting allows healing of esophageal perforations following atrial fibrillation ablation procedures. Heart Rhythm 2005. [DOI: 10.1016/j.hrthm.2005.02.068] [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: 11/26/2022]
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27
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Sorensen SG, Casterella PJ, Muhlestein JB, Pearson RR, Horne BD, Raleigh L, Anderson JL, Lappe DL. 1019-206 Reduced adverse event rates after transcatheter closure of patent foramen ovale when using the amplatzer-PFO™ compared to the CardioSeal™ device. J Am Coll Cardiol 2004. [DOI: 10.1016/s0735-1097(04)91593-8] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
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28
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Jones HU, Muhlestein JB, Jones KW, Bair TL, Lavasani F, Sohrevardi M, Horne BD, Doty D, Lappe DL. Preoperative use of enoxaparin compared with unfractionated heparin increases the incidence of re-exploration for postoperative bleeding after open-heart surgery in patients who present with an acute coronary syndrome: clinical investigation and reports. Circulation 2002; 106:I19-22. [PMID: 12354703] [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] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/26/2023]
Abstract
BACKGROUND Enoxaparin has become an attractive therapy for use during acute coronary syndrome (ACS) because of its potential superior efficacy over unfractionated heparin (UFH), its longer activity, and its subcutaneous route of administration. However, because a significant number of patients presenting with ACS may be sent directly to open heart surgery while still on anticoagulation, it is important to understand any potential bleeding risks that may be associated with the use of enoxaparin under these circumstances. METHODS From 1998 to 2001, 1159 consecutive patients presenting with an acute coronary syndrome who received either UFH (n=1008) or enoxaparin (n=151) before proceeding to open heart surgery for urgent therapy during the same hospitalization were included in this study. Incidence of perioperative bleeding as evidenced by the units of blood products (packed red blood cells or platelets) transfused or the need for surgical re-exploration for postoperative bleeding was recorded. RESULTS Average age was 65+/-11 and 67+/-11 years for patients receiving UFH and enoxaparin, respectively (P=0.005). Seventy-five percent of those receiving UFH and 64% of those receiving enoxaparin (P<0.005) were males. After discharge, the incidence of rehospitalization for hemorrhage requiring return to surgery for re-exploration was 7.9% in the enoxaparin group and 3.7% in the UFH group (adjusted hazard ratio=2.6, P=0.03). The use of blood products did not differ between groups (UFH=2.7+/-6.5 U and enoxaparin=2.3+/-4.5 U; P=NS). CONCLUSION The preoperative use of enoxaparin compared with UFH in patients presenting with an ACS who undergo open-heart surgery during the same hospitalization is associated with a significantly increased incidence of re-exploration for postoperative bleeding. Further study is needed to understand the mechanism of this phenomenon and to develop appropriate guidelines to address this potentially important issue.
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Affiliation(s)
- Heath U Jones
- Cardiovascular Department, LDS Hospital, Salt Lake City, Utah 84143, USA
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Home BD, Muhlestein JB, Maycock CA, Carlquist JF, Lappe DL, Pearson RR, Renlund DG, Anderson JL. The intermountain risk model: predicting mortality by traditional and novel risk factors among patients with significant coronary disease. J Am Coll Cardiol 2002. [DOI: 10.1016/s0735-1097(02)82005-8] [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: 11/25/2022]
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30
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Duffin DC, Muhlestein JB, Allisson SB, Horne BD, Fowles RE, Sorensen SG, Revenaugh JR, Bair TL, Lappe DL. Femoral arterial puncture management after percutaneous coronary procedures: a comparison of clinical outcomes and patient satisfaction between manual compression and two different vascular closure devices. J Invasive Cardiol 2001; 13:354-62. [PMID: 11385148] [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] [Subscribe] [Scholar Register] [Indexed: 02/20/2023]
Abstract
BACKGROUND Vascular access site management is crucial to safe, efficient and comfortable diagnostic or interventional transfemoral percutaneous coronary procedures. Two new femoral access site closure devices, Perclose and Angio-Seal , have been proposed as alternative methods to manual compression (MC). We compared these two devices and tested them in reference to standard MC for safety, effectiveness and patient preference. METHODS Prospective demographic, peri-procedural, and late follow-up data for 1,500 patients undergoing percutaneous coronary procedures were collected from patients receiving femoral artery closure by MC (n = 469), Perclose (n = 492), or Angio-Seal (n = 539). Peri-procedural, post-procedural, and post-hospitalization endpoints were: 1) safety of closure method; 2) efficacy of closure method; and 3) patient satisfaction. RESULTS Patients treated with Angio-Seal experienced shorter times to hemostasis (p < 0.0001, diagnostic and interventional) and ambulation (diagnostic, p = 0.05; interventional, p < 0.0001) than those treated with Perclose. Those treated with Perclose experienced greater access site complications (Perclose vs. Angio-Seal, p = 0.008; Perclose vs. MC, p = 0.06). Patients treated with Angio-Seal reported greater overall satisfaction, better wound healing and lower discomfort (each vs. Perclose or vs. MC, all p < or = 0.0001). For diagnostic cath only, median post-procedural length of stay was reduced by Angio-Seal (Angio-Seal vs. MC, p < 0.0001; Angio-Seal vs. Perclose, p = 0.009). No difference was seen in length of stay for interventional cases. CONCLUSIONS Overall, Angio-Seal performed better than Perclose or MC in reducing time to ambulation and length of stay among patients undergoing diagnostic procedures. There was a higher rate of successful deployment and shorter time to hemostasis for Angio-Seal, and this was accomplished with no increase in bleeding complications throughout the follow-up. Additionally, Angio-Seal performed better than Perclose in exhibiting a superior 30-day patient satisfaction and patient assessment of wound healing with less discomfort.
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Affiliation(s)
- D C Duffin
- Division of Cardiology, LDS Hospital, 8th Avenue and C Street, Salt Lake City, Utah 84143, USA
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Wagoner LE, Taylor DO, Olsen SL, Bristow MR, O'Connell JB, Hammond EH, Lappe DL, Renlund DG. Cyclophosphamide in cardiac transplant recipients with frequent rejection: a six-year retrospective review. Clin Transplant 1996; 10:437-43. [PMID: 8930458] [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: 02/03/2023]
Abstract
Allograft rejection remains a major cause of morbidity and mortality. Cyclophosphamide, a nitrogen mustard, is a potent immunosuppressive agent with effects on both T- and B-lymphocytes, and thus may be effective in preventing further cellular and/or humoral rejection in cardiac transplant recipients with recurrent or recalcitrant rejection. We retrospectively reviewed the records of 320 surviving cardiac transplant recipients. Cyclophosphamide was substituted for azathioprine in 28 patients because of frequent allograft rejection. We then reviewed the rejection history of these 28 patients, specifically looking at rejection frequency, type (cellular, vascular or mixed), and treatment. Cyclophosphamide was substituted for azathioprine at an average of 8.4 +/- 2.8 months after transplantation. Despite a 56.0% reduction in prednisone dose (p < 0.001), at least a threefold reduction in rejection frequency (p < 0.001) was observed, while cyclosporine levels were unchanged. Twenty-eight percent of the patients did not experience even mild rejection after beginning therapy with cyclophosphamide, 55% had 1 or 2 subsequent mild or moderate rejection episodes, and only 17% had more than two subsequent episodes of mild or moderate rejection. Overall, the number of treated rejection episodes decreased from 0.37 episodes per patient month with azathioprine to 0.10 episodes per patient month on therapy with cyclophosphamide. Separating the patients into two groups based on the predominant rejection type (cellular vs. vascular) occurring at the time of cyclophosphamide substitution revealed a similar reduction in cellular and vascular rejection in each respective group. While white blood cell count decreased by 16%, cyclophosphamide was not discontinued in any patient due to leukopenia, and no change was noted in hematocrit. Cyclophosphamide appears to be safe and effective in maintenance immunosuppression and may reduce rejection frequency in some patients with frequently occurring allograft rejection without necessitating the augmentation of either corticosteroids or cyclosporine.
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Affiliation(s)
- L E Wagoner
- Division of Cardiology, University of Utah Health Sciences Center, LDS Hospital, Salt Lake City, USA
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Wagoner LE, Olsen SL, Bristow MR, O'Connell JB, Taylor DO, Lappe DL, Renlund DG. Cyclophosphamide as an alternative to azathioprine in cardiac transplant recipients with suspected azathioprine-induced hepatotoxicity. Transplantation 1993; 56:1415-8. [PMID: 8279012 DOI: 10.1097/00007890-199312000-00027] [Citation(s) in RCA: 15] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/29/2023]
Abstract
AZA has been reported to cause liver dysfunction in some recipients of solid organ transplants. To assess the safety and efficacy of cyclophosphamide in maintenance immunosuppression in the setting of AZA-induced liver dysfunction, we retrospectively reviewed the records of 320 surviving cardiac transplant recipients in Utah. Cyclophosphamide was substituted for AZA in 29 patients due to elevated liver enzymes. Patients were switched to cyclophosphamide 689 +/- 104 days after transplantation; total follow-up after initiation of cyclophosphamide was 540 +/- 56 days. The dose of cyclophosphamide after 2 and 6 months of cyclophosphamide therapy was 62 +/- 6 mg/day (0.8 +/- 0.1 mg/kg/day) and 48 +/- 5 mg/day (0.6 +/- 0.1 mg/kg/day), respectively, compared with 233 +/- 20 mg/day (2.9 +/- 0.2 mg/kg/day) of AZA. The substitution of cyclophosphamide for AZA was associated with a significant improvement in liver function tests. Liver enzymes decreased by up to 49% (P = 0.027), while serum bilirubin decreased by 58% (P < 0.001). Rejection frequency did not increase; neither corticosteroid nor CsA dosage was altered significantly after the substitution of cyclophosphamide. Significant bone marrow suppression was not observed; specifically, no significant change in white blood cell count or hematocrit occurred. Complications of treatment with cyclophosphamide were few; only 1 patient discontinued cyclophosphamide because of alopecia. We conclude that cyclophosphamide appears to be safe in maintenance immunosuppression, permitting the discontinuation of AZA in patients with AZA-induced hepatic dysfunction without necessitating the augmentation of either corticosteroids or CsA.
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Affiliation(s)
- L E Wagoner
- Division of Cardiology, University of Utah Health Sciences Center, LDS Hospital, Salt Lake City
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Ezekowitz MD, Alderson PO, Bulkley BH, Dwyer PN, Watkins L, Lappe DL, Greene HL, Becker LC. Isolated drainage of the superior vena cava into the left atrium in a 52-year-old man: a rare congenital malformation in the adult presenting with cyanosis, polycythemia, and an unsuccessful lung scan. Circulation 1978; 58:751-6. [PMID: 688585 DOI: 10.1161/01.cir.58.4.751] [Citation(s) in RCA: 31] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
This report describes a 52-year-old black male with the isolated finding of an anomalous superior vena cava draining into the left atrium. The patient presented with dizziness, mild cyanosis, polycythemia and normal cardiac and pulmonary findings. The first major diagnostic clue in this confusing clinical presentation was an unsuccessful lung perfusion scan in which intravenous tracer consistently bypassed the lungs. This appears to be the first adult presenting with this rare anomaly. This condition should be suspected if cyanosis, clubbing, and a "normal" cardiac examination coexist and if the more common pulmonary and hematological causes of this triad have been excluded.
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Abstract
Two patients with left atrial myxomas detected with one-dimensional echocardiographic studies were evaluated before and after surgery with real-time phased-array two-dimensional echocardiographic studies. This latter technique provided relatively quantitative information regarding the size, shape, and mobility of the tumor and its effect on cardiac function. In case 1, the two-dimensional echocardiogram showed a relatively immobile tumor measuring 3 x 4.5 cm in diameter in the left atrium only. At surgery a 2 x 4.5-cm myxoma that was attached to the left atrium by a broad-based short stalk was removed. In case 2, the left atrial mass appeared to be 3 x 4 cm in diameter, with much movement during the cardiac cycle. At surgery a 3 x 4-cm left atrial myxoma that was attached to the interatrial septum by a long stalk was removed. In both cases, masses in other cardiac chambers were excluded, the mitral valves were normal, and left ventricular function was normal, all of which were confirmed at surgery and by postoperative echocardiograms. In one patient the information obtained by two-dimensional echocardiographic studies was believed to be sufficient to preempt the need for cardiac catheterization. These cases illutstrate that this new noninvasive technique may provide sufficient quantitative preoperative detail in patients with left atrial tumors to obivate the risk and expense of caridac catheterization.
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Weiss JL, Brinker JA, Lappe DL, Rabson JL, Summer WR, Permutt S, Weisfeldt ML. Leftward septal displacement during right ventricular loading in man: Demonstration by two-dimensional echo. Am J Cardiol 1978. [DOI: 10.1016/0002-9149(78)90223-0] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Stern MD, Lappe DL, Bowen PD, Chimosky JE, Holloway GA, Keiser HR, Bowman RL. Continuous measurement of tissue blood flow by laser-Doppler spectroscopy. Am J Physiol 1977; 232:H441-8. [PMID: 556582 DOI: 10.1152/ajpheart.1977.232.4.h441] [Citation(s) in RCA: 73] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Abstract
Laser light scattered from tissue in vivo is broadened in line width as a result of the Doppler shift produced by moving red cells in the microcirculation. A feasibility study was carried out to demonstrate use of this effect to measure and monitor tissue blood flow. Light from a helium-neon laser illuminated a 1-mm area of tissue (human skin or rat renal cortex), and the backscattered light was detected with a photomultiplier. The spectrum of the Doppler beat notes was analyzed directly with a digital spectrum analyzer, or processed by analog circuitry to yield a flow parameter based on the root-mean-square Doppler line width. This parameter was compared with 133Xe washout in the skin of volunteers subjected to UV-induced erythema and the skin of volunteers subjected to UV-induced erythema and was found to vary in an approximately linear manner with skin blood flow. The laser instrument provided continuous monitoring of blood flow fluctuations, including the pulsatile component. The instrument was used to monitor flow in the outer cortex of the rat kidney during administration of norepinephrine, angiotensin, hydralazine, dextran, dopamine, nitroprusside, and angiotensin blocked by saralasin. Dynamic and steady-state responses were consistent with known pharmacology and renal physiology, and with the assumption that vasoconstrictor angiotensin II receptors in the kidney are accessible to blood-borne inhibitors. The laser-Doppler method is a promising tool for rapid monitoring of dynamic changes in tissue perfusion.
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Graber JD, Conti CR, Lappe DL, Ross RS. Effect of pacing-induced tachycardia and myocardial ischemia on ventricular pressure-velocity relationships in man. Circulation 1972; 46:74-83. [PMID: 5039826 DOI: 10.1161/01.cir.46.1.74] [Citation(s) in RCA: 18] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/13/2023]
Abstract
Ventricular function was evaluated in 18 patients prior to left ventriculography and selective coronary arteriography. Simultaneous left ventricular pressure (catheter-tip manometer) and dP/dt were recorded at resting heart rates and during tachycardia induced by right atrial pacing. Pressure-velocity curves were constructed from which V
max
and maximum measured contractile element velocity (max V
CE
) were obtained. V
max
and max V
CE
initially increased with pacing-induced tachycardia in 17 of the 18 patients. Eight patients developed evidence of myocardial ischemia during atrial pacing. During the period of myocardial ischemia there was a decrease in V
max
and max V
CE
in all eight patients despite constant or increasing heart rate. In the 10 patients who did not develop evidence of myocardial ischemia with pacing-induced tachycardia, V
max
and max V
CE
continued to increase or remained constant with increasing rate. Peak left ventricular dP/dt increased coincident with the onset of myocardial ischemia in six of eight patients despite a fall in V
max
and max V
CE
in all eight patients during the ischemic period. A highly significant difference was demonstrated between V
max
values of patients with normal ejection fractions and patients with low ejection fractions, both at rest and during pacing-induced tachycardia.
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