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Horne BD, Anderson JL, May HT, Le VT, Bair TL, Bennett ST, Knowlton KU, Muhlestein JB. Intermittent fasting and changes in clinical risk scores: Secondary analysis of a randomized controlled trial. Int J Cardiol Cardiovasc Risk Prev 2023; 19:200209. [PMID: 37727698 PMCID: PMC10505676 DOI: 10.1016/j.ijcrp.2023.200209] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 04/24/2023] [Revised: 07/28/2023] [Accepted: 09/07/2023] [Indexed: 09/21/2023]
Abstract
Background Intermittent fasting may increase longevity and lower cardiometabolic risk. This study evaluated whether fasting modifies clinical risk scores for mortality [i.e., Intermountain Mortality Risk Score (IMRS)] or chronic diseases [e.g., Pooled Cohort Risk Equations (PCRE), Intermountain Chronic Disease score (ICHRON)]. Methods and results Subjects (N = 71) completing the WONDERFUL trial were aged 21-70 years, had ≥1 metabolic syndrome criteria, elevated cholesterol, and no anti-diabetes medications, statins, or chronic diseases. The intermittent fasting arm underwent 24-h water-only fasting twice-per-week for 4 weeks and once-per-week for 22 weeks (26 weeks total). Analyses examined the IMRS change score at 26 weeks vs. baseline between intermittent fasting (n = 38) and ad libitum controls (n = 33), and change scores for PCRE, ICHRON, HOMA-IR, and a metabolic syndrome score (MSS). Age averaged 49 years; 65% were female. Intermittent fasting increased IMRS (0.78 ± 2.14 vs. controls: -0.61 ± 2.56; p = 0.010) but interacted with baseline IMRS (p-interaction = 0.010) to reduce HOMA-IR (but not MSS) more in subjects with higher baseline IMRS (median HOMA-IR change: fasters, -0.95; controls, +0.05) vs. lower baseline IMRS (-0.29 vs. -0.32, respectively). Intermittent fasting reduced ICHRON (-0.92 ± 2.96 vs. 0.58 ± 3.07; p = 0.035) and tended to reduce PCRE (-0.20 ± 0.22 vs. -0.14 ± 0.21; p = 0.054). Conclusions Intermittent fasting increased 1-year IMRS mortality risk, but decreased 10-year chronic disease risk (PCRE and ICHRON). It also reduced HOMA-IR more in subjects with higher baseline IMRS. Increased IMRS suggests fasting may elevate short-term mortality risk as a central trigger for myriad physiological responses that elicit long-term health improvements. Increased IMRS may also reveal short-term fasting-induced safety concerns.
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Affiliation(s)
- Benjamin D. Horne
- Intermountain Medical Center Heart Institute, Salt Lake City, UT, USA
- Division of Cardiovascular Medicine, Department of Medicine, Stanford University, Stanford, CA, USA
| | - Jeffrey L. Anderson
- Intermountain Medical Center Heart Institute, Salt Lake City, UT, USA
- Cardiology Division, Department of Internal Medicine, University of Utah, Salt Lake City, UT, USA
| | - Heidi T. May
- Intermountain Medical Center Heart Institute, Salt Lake City, UT, USA
| | - Viet T. Le
- Intermountain Medical Center Heart Institute, Salt Lake City, UT, USA
- Rocky Mountain University of Health Professions, Provo, UT, USA
| | - Tami L. Bair
- Intermountain Medical Center Heart Institute, Salt Lake City, UT, USA
| | - Sterling T. Bennett
- Intermountain Central Laboratory, Intermountain Medical Center, Salt Lake City, UT, USA
- Department of Pathology, University of Utah, Salt Lake City, UT, USA
| | - Kirk U. Knowlton
- Intermountain Medical Center Heart Institute, Salt Lake City, UT, USA
- Division of Cardiovascular Medicine, Department of Medicine, University of California San Diego, La Jolla, CA, USA
| | - Joseph B. Muhlestein
- Intermountain Medical Center Heart Institute, Salt Lake City, UT, USA
- Cardiology Division, Department of Internal Medicine, University of Utah, Salt Lake City, UT, USA
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McKellar SH, Harkness J, Reid BB, Sekaran NK, May HT, Whisenant BK. Residual or recurrent mitral regurgitation predicts mortality following transcatheter edge-to-edge mitral valve repair. JTCVS Open 2023; 16:191-206. [PMID: 38204616 PMCID: PMC10775131 DOI: 10.1016/j.xjon.2023.10.019] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 02/28/2023] [Revised: 09/26/2023] [Accepted: 10/04/2023] [Indexed: 01/12/2024]
Abstract
Objective Although regurgitant mitral valves can be repaired through surgical or transcatheter approaches, contemporary comparative outcomes are limited with the impact of residual and recurrent mitral regurgitation (MR) on clinical outcomes being poorly defined. We hypothesized that moderate (2+) or greater residual or recurrent (RR) MR-regardless of type of repair-predicts worse clinical outcomes. Methods Our institutional experience of 660 consecutive patients undergoing mitral valve repair (2015-2021) consisting of 393 surgical mitral valve repair (SMVr) and 267 transcatheter edge-to-edge mitral valve repair (TEER) was studied. The echocardiographic impact of RRMR (2+) following both SMVr and TEER on death and reintervention was evaluated. Results Patients averaged 67.8 ± 14.2 years (SMVr = 63.8 ± 13.3 vs 73.6 ± 13.6, P < .0001) and 62.1% were male. Baseline clinical and demographic data were vastly different between the 2 groups. Residual or recurrent 2+ or greater MR developed in 25% (n = 68) of patients who received TEER compared with 6% (n = 25) of SMVr (P < .0001). Reintervention (9.3% vs 2.4%, P = .002) and death (37.9% vs 10.4%, P < .0001) rates at 3-years were greater among the TEER group versus SMVr group. Given the heterogeneity in baseline characteristics and difference in survival, each cohort was analyzed separately, stratified by RRMR, using multivariable modeling to identify predictors of repeat reintervention and death. There were too few events of RRMR in the SMVr cohort for evaluation. For the TEER subgroups, we observed greater long-term mortality, but not reintervention among those with RRMR., Hypertension was the strongest predictor of death and obesity was for reintervention. Conclusions Patients undergoing SMVr and TEER are vastly different with respect to baseline patient characteristics and clinical outcomes, with patients who undergo TEER being much greater risk with poorer prognosis. Moderate or greater RRMR predicted worse long-term survival but not reintervention among patients who received TEER. Given the difference in survival among patients with RRMR following TEER, care must be taken to ensure that patients entering clinical trials and receiving TEER should have a high probability of achieving mild or less MR as seen in contemporary surgical results.
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Affiliation(s)
- Stephen H. McKellar
- Division of Cardiovascular Surgery, Intermountain Heart Institute, Intermountain Medical Center, Salt Lake City, Utah
| | - James Harkness
- Division of Cardiology, Intermountain Heart Institute, Intermountain Medical Center, Salt Lake City, Utah
| | - Bruce B. Reid
- Division of Cardiovascular Surgery, Intermountain Heart Institute, Intermountain Medical Center, Salt Lake City, Utah
| | - Nishant K. Sekaran
- Division of Cardiology, Intermountain Heart Institute, Intermountain Medical Center, Salt Lake City, Utah
| | - Heidi T. May
- Division of Cardiology, Intermountain Heart Institute, Intermountain Medical Center, Salt Lake City, Utah
| | - Brian K. Whisenant
- Division of Cardiology, Intermountain Heart Institute, Intermountain Medical Center, Salt Lake City, Utah
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Le VT, Knight S, Watrous JD, Najhawan M, Dao K, McCubrey RO, Bair TL, Horne BD, May HT, Muhlestein JB, Nelson JR, Carlquist JF, Knowlton KU, Jain M, Anderson JL. Higher docosahexaenoic acid levels lower the protective impact of eicosapentaenoic acid on long-term major cardiovascular events. Front Cardiovasc Med 2023; 10:1229130. [PMID: 37680562 PMCID: PMC10482040 DOI: 10.3389/fcvm.2023.1229130] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/25/2023] [Accepted: 07/26/2023] [Indexed: 09/09/2023] Open
Abstract
Introduction Long-chain omega-3 polyunsaturated fatty acids (OM3 PUFA) are commonly used for cardiovascular disease prevention. High-dose eicosapentaenoic acid (EPA) is reported to reduce major adverse cardiovascular events (MACE); however, a combined EPA and docosahexaenoic acid (DHA) supplementation has not been proven to do so. This study aimed to evaluate the potential interaction between EPA and DHA levels on long-term MACE. Methods We studied a cohort of 987 randomly selected subjects enrolled in the INSPIRE biobank registry who underwent coronary angiography. We used rapid throughput liquid chromatography-mass spectrometry to quantify the EPA and DHA plasma levels and examined their impact unadjusted, adjusted for one another, and fully adjusted for comorbidities, EPA + DHA, and the EPA/DHA ratio on long-term (10-year) MACE (all-cause death, myocardial infarction, stroke, heart failure hospitalization). Results The average subject age was 61.5 ± 12.2 years, 57% were male, 41% were obese, 42% had severe coronary artery disease (CAD), and 311 (31.5%) had a MACE. The 10-year MACE unadjusted hazard ratio (HR) for the highest (fourth) vs. lowest (first) quartile (Q) of EPA was HR = 0.48 (95% CI: 0.35, 0.67). The adjustment for DHA changed the HR to 0.30 (CI: 0.19, 0.49), and an additional adjustment for baseline differences changed the HR to 0.36 (CI: 0.22, 0.58). Conversely, unadjusted DHA did not significantly predict MACE, but adjustment for EPA resulted in a 1.81-fold higher risk of MACE (CI: 1.14, 2.90) for Q4 vs. Q1. However, after the adjustment for baseline differences, the risk of MACE was not significant for DHA (HR = 1.37; CI: 0.85, 2.20). An EPA/DHA ratio ≥1 resulted in a lower rate of 10-year MACE outcomes (27% vs. 37%, adjusted p-value = 0.013). Conclusions Higher levels of EPA, but not DHA, are associated with a lower risk of MACE. When combined with EPA, higher DHA blunts the benefit of EPA and is associated with a higher risk of MACE in the presence of low EPA. These findings can help explain the discrepant results of EPA-only and EPA/DHA mixed clinical supplementation trials.
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Affiliation(s)
- Viet T. Le
- Intermountain Medical Center, Intermountain Heart Institute, Salt Lake City, UT, United States
- Department of Physician Assistant Studies, Rocky Mountain University of Health Professions, Provo, UT, United States
| | - Stacey Knight
- Intermountain Medical Center, Intermountain Heart Institute, Salt Lake City, UT, United States
- The University of Utah, School of Medicine, Salt Lake City, UT, United States
| | - Jeramie D. Watrous
- Department of Medicine, University of California San Diego, San Diego, CA, United States
| | - Mahan Najhawan
- Department of Medicine, University of California San Diego, San Diego, CA, United States
| | - Khoi Dao
- Department of Medicine, University of California San Diego, San Diego, CA, United States
| | - Raymond O. McCubrey
- Intermountain Medical Center, Intermountain Heart Institute, Salt Lake City, UT, United States
| | - Tami L. Bair
- Intermountain Medical Center, Intermountain Heart Institute, Salt Lake City, UT, United States
| | - Benjamin D. Horne
- Intermountain Medical Center, Intermountain Heart Institute, Salt Lake City, UT, United States
- Division of Cardiovascular Medicine, Department of Medicine, Stanford University, Stanford, CA, United States
| | - Heidi T. May
- Intermountain Medical Center, Intermountain Heart Institute, Salt Lake City, UT, United States
| | - Joseph B. Muhlestein
- Intermountain Medical Center, Intermountain Heart Institute, Salt Lake City, UT, United States
- The University of Utah, School of Medicine, Salt Lake City, UT, United States
| | - John R. Nelson
- California Cardiovascular Institute, Fresno, CA, United States
| | - John F. Carlquist
- Intermountain Medical Center, Intermountain Heart Institute, Salt Lake City, UT, United States
- The University of Utah, School of Medicine, Salt Lake City, UT, United States
| | - Kirk U. Knowlton
- Intermountain Medical Center, Intermountain Heart Institute, Salt Lake City, UT, United States
- The University of Utah, School of Medicine, Salt Lake City, UT, United States
- Department of Medicine, University of California San Diego, San Diego, CA, United States
| | - Mohit Jain
- Department of Medicine, University of California San Diego, San Diego, CA, United States
| | - Jeffrey L. Anderson
- Intermountain Medical Center, Intermountain Heart Institute, Salt Lake City, UT, United States
- The University of Utah, School of Medicine, Salt Lake City, UT, United States
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Buckler AJ, Doros G, Kinninger A, Lakshmanan S, Le VT, Libby P, May HT, Muhlestein JB, Nelson JR, Nicolaou A, Roy SK, Shaikh K, Shekar C, Tayek JA, Zheng L, Bhatt DL, Budoff MJ. Quantitative imaging biomarkers of coronary plaque morphology: insights from EVAPORATE. Front Cardiovasc Med 2023; 10:1204071. [PMID: 37600044 PMCID: PMC10435977 DOI: 10.3389/fcvm.2023.1204071] [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] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2023] [Accepted: 07/12/2023] [Indexed: 08/22/2023] Open
Abstract
Aims Residual cardiovascular risk persists despite statin therapy. In REDUCE-IT, icosapent ethyl (IPE) reduced total events, but the mechanisms of benefit are not fully understood. EVAPORATE evaluated the effects of IPE on plaque characteristics by coronary computed tomography angiography (CCTA). Given the conclusion that the IPE-treated patients demonstrate that plaque burden decreases has already been published in the primary study analysis, we aimed to demonstrate whether the use of an analytic technique defined and validated in histological terms could extend the primary study in terms of whether such changes could be reliably seen in less time on drug, at the individual (rather than only at the cohort) level, or both, as neither of these were established by the primary study result. Methods and Results EVAPORATE randomized the patients to IPE 4 g/day or placebo. Plaque morphology, including lipid-rich necrotic core (LRNC), fibrous cap thickness, and intraplaque hemorrhage (IPH), was assessed using the ElucidVivo® (Elucid Bioimaging Inc.) on CCTA. The changes in plaque morphology between the treatment groups were analyzed. A neural network to predict treatment assignment was used to infer patient representation that encodes significant morphological changes. Fifty-five patients completed the 18-month visit in EVAPORATE with interpretable images at each of the three time points. The decrease of LRNC between the patients on IPE vs. placebo at 9 months (reduction of 2 mm3 vs. an increase of 41 mm3, p = 0.008), widening at 18 months (6 mm3 vs. 58 mm3 increase, p = 0.015) were observed. While not statistically significant on a univariable basis, reductions in wall thickness and increases in cap thickness motivated multivariable modeling on an individual patient basis. The per-patient response assessment was possible using a multivariable model of lipid-rich phenotype at the 9-month follow-up, p < 0.01 (sustained at 18 months), generalizing well to a validation cohort. Conclusion Plaques in the IPE-treated patients acquired more characteristics of stability. Reliable assessment using histologically validated analysis of individual response is possible at 9 months, with sustained stabilization at 18 months, providing a quantitative basis to elucidate drug mechanism and assess individual patient response.
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Affiliation(s)
- Andrew J. Buckler
- Department of Molecular Medicine, Karolinska Institutet, Stockholm, Sweden
- Elucid Bioimaging Inc., Boston, MA, United States
| | | | - April Kinninger
- Department of Medicine, Lundquist Institute at Harbor-UCLA Medical Center, Torrance, CA, United States
| | - Suvasini Lakshmanan
- Department of Medicine, Lundquist Institute at Harbor-UCLA Medical Center, Torrance, CA, United States
| | - Viet T. Le
- Intermountain Heart Institute, Intermountain Medical Center, Salt Lake City, UT, United States
- Rocky Mountain University of Health Profession, Provo, UT, United States
| | - Peter Libby
- Brigham and Women’s Hospital Heart & Vascular Center and Harvard Medical School, Boston, MA, United States
| | - Heidi T. May
- Intermountain Heart Institute, Intermountain Medical Center, Salt Lake City, UT, United States
| | - Joseph B. Muhlestein
- Intermountain Heart Institute, Intermountain Medical Center, Salt Lake City, UT, United States
| | - John R. Nelson
- California Cardiovascular Institute, Fresno, CA, United States
| | | | - Sion K. Roy
- Department of Medicine, Lundquist Institute at Harbor-UCLA Medical Center, Torrance, CA, United States
| | - Kashif Shaikh
- Department of Medicine, Lundquist Institute at Harbor-UCLA Medical Center, Torrance, CA, United States
| | - Chandana Shekar
- Department of Medicine, Lundquist Institute at Harbor-UCLA Medical Center, Torrance, CA, United States
| | - John A. Tayek
- Department of Medicine, Lundquist Institute at Harbor-UCLA Medical Center, Torrance, CA, United States
| | - Luke Zheng
- BAIM Institute, Boston, MA, United States
| | - Deepak L. Bhatt
- Brigham and Women’s Hospital Heart & Vascular Center and Harvard Medical School, Boston, MA, United States
| | - Matthew J. Budoff
- Department of Medicine, Lundquist Institute at Harbor-UCLA Medical Center, Torrance, CA, United States
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5
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Horwitz LI, Thaweethai T, Brosnahan SB, Cicek MS, Fitzgerald ML, Goldman JD, Hess R, Hodder SL, Jacoby VL, Jordan MR, Krishnan JA, Laiyemo AO, Metz TD, Nichols L, Patzer RE, Sekar A, Singer NG, Stiles LE, Taylor BS, Ahmed S, Algren HA, Anglin K, Aponte-Soto L, Ashktorab H, Bassett IV, Bedi B, Bhadelia N, Bime C, Bind MAC, Black LJ, Blomkalns AL, Brim H, Castro M, Chan J, Charney AW, Chen BK, Chen LQ, Chen P, Chestek D, Chibnik LB, Chow DC, Chu HY, Clifton RG, Collins S, Costantine MM, Cribbs SK, Deeks SG, Dickinson JD, Donohue SE, Durstenfeld MS, Emery IF, Erlandson KM, Facelli JC, Farah-Abraham R, Finn AV, Fischer MS, Flaherman VJ, Fleurimont J, Fonseca V, Gallagher EJ, Gander JC, Gennaro ML, Gibson KS, Go M, Goodman SN, Granger JP, Greenway FL, Hafner JW, Han JE, Harkins MS, Hauser KSP, Heath JR, Hernandez CR, Ho O, Hoffman MK, Hoover SE, Horowitz CR, Hsu H, Hsue PY, Hughes BL, Jagannathan P, James JA, John J, Jolley S, Judd SE, Juskowich JJ, Kanjilal DG, Karlson EW, Katz SD, Kelly JD, Kelly SW, Kim AY, Kirwan JP, Knox KS, Kumar A, Lamendola-Essel MF, Lanca M, Lee-lannotti JK, Lefebvre RC, Levy BD, Lin JY, Logarbo BP, Logue JK, Longo MT, Luciano CA, Lutrick K, Malakooti SK, Mallett G, Maranga G, Marathe JG, Marconi VC, Marshall GD, Martin CF, Martin JN, May HT, McComsey GA, McDonald D, Mendez-Figueroa H, Miele L, Mittleman MA, Mohandas S, Mouchati C, Mullington JM, Nadkarni GN, Nahin ER, Neuman RB, Newman LT, Nguyen A, Nikolich JZ, Ofotokun I, Ogbogu PU, Palatnik A, Palomares KTS, Parimon T, Parry S, Parthasarathy S, Patterson TF, Pearman A, Peluso MJ, Pemu P, Pettker CM, Plunkett BA, Pogreba-Brown K, Poppas A, Porterfield JZ, Quigley JG, Quinn DK, Raissy H, Rebello CJ, Reddy UM, Reece R, Reeder HT, Rischard FP, Rosas JM, Rosen CJ, Rouphael NG, Rouse DJ, Ruff AM, Saint Jean C, Sandoval GJ, Santana JL, Schlater SM, Sciurba FC, Selvaggi C, Seshadri S, Sesso HD, Shah DP, Shemesh E, Sherif ZA, Shinnick DJ, Simhan HN, Singh U, Sowles A, Subbian V, Sun J, Suthar MS, Teunis LJ, Thorp JM, Ticotsky A, Tita ATN, Tragus R, Tuttle KR, Urdaneta AE, Utz PJ, VanWagoner TM, Vasey A, Vernon SD, Vidal C, Walker T, Ward HD, Warren DE, Weeks RM, Weiner SJ, Weyer JC, Wheeler JL, Whiteheart SW, Wiley Z, Williams NJ, Wisnivesky JP, Wood JC, Yee LM, Young NM, Zisis SN, Foulkes AS. Researching COVID to Enhance Recovery (RECOVER) adult study protocol: Rationale, objectives, and design. PLoS One 2023; 18:e0286297. [PMID: 37352211 PMCID: PMC10289397 DOI: 10.1371/journal.pone.0286297] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/28/2023] [Accepted: 05/12/2023] [Indexed: 06/25/2023] Open
Abstract
IMPORTANCE SARS-CoV-2 infection can result in ongoing, relapsing, or new symptoms or other health effects after the acute phase of infection; termed post-acute sequelae of SARS-CoV-2 infection (PASC), or long COVID. The characteristics, prevalence, trajectory and mechanisms of PASC are ill-defined. The objectives of the Researching COVID to Enhance Recovery (RECOVER) Multi-site Observational Study of PASC in Adults (RECOVER-Adult) are to: (1) characterize PASC prevalence; (2) characterize the symptoms, organ dysfunction, natural history, and distinct phenotypes of PASC; (3) identify demographic, social and clinical risk factors for PASC onset and recovery; and (4) define the biological mechanisms underlying PASC pathogenesis. METHODS RECOVER-Adult is a combined prospective/retrospective cohort currently planned to enroll 14,880 adults aged ≥18 years. Eligible participants either must meet WHO criteria for suspected, probable, or confirmed infection; or must have evidence of no prior infection. Recruitment occurs at 86 sites in 33 U.S. states, Washington, DC and Puerto Rico, via facility- and community-based outreach. Participants complete quarterly questionnaires about symptoms, social determinants, vaccination status, and interim SARS-CoV-2 infections. In addition, participants contribute biospecimens and undergo physical and laboratory examinations at approximately 0, 90 and 180 days from infection or negative test date, and yearly thereafter. Some participants undergo additional testing based on specific criteria or random sampling. Patient representatives provide input on all study processes. The primary study outcome is onset of PASC, measured by signs and symptoms. A paradigm for identifying PASC cases will be defined and updated using supervised and unsupervised learning approaches with cross-validation. Logistic regression and proportional hazards regression will be conducted to investigate associations between risk factors, onset, and resolution of PASC symptoms. DISCUSSION RECOVER-Adult is the first national, prospective, longitudinal cohort of PASC among US adults. Results of this study are intended to inform public health, spur clinical trials, and expand treatment options. REGISTRATION NCT05172024.
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Affiliation(s)
- Leora I. Horwitz
- Department of Population Health, NYU Grossman School of Medicine, New York, New York, United States of America
| | - Tanayott Thaweethai
- Department of Biostatistics, Massachusetts General Hospital, Boston, Massachusetts, United States of America
| | - Shari B. Brosnahan
- Division of Pulmonary Critical Care and Sleep Medicine, NYU Langone Health, New York, New York, United States of America
| | - Mine S. Cicek
- Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, Minnesota, United States of America
| | - Megan L. Fitzgerald
- Patient Led Research Collaboration on COVID-19, Washington, DC, United States of America
| | - Jason D. Goldman
- Division of Infectious Diseases, Providence Swedish Medical Center, Seattle, Washington, United States of America
| | - Rachel Hess
- Department of Population Health Sciences and Internal Medicine, University of Utah School of Medicine, Salt Lake City, Utah, United States of America
| | - S. L. Hodder
- Department of Medicine, West Virginia University, Morgantown, West Virginia, United States of America
| | - Vanessa L. Jacoby
- Department of Obstetrics, Gynecology, and Reproductive Sciences, University of California, San Francisco, San Francisco, California, United States of America
| | - Michael R. Jordan
- Division of Geographic Medicine and Infectious Diseases, Tufts Medical Center, Medford, Massachusetts, United States of America
| | - Jerry A. Krishnan
- Department of Medicine, University of Illinois Chicago, Chicago, Illinois, United States of America
| | - Adeyinka O. Laiyemo
- Department of Medicine, Howard University, Washington, DC, United States of America
| | - Torri D. Metz
- Department of Obstetrics and Gynecology, University of Utah Health, Salt Lake City, Utah, United States of America
| | - Lauren Nichols
- Body Politic COVID-19 Support Group, Boston, Massachusetts, United States of America
| | - Rachel E. Patzer
- Department of Medicine and Surgery, Health Services Research Center, Emory University School of Medicine, Atlanta, Georgia, United States of America
| | - Anisha Sekar
- Patient Led Research Collaboration on COVID-19, Washington, DC, United States of America
| | - Nora G. Singer
- Department of Medicine and Rheumatology, The MetroHealth Medical Center, Cleveland, Ohio, United States of America
| | - Lauren E. Stiles
- Department of Neurology, Stony Brook University Renaissance School of Medicine, Stony Brook, New York, United States of America
| | - Barbara S. Taylor
- Department of Medicine, Division of Infectious Diseases and Infectious Diseases, Long School of Medicine, University of Texas Health Science Center San Antonio, San Antonio, Texas, United States of America
| | - Shifa Ahmed
- Department of Biostatistics, Massachusetts General Hospital, Boston, Massachusetts, United States of America
| | - Heather A. Algren
- Swedish Center for Research and Innovation, Providence Swedish Medical Center, Seattle, Washington, United States of America
| | - Khamal Anglin
- Department of Epidemiology and Biostatistics, University of California at San Francisco Institute of Global Health Sciences, San Francisco, San Francisco, California, United States of America
| | - Lisa Aponte-Soto
- College of Science and Health, Department of Health Sciences, DePaul University, Chicago, Illinois, United States of America
| | - Hassan Ashktorab
- Department of Medicine, Howard University, Washington, DC, United States of America
| | - Ingrid V. Bassett
- Medical Practice Evaluation Center, Department of Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, United States of America
| | - Brahmchetna Bedi
- Department of Medicine, Emory University, Atlanta, Georgia, United States of America
| | - Nahid Bhadelia
- Center for Emerging Infectious Diseases Policy and Research, Boston University School of Medicine, Boston, Massachusetts, United States of America
| | - Christian Bime
- Department of Medicine, University of Arizona, Tucson, Arizona, United States of America
| | - Marie-Abele C. Bind
- Department of Biostatistics, Massachusetts General Hospital, Boston, Massachusetts, United States of America
| | - Lora J. Black
- Department of Clinical Research, Sanford Research, Sioux Falls, South Dakota, United States of America
| | - Andra L. Blomkalns
- Department of Emergency Medicine, Stanford University, Stanford, California, United States of America
| | - Hassan Brim
- Department of Pathology, Howard University, Washington, DC, United States of America
| | - Mario Castro
- Division of Pulmonary and Critical Care, University of Kansas Medical Center, Kansas City, Kansas City, United States of America
| | - James Chan
- Department of Biostatistics, Massachusetts General Hospital, Boston, Massachusetts, United States of America
| | - Alexander W. Charney
- Charles Bronfman Institute for Personalized Medicine, Icahn School of Medicine at Mount Sinai, New York, New York, United States of America
| | - Benjamin K. Chen
- Division of Infectious Disease, Department of Medicine, Icahn School of Medicine at Mount Sinai, New York, New York, United States of America
| | - Li Qing Chen
- Department of Medicine, Brigham and Women’s Hospital, Boston, Massachusetts, United States of America
| | - Peter Chen
- Department of Medicine, Cedars-Sinai Medical Center, Los Angeles, California, United States of America
| | - David Chestek
- Department of Emergency Medicine, University of Illinois Chicago, Chicago, Illinois, United States of America
| | - Lori B. Chibnik
- Department of Neurology, Massachusetts General Hospital, Boston, Massachusetts, United States of America
| | - Dominic C. Chow
- Department of Medicine, University of Hawaii at Manoa John A. Burns School of Medicine, Honolulu, Hawaii, United States of America
| | - Helen Y. Chu
- Department of Allergy & Infectious Diseases, University of Washington, Seattle, Washington, United States of America
| | - Rebecca G. Clifton
- Department of Biostatistics, George Washington University, Washington, DC, United States of America
| | - Shelby Collins
- Department of Medicine, Emory University, Atlanta, Georgia, United States of America
| | - Maged M. Costantine
- Department of Obstetrics and Gynecology, The Ohio State University Hospital, Columbus, Ohio, United States of America
| | - Sushma K. Cribbs
- Department of Medicine, Emory University, Atlanta, Georgia, United States of America
| | - Steven G. Deeks
- Department of Medicine, University of California, San Francisco, San Francisco, California, United States of America
| | - John D. Dickinson
- Department of Internal Medicine, University of Nebraska Medical Center, Omaha, Nebraska, United States of America
| | - Sarah E. Donohue
- Department of Research Services, University of Illinois College of Medicine, Peoria, Illinois, United States of America
| | - Matthew S. Durstenfeld
- Department of Medicine, Division of Cardiology at Zuckerberg San Francisco General, University of California San Francisco, San Francisco, California, United States of America
| | - Ivette F. Emery
- MaineHealth Institute for Research, MaineHealth, Scarborough, Maine, United States of America
| | - Kristine M. Erlandson
- Department of Medicine, University of Colorado Anschutz Medical Campus, Aurora, Colorado, United States of America
| | - Julio C. Facelli
- Department of Biomedical Informatics and Clinical and Translational Science Institute, University of Utah, Salt Lake City, Utah, United States of America
| | - Rachael Farah-Abraham
- Department of Medicine, Division of Infectious Diseases, Emory University School of Medicine, Atlanta, Georgia, United States of America
| | - Aloke V. Finn
- Department of Pathology, CVPath Institute, Gaithersburg, Maryland, United States of America
| | - Melinda S. Fischer
- Department of Medicine, Division of Infectious Diseases and Infectious Diseases, Long School of Medicine, University of Texas Health Science Center San Antonio, San Antonio, Texas, United States of America
| | - Valerie J. Flaherman
- Department of Pediatrics, University of California, San Francisco, San Francisco, California, United States of America
| | - Judes Fleurimont
- Mile Square Health Center, University of Illinois Chicago, University of Illinois Chicago, Chicago, Illinois, United States of America
| | - Vivian Fonseca
- Department of Medicine, Tulane University School of Medicine, New Orleans, Louisiana, United States of America
| | - Emily J. Gallagher
- Department of Endocrinology, Diabetes and Bone Disease, Icahn School of Medicine at Mount Sinai, New York, New York, United States of America
| | - Jennifer C. Gander
- Center for Research and Evaluation, Kaiser Permanente of Georgia, Atlanta, Georgia, United States of America
| | - Maria Laura Gennaro
- Public Health Research Institute and Department of Medicine, Rutgers New Jersey Medical School, Newark, New Jersey, United States of America
| | - Kelly S. Gibson
- Department of Obstetrics and Gynecology, MetroHealth System, Cleveland, Ohio, United States of America
| | - Minjoung Go
- Department of Medicine, Stanford University, Stanford, California, United States of America
| | - Steven N. Goodman
- Department of Epidemiology and Population Health, Stanford University School of Medicine, Stanford, California, United States of America
| | - Joey P. Granger
- Department of Physiology & Biophysics, University of Mississippi Medical Center, Jackson, Mississippi, United States of America
| | - Frank L. Greenway
- Clinical Trials, Pennington Biomedical Research Center, Baton Rouge, Louisiana, United States of America
| | - John W. Hafner
- Department of Emergency Medicine, OSF Saint Francis Medical Center, Peoria, Illinois, United States of America
| | - Jenny E. Han
- Department of Pulmonary and Critical Care, Emory University School of Medicine, Atlanta, Georgia, United States of America
| | - Michelle S. Harkins
- Department of Internal Medicine University of New Mexico, Health Science Center, Albuquerque, New Mexico, United States of America
| | - Kristine S. P. Hauser
- Clinical Research Center, Beth Israel Deaconess Medical Center, Boston, Massachusetts, United States of America
| | - James R. Heath
- Department of Bioengineering, Institute for Systems Biology, Seattle, Washington, United States of America
| | - Carla R. Hernandez
- Clinical Research Center, University Hospitals Cleveland Medical Center, Cleveland, Ohio, United States of America
| | - On Ho
- Seattle Children’s Therapeutics, Seattle, Washington, United States of America
| | - Matthew K. Hoffman
- Department of Obstetrics and Gynecology, Christiana Care Health Services, Newark, Delaware, United States of America
| | - Susan E. Hoover
- Department of Clinical Research, Sanford Research, Sioux Falls, South Dakota, United States of America
| | - Carol R. Horowitz
- Institute for Health Equity Research, Icahn School of Medicine at Mount Sinai, New York, New York, United States of America
| | - Harvey Hsu
- Department of Internal Medicine, University of Arizona, Phoenix, Arizona, United States of America
| | - Priscilla Y. Hsue
- Department of Medicine, University of California, San Francisco, San Francisco, California, United States of America
| | - Brenna L. Hughes
- Department of Obstetrics and Gynecology, Duke University, Durham, North Carolina, United States of America
| | - Prasanna Jagannathan
- Department of Medicine, Stanford University, Stanford, California, United States of America
| | - Judith A. James
- Department of Arthritis & Clinical Immunology, Oklahoma Medical Research Foundation, Oklahoma City, Oklahoma, United States of America
| | - Janice John
- Department of Family Medicine, Cambridge Health Alliance, Cambridge, Massachusetts, United States of America
| | - Sarah Jolley
- Department of Pulmonary and Critical Care Medicine, University of Colorado, Aurora, Colorado, United States of America
| | - S. E. Judd
- Department of Biostatistics, University of Alabama at Birmingham, Birmingham, Alabama, United States of America
| | - Joy J. Juskowich
- Department of Medicine, Division of Infectious Diseases, West Virginia School of Medicine, Morgantown, West Virginia, United States of America
| | - Diane G. Kanjilal
- Department of Infectious Diseases, Massachusetts General Hospital, Boston, Massachusetts, United States of America
| | - Elizabeth W. Karlson
- Department of Medicine, Harvard Medical School, Boston, Massachusetts, United States of America
| | - Stuart D. Katz
- Department of Medicine, NYU Langone Health, New York, New York, United States of America
| | - J. Daniel Kelly
- Department of Medicine, University of California, San Francisco, San Francisco, California, United States of America
| | - Sara W. Kelly
- Department of Pediatrics & Department of Research Services, University of Illinois College of Medicine, Peoria, Illinois, United States of America
| | - Arthur Y. Kim
- Department of Infectious Diseases, Massachusetts General Hospital, Boston, Massachusetts, United States of America
| | - John P. Kirwan
- Department Integrated Physiology and Molecular Medicine, Pennington Biomedical Research Center, Baton Rouge, Louisiana, United States of America
| | - Kenneth S. Knox
- Department of Internal Medicine, University of Arizona, Phoenix, Arizona, United States of America
| | - Andre Kumar
- Department of Medicine, Stanford University, Stanford, California, United States of America
| | | | - Margaret Lanca
- Department of Psychiatry, Harvard Medical School, Boston, Massachusetts, United States of America
| | - Joyce K. Lee-lannotti
- Department of Internal Medicine and Neurology, University of Arizona College of Medicine Phoenix, Phoenix, Arizona, United States of America
| | - R. Craig Lefebvre
- Communications Practice Area, RTI International, Research Triangle Park, North Carolina, United States of America
| | - Bruce D. Levy
- Department of Internal Medicine, Brigham and Women’s Hospital, Boston, Massachusetts, United States of America
| | - Janet Y. Lin
- Department of Emergency Medicine, University of Illinois Chicago, Chicago, Illinois, United States of America
| | - Brian P. Logarbo
- Tulane Center for Clinical Research, Tulane University School of Medicine, New Orleans, Louisiana, United States of America
| | - Jennifer K. Logue
- Department of Medicine, University of Washington, Seattle, Washington, United States of America
| | - Michele T. Longo
- Tulane Center for Clinical Neurosciences, Tulane School of Medicine, New Orleans, Louisiana, United States of America
| | - Carlos A. Luciano
- Department of Neurology, University of Puerto Rico School of Medicine, San Juan, Puerto Rico, United States of America
| | - Karen Lutrick
- Department of Family & Community Medicine, University of Arizona, College of Medicine – Tucson, Tucson, Arizona, United States of America
| | - Shahdi K. Malakooti
- Department of Medicine, Case Western Reserve University School of Medicine, Cleveland, Ohio, United States of America
| | - Gail Mallett
- Department of Obstetrics and Gynecology, Northwestern University, Chicago, Illinois, United States of America
| | - Gabrielle Maranga
- Department of Population Health, NYU Grossman School of Medicine, New York, New York, United States of America
| | - Jai G. Marathe
- Department of Medicine, Section of Infectious Diseases, Boston University Medical Center, Boston, Massachusetts, United States of America
| | - Vincent C. Marconi
- Department of Medicine, Infectious Diseases and Department of Global Health, Emory University School of Medicine, Atlanta, Georgia, United States of America
| | - Gailen D. Marshall
- Department of Medicine, University of Mississippi Medical Center, Jackson, Mississippi, United States of America
| | - Christopher F. Martin
- Department of Medicine, Division of Infectious Diseases, Emory University School of Medicine, Atlanta, Georgia, United States of America
| | - Jeffrey N. Martin
- Department of Epidemiology and Biostatistics, University of California, San Francisco, San Francisco, California, United States of America
| | - Heidi T. May
- Department of Cardiology, Intermountain Medical Center, Salt Lake City, Utah, United States of America
| | - Grace A. McComsey
- Department of Medicine, Department of Pediatrics, Case Western Reserve University School of Medicine, Cleveland, Ohio, United States of America
| | - Dylan McDonald
- Department of Allergy & Infectious Diseases, University of Washington, Seattle, Washington, United States of America
| | - Hector Mendez-Figueroa
- Department of Obstetrics, Gynecology and Reproductive Sciences, University of Texas Health Science Center at Houston, Houston, Texas, United States of America
| | - Lucio Miele
- Department of Genetics, Louisiana State University Health Sciences Center, New Orleans, Louisiana, United States of America
| | - Murray A. Mittleman
- Department of Epidemiology, Harvard T.H. Chan School of Public Health, Boston, Massachusetts, United States of America
| | - Sindhu Mohandas
- Department of Infectious Diseases, Children’s Hospital Los Angeles, University of Southern California, Los Angeles, California, United States of America
| | - Christian Mouchati
- Department of Medicine, Case Western Reserve University School of Medicine, Cleveland, Ohio, United States of America
| | - Janet M. Mullington
- Department of Neurology and Sleep Medicine, Beth Israel Deaconess Medical Center, Boston, Massachusetts, United States of America
| | - Girish N. Nadkarni
- Division of General Internal Medicine, Icahn School of Medicine at Mount Sinai, New York, New York, United States of America
| | - Erica R. Nahin
- Department of Medicine, NYU Langone Health, New York, New York, United States of America
| | - Robert B. Neuman
- Division of Cardiology, Kaiser Permanente of Georgia, Atlanta, Georgia, United States of America
| | - Lisa T. Newman
- Department of Social, Statistical and Environmental Sciences, RTI International, Research Triangle Park, North Carolina, United States of America
| | - Amber Nguyen
- Department of Biostatistics, Massachusetts General Hospital, Boston, Massachusetts, United States of America
| | - Janko Z. Nikolich
- Department of Immunobiology, University of Arizona College of Medicine, Tucson, Arizona, United States of America
| | - Igho Ofotokun
- Department of Medicine, Division of Infectious Diseases, Emory University School of Medicine, Atlanta, Georgia, United States of America
| | - Princess U. Ogbogu
- Division of Pediatric Allergy, Immunology, and Rheumatology, University Hospitals Rainbow Babies and Children’s Hospital, Cleveland, Ohio, United States of America
| | - Anna Palatnik
- Department of Obstetrics and Gynecology, Medical College of Wisconsin, Milwaukee, Wisconsin, United States of America
| | - Kristy T. S. Palomares
- Department of Obstetrics and Gynecology, Division of Maternal Fetal Medicine, Saint Peter’s University Hospital, New Brunswick, New Jersey, United States of America
| | - Tanyalak Parimon
- Department of Medicine, Cedars-Sinai Medical Center, Los Angeles, California, United States of America
| | - Samuel Parry
- Department of Obstetrics and Gynecology, University of Pennsylvania, Philadelphia, Pennsylvania, United States of America
| | - Sairam Parthasarathy
- Department of Medicine, University of Arizona, Tucson, Arizona, United States of America
| | - Thomas F. Patterson
- Department of Medicine, Department of Infectious Disease, University of Texas Health, San Antonio, Texas, United States of America
| | - Ann Pearman
- Department of Medicine, Case Western Reserve University School of Medicine, Cleveland, Ohio, United States of America
| | - Michael J. Peluso
- Division of HIV, Infectious Disease, and Global Medicine, University of California, San Francisco, California, United States of America
| | - Priscilla Pemu
- Department of Medicine, Morehouse School of Medicine, Atlanta, Georgia, United States of America
| | - Christian M. Pettker
- Department of Obstetrics, Gynecology & Reproductive Sciences, Yale School of Medicine, New Haven, Connecticut, United States of America
| | - Beth A. Plunkett
- Department of Obstetrics and Gynecology, NorthShore University Health System, Evanston, Illinois, United States of America
| | - Kristen Pogreba-Brown
- Department of Epidemiology and Biostatistics, University of Arizona, Tucson, Arizona, United States of America
| | - Athena Poppas
- Division of Cardiology, Warren Alpert Medical School of Brown University, Providence, Rhode Island, United States of America
| | - J. Zachary Porterfield
- Department of Internal Medicine, Division of Infectious Diseases, University of Kentucky, Lexington, Kentucky, United States of America
| | - John G. Quigley
- Department of Medicine, Division of Hematology/Oncology, University of Illinois Chicago, Chicago, Illinois, United States of America
| | - Davin K. Quinn
- Department of Psychiatry and Behavioral Sciences, University of New Mexico School of Medicine, Albuquerque, New Mexico, United States of America
| | - Hengameh Raissy
- Department of Pediatrics, University of New Mexico, Health Sciences Center, Albuquerque, New Mexico, United States of America
| | - Candida J. Rebello
- Department of Nutrition and Chronic Disease, Pennington Biomedical Research Center, Baton Rouge, Louisiana, United States of America
| | - Uma M. Reddy
- Department of Obstetrics and Gynecology, Columbia University, New York, New York, United States of America
| | - Rebecca Reece
- Department of Medicine, Division of Infectious Diseases, West Virginia School of Medicine, Morgantown, West Virginia, United States of America
| | - Harrison T. Reeder
- Department of Biostatistics, Massachusetts General Hospital, Boston, Massachusetts, United States of America
| | - Franz P. Rischard
- Department of Pulmonary and Critical Care, University of Arizona, Tucson, Arizona, United States of America
| | - Johana M. Rosas
- Department of Medicine, NYU Langone Health, New York, New York, United States of America
| | - Clifford J. Rosen
- MaineHealth Institute for Research, MaineHealth, Scarborough, Maine, United States of America
| | - Nadine G. Rouphael
- Department of Medicine, Emory University, Atlanta, Georgia, United States of America
| | - Dwight J. Rouse
- Department of Obstetrics and Gynecology, Brown University, Providence, Rhode Island, United States of America
| | - Adam M. Ruff
- Division of Pulmonary and Critical Care, University of Kansas Medical Center, Kansas City, Kansas City, United States of America
| | - Christina Saint Jean
- Department of Population Health, NYU Grossman School of Medicine, New York, New York, United States of America
| | - Grecio J. Sandoval
- Department of Biostatistics, George Washington University, Washington, DC, United States of America
| | - Jorge L. Santana
- Department of Medicine, University of Puerto Rico, San Juan, Puerto Rico, United States of America
| | - Shannon M. Schlater
- Department of Internal Medicine, University of Utah, Salt Lake City, Utah, United States of America
| | - Frank C. Sciurba
- Department of Medicine, Division of Pulmonary Allergy and Critical Care Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania, United States of America
| | - Caitlin Selvaggi
- Department of Biostatistics, Massachusetts General Hospital, Boston, Massachusetts, United States of America
| | - Sudha Seshadri
- Glenn Biggs Institute for Alzheimer’s and Neurodegenerative Diseases, University of Texas Health Sciences Center San Antonio, San Antonio, Texas, United States of America
| | - Howard D. Sesso
- Division of Preventive Medicine, Brigham and Women’s Hospital, Boston, Massachusetts, United States of America
| | - Dimpy P. Shah
- Department of Population Health Sciences, Mays Cancer Center, University of Texas Health, San Antonio, Texas, United States of America
| | - Eyal Shemesh
- Department of Pediatrics, Icahn School of Medicine at Mount Sinai, New York, New York, United States of America
| | - Zaki A. Sherif
- Department of Biochemistry & Molecular Biology, Howard University College of Medicine, Washington, DC, United States of America
| | - Daniel J. Shinnick
- Department of Biostatistics, Massachusetts General Hospital, Boston, Massachusetts, United States of America
| | - Hyagriv N. Simhan
- Department of Obstetrics, Gynecology, and Reproductive Sciences, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, United States of America
| | - Upinder Singh
- Department of Internal Medicine, Stanford University, Stanford, California, United States of America
| | - Amber Sowles
- Department of Obstetrics and Gynecology, University of Utah Health, Salt Lake City, Utah, United States of America
| | - Vignesh Subbian
- Department of Biomedical Engineering, Department of Systems and Industrial Engineering, University of Arizona College of Engineering, Tucson, Arizona, United States of America
| | - Jun Sun
- Department of Medicine, University of Illinois Chicago, Chicago, Illinois, United States of America
| | - Mehul S. Suthar
- Department of Pediatrics, Emory Vaccine Center, Emory University, Atlanta, Georgia, United States of America
| | - Larissa J. Teunis
- Health Services Research Center, Emory University, Atlanta, Georgia, United States of America
| | - John M. Thorp
- Department of Obstetrics and Gynecology, University of North Carolina Chapel Hill, Chapel Hill, North Carolina, United States of America
| | - Amberly Ticotsky
- Department of Family Medicine, Cambridge Health Alliance, Cambridge, Massachusetts, United States of America
| | - Alan T. N. Tita
- Department of Obstetrics and Gynecology and Center for Women’s Reproductive Health, University of Alabama at Birmingham, Birmingham, Alabama, United States of America
| | - Robin Tragus
- Department of Medicine, University of Texas Health Science Center, San Antonio, Texas, United States of America
| | - Katherine R. Tuttle
- Department of Medicine, Division of Nephrology, University of Washington School of Medicine, Spokane, Washington, United States of America
| | - Alfredo E. Urdaneta
- Department of Emergency Medicine, Stanford University, Stanford, California, United States of America
| | - P. J. Utz
- Department of Internal Medicine, Stanford University, Stanford, California, United States of America
| | - Timothy M. VanWagoner
- Department of Pediatrics, University of Oklahoma Health Sciences Center, Oklahoma City, Oklahoma, United States of America
| | - Andrew Vasey
- Department of Internal Medicine, University of Nebraska Medical Center, Omaha, Nebraska, United States of America
| | - Suzanne D. Vernon
- Department of Research, Bateman Horne Center, Salt Lake City, Utah, United States of America
| | - Crystal Vidal
- Department of Population Health, NYU Grossman School of Medicine, New York, New York, United States of America
| | - Tiffany Walker
- Department of Medicine, Emory University, Atlanta, Georgia, United States of America
| | - Honorine D. Ward
- Department of Medicine, Tufts Medical Center, Boston, Massachusetts, United States of America
| | - David E. Warren
- Department of Neurological Sciences, University of Nebraska Medical Center, Omaha, Nebraska, United States of America
| | - Ryan M. Weeks
- Department of Microbiology, Immunology, and Molecular Genetics, University of Kentucky, Lexington, Kentucky, United States of America
| | - Steven J. Weiner
- Department of Biostatistics, George Washington University, Washington, DC, United States of America
| | - Jordan C. Weyer
- Center for Individualized Medicine, Mayo Clinic, Rochester, Minnesota, United States of America
| | - Jennifer L. Wheeler
- Center for Individualized Medicine, Mayo Clinic, Rochester, Minnesota, United States of America
| | - Sidney W. Whiteheart
- Department of Molecular and Cellular Biochemistry, University of Kentucky, Lexington, Kentucky, United States of America
| | - Zanthia Wiley
- Department of Medicine, Division of Infectious Diseases, Emory University School of Medicine, Atlanta, Georgia, United States of America
| | - Natasha J. Williams
- Institute for Excellence in Health Equity, NYU Grossman School of Medicine, New York, New York, United States of America
| | - Juan P. Wisnivesky
- Division of General Internal Medicine, Icahn School of Medicine at Mount Sinai, New York, New York, United States of America
| | - John C. Wood
- Department of Pediatrics and Radiology, Children’s Hospital of Los Angeles, Los Angeles, California, United States of America
| | - Lynn M. Yee
- Department of Obstetrics and Gynecology, Northwestern University Feinberg School of Medicine, Chicago, Illinois, United States of America
| | - Natalie M. Young
- Swedish Center for Research and Innovation, Providence Swedish Medical Center, Seattle, Washington, United States of America
| | - Sokratis N. Zisis
- Department of Medicine, Department of Pediatrics, Case Western Reserve University School of Medicine, Cleveland, Ohio, United States of America
| | - Andrea S. Foulkes
- Department of Biostatistics, Massachusetts General Hospital, Boston, Massachusetts, United States of America
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Anderson JL, Knight S, May HT, Le VT, Bair TL, Knowlton KU, Muhlestein JB. Frequency and Outcomes of Patients Presenting with Non-ST Elevation Myocardial Infarction (NSTEMI) without Standard Modifiable Risk Factors: A US Healthcare Experience. J Clin Med 2023; 12:jcm12093263. [PMID: 37176703 PMCID: PMC10179010 DOI: 10.3390/jcm12093263] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/13/2023] [Revised: 04/17/2023] [Accepted: 04/26/2023] [Indexed: 05/15/2023] Open
Abstract
Patients with ST-elevation myocardial infarction (STEMI), but without standard modifiable risk factors (SMuRF-less), are surprisingly common and appear to have a worse, or at best similar, short-term prognosis. However, relatively little attention has been paid to the prevalence and prognosis of SMuRF-less patients with non-STEMI (NSTEMI). The aim of our study was to identify the proportion and outcomes of SMuRF-less NSTEMI patients in a large US healthcare population. Patients with NSTEMI between 2001-2021 presenting to Intermountain Healthcare hospitals and catheterization laboratories were included. SMuRF-less status was defined as no clinical diagnosis of, or treatment for, hypertension, hyperlipidemia, diabetes, and smoking. Outcomes were assessed at 60 days and long-term for major adverse cardiovascular events (MACE: death, myocardial infarction, and heart failure hospitalization). Multivariable Cox proportional hazard regression was used to determine MACE hazard ratios (HR) for SMuRF-less versus patients with SMuRF. NSTEMI patients totaled 8196, of which 1458 (17.8%) were SMuRF-less. SMuRF-less patients were younger, more frequently male, had fewer comorbidities, and were slightly less likely to have revascularization. For SMuRF-less patients, 60-day MACE outcomes were lower (adj HR = 0.55, p < 0.0001), and this persisted for long-term MACE outcomes (adj HR = 0.64, p < 0.0001) and for each of its components. In this large US healthcare population, SMuRF-less NSTEMI presentation, as with STEMI presentation, was found to be common (17.8%). However, unlike STEMI reports, short- and long-term outcomes were better for SMuRF-less patients. Further studies to increase understanding of risk factors and preventive measures for NSTEMI in SMuRF-less patients are indicated.
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Affiliation(s)
- Jeffrey L Anderson
- Intermountain Medical Center Heart Institute, 5171 So. Cottonwood Street, Building 1, 5th Floor, Murray, UT 84107, USA
- Department of Internal Medicine, The University of Utah School of Medicine, Salt Lake City, UT 84112, USA
| | - Stacey Knight
- Intermountain Medical Center Heart Institute, 5171 So. Cottonwood Street, Building 1, 5th Floor, Murray, UT 84107, USA
- Department of Internal Medicine, The University of Utah School of Medicine, Salt Lake City, UT 84112, USA
| | - Heidi T May
- Intermountain Medical Center Heart Institute, 5171 So. Cottonwood Street, Building 1, 5th Floor, Murray, UT 84107, USA
| | - Viet T Le
- Intermountain Medical Center Heart Institute, 5171 So. Cottonwood Street, Building 1, 5th Floor, Murray, UT 84107, USA
- The Rocky Mountain University of Health Professions, Provo, UT 84606, USA
| | - Tami L Bair
- Intermountain Medical Center Heart Institute, 5171 So. Cottonwood Street, Building 1, 5th Floor, Murray, UT 84107, USA
| | - Kirk U Knowlton
- Intermountain Medical Center Heart Institute, 5171 So. Cottonwood Street, Building 1, 5th Floor, Murray, UT 84107, USA
- Department of Internal Medicine, The University of Utah School of Medicine, Salt Lake City, UT 84112, USA
| | - Joseph B Muhlestein
- Intermountain Medical Center Heart Institute, 5171 So. Cottonwood Street, Building 1, 5th Floor, Murray, UT 84107, USA
- Department of Internal Medicine, The University of Utah School of Medicine, Salt Lake City, UT 84112, USA
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Sessions AJ, May HT, Crandall BG, Day JD, Cutler MJ, Groh CA, Navaravong L, Ranjan R, Steinberg BA, Jared Bunch T. Response to "Delay in AF ablation costs lives". J Cardiovasc Electrophysiol 2023; 34:1094-1095. [PMID: 36864718 DOI: 10.1111/jce.15878] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/19/2023] [Accepted: 02/20/2023] [Indexed: 03/04/2023]
Affiliation(s)
| | - Heidi T May
- Department of Cardiology, Intermountain Medical Center, Intermountain Heart Institute, Salt Lake City, Utah, USA
| | - Brian G Crandall
- Department of Cardiology, Intermountain Medical Center, Intermountain Heart Institute, Salt Lake City, Utah, USA
| | - John D Day
- Department of Cardiology, St. Marks Hospital, Utah, Salt Lake City, USA
| | - Michael J Cutler
- Department of Cardiology, Intermountain Medical Center, Intermountain Heart Institute, Salt Lake City, Utah, USA
| | - Christopher A Groh
- Department of Internal Medicine, Division of Cardiology, University Hospital, University of Utah School of Medicine, Salt Lake City, Utah, USA
| | - Leenapong Navaravong
- Department of Internal Medicine, Division of Cardiology, University Hospital, University of Utah School of Medicine, Salt Lake City, Utah, USA
| | - Ravi Ranjan
- Department of Internal Medicine, Division of Cardiology, University Hospital, University of Utah School of Medicine, Salt Lake City, Utah, USA
| | - Benjamin A Steinberg
- Department of Internal Medicine, Division of Cardiology, University Hospital, University of Utah School of Medicine, Salt Lake City, Utah, USA
| | - T Jared Bunch
- Department of Internal Medicine, Division of Cardiology, University Hospital, University of Utah School of Medicine, Salt Lake City, Utah, USA
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Sessions AJ, May HT, Crandall BG, Day JD, Cutler MJ, Groh CA, Navaravong L, Ranjan R, Steinberg BA, J Bunch T. Increasing time between first diagnosis of atrial fibrillation and catheter ablation adversely affects long-term outcomes in patients with and without structural heart disease. J Cardiovasc Electrophysiol 2023; 34:507-515. [PMID: 36640433 DOI: 10.1111/jce.15810] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/18/2022] [Revised: 12/05/2022] [Accepted: 12/20/2022] [Indexed: 01/15/2023]
Abstract
INTRODUCTION Atrial Fibrillation (AF) is a common arrhythmia often comorbid with systolic or diastolic heart failure (HF). Catheter ablation is a more effective treatment for AF with concurrent left ventricular dysfunction, however, the optimal timing of use in these patients is unknown. METHODS All patients that received a catheter ablation for AF(n = 9979) with 1 year of follow-up within the Intermountain Healthcare system were included. Patients with were identified by the presence of structural disease by ejection fraction (EF): EF ≤ 35% (n = 1024) and EF > 35% (n = 8955). Recursive partitioning categories were used to separate patients into clinically meaningful strata based upon time from initial AF diagnosis until ablation: 30-180(n = 2689), 2:181-545(n = 1747), 3:546-1825(n = 2941), and 4:>1825(n = 2602) days. RESULTS The mean days from AF diagnosis to first ablation was 3.5 ± 3.8 years (EF > 35%: 3.5 ± 3.8 years, EF ≤ 35%: 3.4 ± 3.8 years, p = .66). In the EF > 35% group, delays in treatment (181-545 vs. 30-180, 546-1825 vs. 30-180, >1825 vs. 30-180 days) increased the risk of death with a hazard ratio (HR) of 2.02(p < .0001), 2.62(p < .0001), and 4.39(p < .0001) respectively with significant risks for HF hospitalization (HR:1.44-3.69), stroke (HR:1.11-2.14), and AF recurrence (HR:1.42-1.81). In patients with an EF ≤ 35%, treatment delays also significantly increased risk of death (HR 2.07-3.77) with similar trends in HF hospitalization (HR:1.63-1.09) and AF recurrence (HR:0.79-1.24). CONCLUSION Delays in catheter ablation for AF resulted in increased all-cause mortality in all patients with differential impact observed on HF hospitalization, stroke, and AF recurrence risks by baseline EF. These data favor earlier use of ablation for AF in patients with and without structural heart disease.
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Affiliation(s)
| | - Heidi T May
- Department of Cardiology, Intermountain Medical Center, Intermountain Heart Institute, Salt Lake City, Utah, USA
| | - Brian G Crandall
- Department of Cardiology, Intermountain Medical Center, Intermountain Heart Institute, Salt Lake City, Utah, USA
| | - John D Day
- St. Marks Hospital, Salt Lake City, Utah, USA
| | - Michael J Cutler
- Department of Cardiology, Intermountain Medical Center, Intermountain Heart Institute, Salt Lake City, Utah, USA
| | - Christopher A Groh
- Department of Internal Medicine, Division of Cardiology, University Hospital, Salt Lake City, Utah, USA
| | - Leenapong Navaravong
- Department of Internal Medicine, Division of Cardiology, University Hospital, Salt Lake City, Utah, USA
| | - Ravi Ranjan
- Department of Internal Medicine, Division of Cardiology, University Hospital, Salt Lake City, Utah, USA
| | - Benjamin A Steinberg
- Department of Internal Medicine, Division of Cardiology, University Hospital, Salt Lake City, Utah, USA
| | - Thomas J Bunch
- Department of Internal Medicine, Division of Cardiology, University Hospital, Salt Lake City, Utah, USA
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Otvos JD, Shalaurova I, May HT, Muhlestein JB, Wilkins JT, McGarrah RW, Kraus WE. Multimarkers of metabolic malnutrition and inflammation and their association with mortality risk in cardiac catheterisation patients: a prospective, longitudinal, observational, cohort study. Lancet Healthy Longev 2023; 4:e72-e82. [PMID: 36738747 DOI: 10.1016/s2666-7568(23)00001-6] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/25/2022] [Revised: 12/20/2022] [Accepted: 12/20/2022] [Indexed: 02/04/2023] Open
Abstract
BACKGROUND Complex and incompletely understood metabolic dysfunction associated with inflammation and protein-energy wasting contribute to the increased mortality risk of older patients and those with chronic organ diseases affected by cachexia, sarcopenia, malnutrition, and frailty. However, these wasting syndromes have uncertain relevance for patients with cardiovascular disease or people at lower risk. Studies are hampered by imperfect objective clinical assessment tools for these intertwined metabolic malnutrition and inflammation syndromes. We aimed to assess, in two independent cohorts of patients who underwent cardiac catheterisation, the mortality risk associated with the metabolic vulnerability index (MVX), a multimarker derived from six simultaneously measured serum biomarkers plausibly linked to these dysmetabolic syndromes. METHODS In this prospective, longitudinal, observational study, we included patients aged ≥18 years recruited into the CATHGEN biorepository (Jan 2, 2001, to Dec 30, 2011) and the Intermountain Heart Collaborative Study (Sept 12, 2000, to Sept 21, 2006) who underwent coronary angiography and had clinical nuclear magnetic resonance metabolomic profiling done on frozen plasma obtained at catheterisation. We aggregated six mortality risk biomarkers (GlycA, small HDL, valine, leucine, isoleucine, and citrate concentrations) into sex-specific MVX multimarker scores using coefficients from predictive models for all-cause mortality in the CATHGEN cohort. We assessed associations of biomarkers and MVX with mortality in both cohorts using Cox proportional hazards models adjusted for 15 clinical covariates. FINDINGS We included 5876 participants from the CATHGEN biorepository and 2888 from the Intermountain Heart study. Median follow-up was 6·2 years (IQR 4·4-8·9) in CATHGEN and 8·2 years (6·9-9·2) in the Intermountain Heart study. The six nuclear magnetic resonance biomarkers and MVX made strong, independent contributions to 5-year mortality risk prediction in both cohorts (hazard ratio 2·18 [95% CI 2·03-2·34] in the CATHGEN cohort and 1·67 [1·50-1·87] in the Intermountain Heart cohort). CATHGEN subgroup analyses showed similar MVX associations in men and women, older and younger individuals, for death from cardiovascular or non-cardiovascular causes, and in patients with or without multiple comorbidities. INTERPRETATION MVX made a dominant contribution to mortality prediction in patients with cardiovascular disease and in low-risk subgroups without pre-existing disease, suggesting that metabolic malnutrition-inflammation syndromes might have a more universal role in survival than previously thought. FUNDING Labcorp.
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Affiliation(s)
- James D Otvos
- Labcorp Diagnostics, Morrisville, NC, USA; Lipoprotein Metabolism Laboratory, Translational Vascular Medicine Branch, National Heart, Lung, and Blood Institute, National Institutes of Health, Bethesda, MD, USA.
| | | | - Heidi T May
- Intermountain Medical Center, Intermountain Heart Institute, Murray, UT, USA
| | - Joseph B Muhlestein
- Intermountain Medical Center, Intermountain Heart Institute, Murray, UT, USA
| | - John T Wilkins
- Division of Cardiology, Department of Medicine, and Department of Preventive Medicine, Feinberg School of Medicine, Northwestern University, Chicago, IL, USA
| | - Robert W McGarrah
- Duke Molecular Physiology Institute, Duke University School of Medicine, Durham, NC, USA
| | - William E Kraus
- Duke Molecular Physiology Institute, Duke University School of Medicine, Durham, NC, USA
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10
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Anderson JL, Knight S, May HT, Le VT, Almajed J, Bair TL, Knowlton KU, Muhlestein JB. Cardiovascular Outcomes of ST-Elevation Myocardial Infarction (STEMI) Patients without Standard Modifiable Risk Factors (SMuRF-Less): The Intermountain Healthcare Experience. J Clin Med 2022; 12:jcm12010075. [PMID: 36614876 PMCID: PMC9821748 DOI: 10.3390/jcm12010075] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/22/2022] [Revised: 12/16/2022] [Accepted: 12/19/2022] [Indexed: 12/24/2022] Open
Abstract
Studies primarily outside the United States have reported that SMuRF-less STEMI patients are surprisingly common (14-27%) and have a worse in-hospital/short-term prognosis. Given potential demographic and management differences over time and in the US, we aimed to identify the proportion and outcomes of SMuRF-less STEMI patients in a large US healthcare population. Patients with a first STEMI presenting to Intermountain Healthcare catheterization laboratories between 2001-2021 were included. SMuRF included a clinical diagnosis of, or treatment for, hypertension, hyperlipidemia, diabetes, and smoking. Follow-up MACE were defined as death, MI, and heart failure hospitalization (HFH) by 60 days and long-term. Qualifying STEMI patients totaled 3510, 26.2% (919) with no SMuRF. SMuRF-less patients were younger, more frequently male, and had fewer comorbidities. Neither total MACE (adj HR 0.95, p = 0.72) nor death (adj HR 1.06, p = 0.69) differed by SMuRF status at 60 days. Long-term outcomes were more frequent in SMuRF patients, which remained significant for total MACE (adj HR 0.83, p = 0.02) and HFH (HR 0.36, p = 0.0005) after adjustment for baseline differences other than SMuRF. Results were consistent through subgroup and sensitivity analyses. In this moderately large US healthcare population, SMuRF-less STEMI presentation was confirmed to be common (26.2%). However, unlike earlier, mostly non-US reports, adjusted short-term outcomes were similar, and long-term outcomes were more favorable. Further studies to increase understanding, recognition, and treatment of risk factors in SMuRF-less subjects and to optimize STEMI management are indicated.
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Affiliation(s)
- Jeffrey L. Anderson
- Intermountain Medical Center Heart Institute, Murray, UT 84107, USA
- Department of Internal Medicine, University of Utah School of Medicine, Salt Lake City, UT 84132, USA
- Correspondence: ; Tel.: +1-801-507-4760
| | - Stacey Knight
- Intermountain Medical Center Heart Institute, Murray, UT 84107, USA
- Department of Internal Medicine, University of Utah School of Medicine, Salt Lake City, UT 84132, USA
| | - Heidi T. May
- Intermountain Medical Center Heart Institute, Murray, UT 84107, USA
| | - Viet T. Le
- Intermountain Medical Center Heart Institute, Murray, UT 84107, USA
- Rocky Mountain University of Health Professions, Provo, UT 84606, USA
| | - Jawad Almajed
- Department of Internal Medicine, University of Utah School of Medicine, Salt Lake City, UT 84132, USA
| | - Tami L. Bair
- Intermountain Medical Center Heart Institute, Murray, UT 84107, USA
| | - Kirk U. Knowlton
- Intermountain Medical Center Heart Institute, Murray, UT 84107, USA
- Department of Internal Medicine, University of Utah School of Medicine, Salt Lake City, UT 84132, USA
| | - Joseph B. Muhlestein
- Intermountain Medical Center Heart Institute, Murray, UT 84107, USA
- Department of Internal Medicine, University of Utah School of Medicine, Salt Lake City, UT 84132, USA
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11
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Cutler MJ, May HT, Bair TL, Crandall BG, Osborn JS, Miller JD, Mallender CD, Muhlestein JB, Anderson JL, Knowlton KU, Knight S. Atrial fibrillation is a risk factor for major adverse cardiovascular events in COVID-19. IJC Heart & Vasculature 2022; 43:101127. [PMID: 36188756 PMCID: PMC9513337 DOI: 10.1016/j.ijcha.2022.101127] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/30/2022] [Revised: 09/14/2022] [Accepted: 09/26/2022] [Indexed: 12/15/2022]
Abstract
Background New-onset atrial fibrillation (AF) during COVID-19 infection is associated with worse cardiovascular outcomes and mortality, with new-onset AF being associated with worse clinical outcomes than recurrent AF. However, it is not known whether a prior history of AF is an independent cardiovascular risk factor predicting worse outcomes in COVID-19 patients. The present investigation sought to determine whether AF should be considered a risk factor for worse outcomes in COVID-19 illness. Methods From March 2020-September 2021 patients testing positive for SARS-CoV-2 with a prior AF diagnosis (n = 3623) were propensity matched to non-AF SARS-CoV-2 positive patients (n = 3610). Multivariable Cox hazard regression was used to determine subsequent MACE (all-cause death, myocardial infarction, HF and stroke) risk among patients with and without AF. Results COVID-19 patients with a prior history of AF were more likely to be hospitalized, require ICU care, supplemental oxygen, and ventilator support compared COVID-19 patients without a history of AF. There was a 1.40 times higher rate of MACE in the COVID-19 patients with prior AF compared to patients without prior AF (p < 0.0001). The increased rate of MACE in patients with a prior AF was primarily secondary to increases in heart failure hospitalization and death. This finding was confirmed even after controlling for acute AF during COVID-19 illness (HR 1.22, p = 0.0009). Conclusion AF history was shown to be an independent risk factor for MACE during a COVID-19 illness. Both recurrent and principally new-onset AF were associated with an increased risk of poor clinical outcomes during COVID-19 illness.
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12
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Muhlestein JB, Kammerer J, Bair TL, Knowlton KU, Le VT, Anderson JL, Lappé DL, May HT. Real-world clinical burden and economic assessment associated with hyperkalaemia in a large integrated healthcare system: a retrospective analysis. BMC Prim Care 2022; 23:65. [PMID: 35365076 PMCID: PMC8974122 DOI: 10.1186/s12875-022-01667-1] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 03/25/2021] [Accepted: 03/15/2022] [Indexed: 11/30/2022]
Abstract
Background Hyperkalaemia (HK) is a serious and potentially life-threatening condition. Both acute and chronic conditions may alter potassium homeostasis. Our aim is to describe HK incidence, clinical outcomes, and associated resource use within a large, integrated healthcare system. Methods Adult patients seen at Intermountain Healthcare facilities with a serum potassium (sK) result between January 1, 2003 and December 31, 2018 were retrospectively studied. Descriptive assessment of a population with detected HK, defined by any sK > 5.0 mmol/L and HK frequency and severity to associated resource use and characteristics of HK predictors were made. Multivariable Cox hazard regression was used to evaluate HK to outcomes. Results Of 1,208,815 patients included, 13% had HK. Compared to no-HK, HK patients were older (60 ± 18 vs 43 ± 18 years, P < 0.001), male (51% vs 41%, P < 0.001), and had greater disease burden (Charlson Comorbidity Index 3.5 ± 2.8 vs 1.7 ± 1.4, P < 0.001). At 3 years, more HK patients experienced major adverse cardiovascular events (MACEs) (19 vs 3%, P < 0.001), persisting post-adjustment (multivariable hazard ratio = 1.60, P < 0.001). They incurred higher costs for emergency department services ($552 ± 7,574 vs $207 ± 1,930, P < 0.001) and inpatient stays ($10,956 ± 93,026 vs $1,477 ± 21,423, P < 0.001). HyperK Risk Scores for the derivation and validation cohorts were: 44% low-risk, 45% moderate-risk, 11% high-risk. Strongest HK predictors were renal failure, dialysis, aldosterone blockers, diabetes, and smoking. Conclusion Within this large system, HK was associated with a large clinical burden, affecting over 1 in 10 patients; HK was also associated with increased 3-year MACE risk and higher medical costs. Although risk worsened with more severe or persistently recurring HK, even mild or intermittent HK episodes were associated with significantly greater adverse clinical outcomes and medical costs. The HyperK Score predicted patients who may benefit from closer management to reduce HK risk and associated costs. It should be remembered that our assumptions are valid only for detected HK and not HK per se.
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13
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Horne BD, May HT, Muhlestein JB, Le VT, Bair TL, Knowlton KU, Anderson JL. Association of periodic fasting with lower severity of COVID-19 outcomes in the SARS-CoV-2 prevaccine era: an observational cohort from the INSPIRE registry. BMJ Nutr Prev Health 2022; 5:145-153. [PMID: 36619318 PMCID: PMC9813631 DOI: 10.1136/bmjnph-2022-000462] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [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: 03/18/2022] [Accepted: 05/20/2022] [Indexed: 01/11/2023] Open
Abstract
Objectives Intermittent fasting boosts some host defence mechanisms while modulating the inflammatory response. Lower-frequency fasting is associated with greater survival and lower risk from COVID-19-related comorbidities. This study evaluated associations of periodic fasting with COVID-19 severity and, secondarily, initial infection by SARS-CoV-2. Design Prospective longitudinal observational cohort study. Setting Single-centre secondary care facility in Salt Lake City, Utah, USA with follow-up across a 24-hospital integrated healthcare system. Participants Patients enrolled in the INSPIRE registry in 2013-2020 were studied for the primary outcome if they tested positive for SARS-CoV-2 during March 2020 to February 2021 (n=205) or, for the secondary outcome, if they had any SARS-CoV-2 test result (n=1524). Interventions No treatment assignments were made; individuals reported their personal history of routine periodic fasting across their life span. Main outcome measures A composite of mortality or hospitalisation was the primary outcome and evaluated by Cox regression through February 2021 with multivariable analyses considering 36 covariables. The secondary outcome was whether a patient tested positive for SARS-CoV-2. Results Subjects engaging in periodic fasting (n=73, 35.6%) did so for 40.4±20.6 years (max: 81.9 years) prior to COVID-19 diagnosis. The composite outcome occurred in 11.0% of periodic fasters and 28.8% of non-fasters (p=0.013), with HR=0.61 (95% CI 0.42 to 0.90) favouring fasting. Multivariable analyses confirmed this association. Other predictors of hospitalisation/mortality were age, Hispanic ethnicity, prior MI, prior TIA and renal failure, with trends for race, smoking, hyperlipidaemia, coronary disease, diabetes, heart failure and anxiety, but not alcohol use. In secondary analysis, COVID-19 was diagnosed in 14.3% of fasters and 13.0% of non-fasters (p=0.51). Conclusions Routine periodic fasting was associated with a lower risk of hospitalisation or mortality in patients with COVID-19. Fasting may be a complementary therapy to vaccination that could provide immune support and hyperinflammation control during and beyond the pandemic. Trial registration Clinicaltrials.gov, NCT02450006 (the INSPIRE registry).
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Affiliation(s)
- Benjamin D Horne
- Intermountain Heart Institute, Intermountain Medical Center, Salt Lake City, Utah, USA,Department of Medicine, Division of Cardiovascular Medicine, Stanford University, Stanford, California, USA
| | - Heidi T May
- Intermountain Heart Institute, Intermountain Medical Center, Salt Lake City, Utah, USA
| | - Joseph B Muhlestein
- Intermountain Heart Institute, Intermountain Medical Center, Salt Lake City, Utah, USA,Department of Internal Medicine, Cardiology Division, University of Utah, Salt Lake City, Utah, USA
| | - Viet T Le
- Intermountain Heart Institute, Intermountain Medical Center, Salt Lake City, Utah, USA,Department of Physician Assistant Studies, Rocky Mountain University of Health Professions, Provo, Utah, USA
| | - Tami L Bair
- Intermountain Heart Institute, Intermountain Medical Center, Salt Lake City, Utah, USA
| | - Kirk U Knowlton
- Intermountain Heart Institute, Intermountain Medical Center, Salt Lake City, Utah, USA,Department of Medicine, Division of Cardiovascular Medicine, University of California San Diego, La Jolla, California, USA
| | - Jeffrey L Anderson
- Intermountain Heart Institute, Intermountain Medical Center, Salt Lake City, Utah, USA,Department of Internal Medicine, Cardiology Division, University of Utah, Salt Lake City, Utah, USA
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14
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Horne BD, Anderson JL, May HT, Le VT, Galenko O, Drakos SG, Bair TL, Knowlton KU, Muhlestein JB. Intermittent fasting and changes in Galectin-3: A secondary analysis of a randomized controlled trial of disease-free subjects. Nutr Metab Cardiovasc Dis 2022; 32:1538-1548. [PMID: 35361560 DOI: 10.1016/j.numecd.2022.03.001] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/20/2021] [Revised: 02/08/2022] [Accepted: 03/01/2022] [Indexed: 11/30/2022]
Abstract
BACKGROUND AND AIMS Intermittent fasting reduces risk of interrelated cardiometabolic diseases, including type 2 diabetes and heart failure (HF). Previously, we reported that intermittent fasting reduced homeostasis model assessment of insulin resistance (HOMA-IR) and Metabolic Syndrome Score (MSS) in the WONDERFUL Trial. Galectin-3 may act to reduce insulin resistance. This post hoc evaluation assessed whether intermittent fasting increased galectin-3. METHODS AND RESULTS The WONDERFUL Trial enrolled adults ages 21-70 years with ≥1 metabolic syndrome features or type 2 diabetes who were not taking anti-diabetic medication, were free of statins, and had elevated LDL-C. Subjects were randomized to water-only 24-h intermittent fasting conducted twice-per-week for 4 weeks and once-per-week for 22 weeks or to a parallel control arm with ad libitum energy intake. The study evaluated 26-week change scores of galectin-3 and other biomarkers. Overall, n = 67 subjects (intermittent fasting: n = 36; control: n = 31) completed the trial and had galectin-3 results. At 26-weeks, the galectin-3 change score was increased by intermittent fasting (median: 0.793 ng/mL, IQR: -0.538, 2.245) versus control (median: -0.332 ng/mL, IQR: -0.992, 0.776; p = 0.021). Galectin-3 changes correlated inversely with 26-week change scores of HOMA-IR (r = -0.288, p = 0.018) and MSS (r = -0.238, p = 0.052). Other HF biomarkers were unchanged by fasting. CONCLUSION A 24-h water-only intermittent fasting regimen increased galectin-3. The fasting-triggered galectin-3 elevation was inversely correlated with declines in HOMA-IR and MSS. This may be an evolutionary adaptive survival response that protects human health by modifying disease risks, including by reducing inflammation and insulin resistance. TRIAL REGISTRATION Clinicaltrials.gov, NCT02770313 (registered on May 12, 2016; first subject enrolled: November 30, 2016; final subject's 26-week study visit: February 19, 2020).
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Affiliation(s)
- Benjamin D Horne
- Intermountain Medical Center Heart Institute, Salt Lake City, UT, USA; Division of Cardiovascular Medicine, Department of Medicine, Stanford University, Stanford, CA, USA.
| | - Jeffrey L Anderson
- Intermountain Medical Center Heart Institute, Salt Lake City, UT, USA; Cardiology Division and Nora Eccles Harrison CVRTI, University of Utah, Salt Lake City, UT, USA
| | - Heidi T May
- Intermountain Medical Center Heart Institute, Salt Lake City, UT, USA
| | - Viet T Le
- Intermountain Medical Center Heart Institute, Salt Lake City, UT, USA; Rocky Mountain University of Health Professions, Provo, UT, USA
| | - Oxana Galenko
- Intermountain Medical Center Heart Institute, Salt Lake City, UT, USA
| | - Stavros G Drakos
- Cardiology Division and Nora Eccles Harrison CVRTI, University of Utah, Salt Lake City, UT, USA
| | - Tami L Bair
- Intermountain Medical Center Heart Institute, Salt Lake City, UT, USA
| | - Kirk U Knowlton
- Intermountain Medical Center Heart Institute, Salt Lake City, UT, USA; Division of Cardiovascular Medicine, Department of Medicine, University of California San Diego, La Jolla, CA, USA
| | - Joseph B Muhlestein
- Intermountain Medical Center Heart Institute, Salt Lake City, UT, USA; Cardiology Division and Nora Eccles Harrison CVRTI, University of Utah, Salt Lake City, UT, USA
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Horne BD, Bledsoe JR, Muhlestein JB, May HT, Peltan ID, Webb BJ, Carlquist JF, Bennett ST, Rea S, Bair TL, Grissom CK, Knight S, Ronnow BS, Le VT, Stenehjem E, Woller SC, Knowlton KU, Anderson JL. Association of the Intermountain Risk Score with major adverse health events in patients positive for COVID-19: an observational evaluation of a US cohort. BMJ Open 2022; 12:e053864. [PMID: 35332038 PMCID: PMC8948080 DOI: 10.1136/bmjopen-2021-053864] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/08/2023] Open
Abstract
OBJECTIVES The Intermountain Risk Score (IMRS), composed using published sex-specific weightings of parameters in the complete blood count (CBC) and basic metabolic profile (BMP), is a validated predictor of mortality. We hypothesised that IMRS calculated from prepandemic CBC and BMP predicts COVID-19 outcomes and that IMRS using laboratory results tested at COVID-19 diagnosis is also predictive. DESIGN Prospective observational cohort study. SETTING Primary, secondary, urgent and emergent care, and drive-through testing locations across Utah and in sections of adjacent US states. Viral RNA testing for SARS-CoV-2 was conducted from 3 March to 2 November 2020. PARTICIPANTS Patients aged ≥18 years were evaluated if they had CBC and BMP measured in 2019 and tested positive for COVID-19 in 2020. PRIMARY AND SECONDARY OUTCOME MEASURES The primary outcome was a composite of hospitalisation or mortality, with secondary outcomes being hospitalisation and mortality separately. RESULTS Among 3883 patients, 8.2% were hospitalised and 1.6% died. Subjects with low, mild, moderate and high-risk IMRS had the composite endpoint in 3.5% (52/1502), 8.6% (108/1256), 15.5% (152/979) and 28.1% (41/146) of patients, respectively. Compared with low-risk, subjects in mild-risk, moderate-risk and high-risk groups had HR=2.33 (95% CI 1.67 to 3.24), HR=4.01 (95% CI 2.93 to 5.50) and HR=8.34 (95% CI 5.54 to 12.57), respectively. Subjects aged <60 years had HR=3.06 (95% CI 2.01 to 4.65) and HR=7.38 (95% CI 3.14 to 17.34) for moderate and high risks versus low risk, respectively; those ≥60 years had HR=1.95 (95% CI 0.99 to 3.86) and HR=3.40 (95% CI 1.63 to 7.07). In multivariable analyses, IMRS was independently predictive and was shown to capture substantial risk variation of comorbidities. CONCLUSIONS IMRS, a simple risk score using very basic laboratory results, predicted COVID-19 hospitalisation and mortality. This included important abilities to identify risk in younger adults with few diagnosed comorbidities and to predict risk prior to SARS-CoV-2 infection.
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Affiliation(s)
- Benjamin D Horne
- Intermountain Heart Institute, Intermountain Medical Center, Salt Lake City, Utah, USA
- Division of Cardiovascular Medicine, Department of Medicine, Stanford University, Stanford, CA, USA
| | - Joseph R Bledsoe
- Department of Emergency Medicine, Intermountain Medical Center, Salt Lake City, UT, USA
- Department of Emergency Medicine, Stanford University, Stanford, CA, USA
| | - Joseph B Muhlestein
- Intermountain Heart Institute, Intermountain Medical Center, Salt Lake City, Utah, USA
- Cardiology Division, Department of Internal Medicine, University of Utah, Salt Lake City, Utah, USA
| | - Heidi T May
- Intermountain Heart Institute, Intermountain Medical Center, Salt Lake City, Utah, USA
| | - Ithan D Peltan
- Pulmonary and Critical Care, Intermountain Medical Center, Salt Lake City, Utah, USA
- Division of Respiratory, Critical Care and Occupational Pulmonary Medicine, University of Utah, Salt Lake City, Utah, USA
| | - Brandon J Webb
- Division of Infectious Diseases and Clinical Epidemiology, Department of Medicine, Intermountain Medical Center, Salt Lake City, Utah, USA
- Division of Infectious Diseases and Geographic Medicine, Department of Medicine, Stanford University, Stanford, CA, USA
| | - John F Carlquist
- Intermountain Heart Institute, Intermountain Medical Center, Salt Lake City, Utah, USA
- Cardiology Division, Department of Internal Medicine, University of Utah, Salt Lake City, Utah, USA
| | - Sterling T Bennett
- Intermountain Central Laboratory, Intermountain Medical Center, Salt Lake City, UT, USA
- Department of Pathology, University of Utah, Salt Lake City, UT, USA
| | - Susan Rea
- Care Transformation Information Systems, Intermountain Healthcare, Salt Lake City, UT, USA
| | - Tami L Bair
- Intermountain Heart Institute, Intermountain Medical Center, Salt Lake City, Utah, USA
| | - Colin K Grissom
- Pulmonary and Critical Care, Intermountain Medical Center, Salt Lake City, Utah, USA
- Division of Respiratory, Critical Care and Occupational Pulmonary Medicine, University of Utah, Salt Lake City, Utah, USA
| | - Stacey Knight
- Intermountain Heart Institute, Intermountain Medical Center, Salt Lake City, Utah, USA
| | - Brianna S Ronnow
- Intermountain Heart Institute, Intermountain Medical Center, Salt Lake City, Utah, USA
| | - Viet T Le
- Intermountain Heart Institute, Intermountain Medical Center, Salt Lake City, Utah, USA
| | - Edward Stenehjem
- Division of Infectious Diseases and Clinical Epidemiology, Department of Medicine, Intermountain Medical Center, Salt Lake City, Utah, USA
- Division of Infectious Diseases and Geographic Medicine, Department of Medicine, Stanford University, Stanford, CA, USA
| | - Scott C Woller
- Department of Medicine, Intermountain Medical Center, Salt Lake City, UT, USA
- Department of Internal Medicine, University of Utah, Salt Lake City, UT, USA
| | - Kirk U Knowlton
- Intermountain Heart Institute, Intermountain Medical Center, Salt Lake City, Utah, USA
- Division of Cardiovascular Medicine, Department of Medicine, University of California San Diego, La Jolla, CA, USA
| | - Jeffrey L Anderson
- Intermountain Heart Institute, Intermountain Medical Center, Salt Lake City, Utah, USA
- Cardiology Division, Department of Internal Medicine, University of Utah, Salt Lake City, Utah, USA
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16
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Anderson JL, May HT, Knight S, Bair TL, Horne BD, Knowlton KU. Association of Rhesus Factor Blood Type with Risk of SARS-CoV-2 Infection and COVID-19 Severity. Br J Haematol 2022; 197:573-575. [PMID: 35106763 DOI: 10.1111/bjh.18086] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/02/2021] [Revised: 01/27/2022] [Accepted: 01/28/2022] [Indexed: 11/30/2022]
Affiliation(s)
- Jeffrey L Anderson
- Intermountain Medical Center Heart Institute, Salt Lake City, UT.,University of Utah School of Medicine, Salt Lake City, UT
| | - Heidi T May
- Intermountain Medical Center Heart Institute, Salt Lake City, UT
| | - Stacey Knight
- Intermountain Medical Center Heart Institute, Salt Lake City, UT.,University of Utah School of Medicine, Salt Lake City, UT
| | - Tami L Bair
- Intermountain Medical Center Heart Institute, Salt Lake City, UT
| | - Benjamin D Horne
- Intermountain Medical Center Heart Institute, Salt Lake City, UT.,Stanford University, Stanford, CA
| | - Kirk U Knowlton
- Intermountain Medical Center Heart Institute, Salt Lake City, UT.,University of Utah School of Medicine, Salt Lake City, UT
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Horne BD, Muhlestein JB, Lappé DL, May HT, Le VT, Bair TL, Babcock D, Bride D, Knowlton KU, Anderson JL. Behavioral Nudges as Patient Decision Support for Medication Adherence: The ENCOURAGE Randomized Controlled Trial. Am Heart J 2022; 244:125-134. [PMID: 34798073 DOI: 10.1016/j.ahj.2021.11.001] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [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: 04/06/2021] [Accepted: 11/04/2021] [Indexed: 12/15/2022]
Abstract
BACKGROUND Medication adherence is generally low and challenging to address because patient actions control healthcare delivery outside of medical environments. Behavioral nudging changes clinician behavior, but nudging patient decision-making requires further testing. This trial evaluated whether behavioral nudges can increase statin adherence, measured as the proportion of days covered (PDC). METHODS In a 12-month parallel-group, unblinded, randomized controlled trial, adult patients in Intermountain Healthcare cardiology clinics were enrolled. Inclusion required an indication for statins and membership in SelectHealth insurance. Subjects were randomized 1:1 to control or nudges. Nudge content, timing, frequency, and delivery route were personalized by CareCentra using machine learning of subject motivations and abilities from psychographic assessment, demographics, social determinants, and the Intermountain Mortality Risk Score. PDC calculation used SelectHealth claims data. RESULTS Among 182 subjects, age averaged 63.2±8.5 years, 25.8% were female, baseline LDL-C was 82.5±32.7 mg/dL, and 93.4% had coronary disease. Characteristics were balanced between nudge (n = 89) and control arms (n = 93). The statin PDC was greater at 12 months in the nudge group (PDC: 0.742±0.318) compared to controls (PDC: 0.639±0.358, P = 0.042). Adherent subjects (PDC ≥80%) were more concentrated in the nudge group (66.3% vs controls: 50.5%, P = 0.036) while a composite of death, myocardial infarction, stroke, and revascularization was non-significant (nudges: 6.7% vs control: 10.8%, P = 0.44). CONCLUSIONS Persuasive behavioral nudges driven by artificial intelligence resulted in a clinically important increase in statin adherence in general cardiology patients. This precision patient decision support utilized computerized nudge design and delivery with minimal on-going human input.
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Affiliation(s)
- Benjamin D Horne
- Intermountain Medical Center Heart Institute, Salt Lake City, Utah, USA; Division of Cardiovascular Medicine, Department of Medicine, Stanford University, Stanford, California, USA.
| | - Joseph B Muhlestein
- Intermountain Medical Center Heart Institute, Salt Lake City, Utah, USA; Cardiology Division, Department of Internal Medicine, University of Utah, Salt Lake City, Utah, USA
| | - Donald L Lappé
- Intermountain Medical Center Heart Institute, Salt Lake City, Utah, USA; Cardiology Division, Department of Internal Medicine, University of Utah, Salt Lake City, Utah, USA
| | - Heidi T May
- Intermountain Medical Center Heart Institute, Salt Lake City, Utah, USA
| | - Viet T Le
- Intermountain Medical Center Heart Institute, Salt Lake City, Utah, USA; Rocky Mountain University of Health Professions, Provo, Utah, USA
| | - Tami L Bair
- Intermountain Medical Center Heart Institute, Salt Lake City, Utah, USA
| | - Daniel Babcock
- Intermountain Medical Center Heart Institute, Salt Lake City, Utah, USA
| | - Daniel Bride
- Intermountain Medical Center Heart Institute, Salt Lake City, Utah, USA
| | - Kirk U Knowlton
- Intermountain Medical Center Heart Institute, Salt Lake City, Utah, USA; Division of Cardiovascular Medicine, Department of Medicine, University of California San Diego, La Jolla, California, USA
| | - Jeffrey L Anderson
- Intermountain Medical Center Heart Institute, Salt Lake City, Utah, USA; Cardiology Division, Department of Internal Medicine, University of Utah, Salt Lake City, Utah, USA
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18
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Bartholomew CL, Muhlestein JB, Anderson JL, May HT, Knowlton KU, Bair TL, Le VT, Bailey BW, Horne BD. Association of periodic fasting lifestyles with survival and incident major adverse cardiovascular events in patients undergoing cardiac catheterization. Eur J Prev Cardiol 2022; 28:1774-1781. [PMID: 33624026 DOI: 10.1093/eurjpc/zwaa050] [Citation(s) in RCA: 4] [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] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/29/2020] [Revised: 06/26/2020] [Accepted: 08/10/2020] [Indexed: 12/12/2022]
Abstract
AIMS Animal models repeatedly show fasting increases longevity. Human data, though, are limited to anecdotal claims. This study evaluated the association of routine fasting with survival and, secondarily, with incident major adverse cardiovascular events. METHODS AND RESULTS Cardiac catheterization patients enrolled in the Intermountain INSPIRE longitudinal cohort (n = 2785) during 2013-2015 were followed through March 2019. A fasting survey was completed in n = 2025 (73%) of this cohort and 1957 were included in the final data analysis after 68 participants were removed (24 for data issues and 44 for fasting less than 5 years). Self-reported routine fasting behaviour, years of participation in fasting, and other fasting characteristics were surveyed. Mortality was the primary outcome and incident myocardial infarction (MI), stroke, and heart failure (HF) were secondary. Routine fasters (n = 389, mean age 64 ± 14 years, 34% female) averaged 42 ± 18 years of routine fasting (minimum 5 years). Non-fasters (n = 1568, aged 63 ± 14 years, 36% female) included never fasters (n = 1120 with 0 years of fasting) and previous fasters (n = 448 who averaged 32 ± 21 years of prior fasting but had stopped prior to enrolment). Routine fasters had greater survival vs. non-fasters [adjusted hazard ratio (HR) = 0.54, 95% confidence interval (CI) = 0.36-0.80; P = 0.002] and lower incidence of HF (adjusted HR = 0.31, CI = 0.12-0.78; P = 0.013), but not MI or stroke after adjustment. CONCLUSIONS Routine fasting followed during two-thirds of the lifespan was associated with higher survival after cardiac catheterization. This may in part be explained by an association of routine fasting with a lower incidence of HF. CLINICAL STUDY REGISTRATION The Intermountain INSPIRE registry https://clinicaltrials.gov/, NCT02450006.
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Affiliation(s)
- Ciera L Bartholomew
- Department of Exercise Sciences, 106 SFH, Brigham Young University, Provo, UT 84602, USA
| | - Joseph B Muhlestein
- Intermountain Medical Center Heart Institute, 5121 S. Cottonwood St., Salt Lake City, UT 84107, USA.,Cardiology Division, Department of Internal Medicine, University of Utah, Salt Lake City, UT, USA
| | - Jeffrey L Anderson
- Intermountain Medical Center Heart Institute, 5121 S. Cottonwood St., Salt Lake City, UT 84107, USA.,Cardiology Division, Department of Internal Medicine, University of Utah, Salt Lake City, UT, USA
| | - Heidi T May
- Intermountain Medical Center Heart Institute, 5121 S. Cottonwood St., Salt Lake City, UT 84107, USA
| | - Kirk U Knowlton
- Intermountain Medical Center Heart Institute, 5121 S. Cottonwood St., Salt Lake City, UT 84107, USA.,Division of Cardiovascular Medicine, Department of Medicine, University of California San Diego, 9500 Gilman Drive, Mail Code 7411, La Jolla, CA 92037-7411 USA
| | - Tami L Bair
- Intermountain Medical Center Heart Institute, 5121 S. Cottonwood St., Salt Lake City, UT 84107, USA
| | - Viet T Le
- Intermountain Medical Center Heart Institute, 5121 S. Cottonwood St., Salt Lake City, UT 84107, USA.,Principle PA Faculty, Rocky Mountain University of Health Professions, 122 E 1700 S building 3, Provo, UT 84606, USA
| | - Bruce W Bailey
- Department of Exercise Sciences, 106 SFH, Brigham Young University, Provo, UT 84602, USA
| | - Benjamin D Horne
- Intermountain Medical Center Heart Institute, 5121 S. Cottonwood St., Salt Lake City, UT 84107, USA.,Division of Cardiovascular Medicine, Department of Medicine, Stanford University, 870 Quarry Road, Stanford, CA 94305, USA
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19
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Burnham TS, May HT, Bair TL, Anderson JA, Crandall BG, Cutler MJ, Day JD, Freedman RA, Knowlton KU, Muhlestein JB, Navaravong L, Ranjan RA, Steinberg BA, Bunch TJ. Long-term outcomes in patients treated with flecainide for atrial fibrillation with stable coronary artery disease. Am Heart J 2022; 243:127-139. [PMID: 34537183 DOI: 10.1016/j.ahj.2021.08.013] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/13/2020] [Accepted: 08/18/2021] [Indexed: 11/01/2022]
Abstract
BACKGROUND Class 1C antiarrhythmic drugs (AAD) have been associated with harm in patients treated for ventricular arrhythmias with a prior myocardial infarction. Consensus guidelines have advocated that these drugs not be used in patients with stable coronary artery disease (CAD). However, long-term data are lacking to know if unique risks exist when these drugs are used for atrial fibrillation (AF) in patients with CAD without a prior myocardial infarction. METHODS In 24,315 patients treated with the initiation of AADs, two populations were evaluated: (1) propensity-matched AF patients with CAD were created based upon AAD class (flecainide, n = 1,114, vs class-3 AAD, n = 1,114) and (2) AF patients who had undergone a percutaneous coronary intervention or coronary artery bypass graft (flecainide, n = 150, and class-3 AAD, n = 1,453). Outcomes at 3 years for mortality, heart failure (HF) hospitalization, ventricular tachycardia (VT), and MACE were compared between the groups. RESULTS At 3 years, mortality (9.1% vs 19.3%, P < .0001), HF hospitalization (12.5% vs 18.3%, P < .0001), MACE (22.9% vs 36.6%, P < .0001), and VT (5.8% vs 8.5%, P = .02) rates were significantly lower in the flecainide group for population 1. In population 2, adverse event rates were also lower, although not significantly, in the flecainide compared to the class-3 AAD group for mortality (20.9% vs 25.8%, P = .26), HF hospitalization (24.5% vs 26.1%, P = .73), VT (10.9% vs 14.7%, P = .28) and MACE (44.5% vs 49.5%, P = .32). CONCLUSIONS Flecainide in select patients with stable CAD for AF has a favorable safety profile compared to class-3 AADs. These data suggest the need for prospective trials of flecainide in AF patients with CAD to determine if the current guideline-recommended exclusion is warranted.
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20
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Knowlton KU, Knight S, Muhlestein JB, Le VT, Horne BD, May HT, Stenehjem EA, Anderson JL. A small but significantly greater incidence of inflammatory heart disease identified after vaccination for SARS-CoV-2 (severe acute respiratory syndrome coronavirus 2). Open Forum Infect Dis 2021; 9:ofab663. [PMID: 35141346 PMCID: PMC8755376 DOI: 10.1093/ofid/ofab663] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/19/2021] [Accepted: 12/29/2021] [Indexed: 11/14/2022] Open
Abstract
Abstract
Background
SARS-CoV-2 vaccines are being administered on an unprecedented scale. Assessing the risks of side effects is needed to aid clinicians in early detection and treatment. This study examined the risk of inflammatory heart disease, including pericarditis and myocarditis, following SARS-CoV-2 vaccination.
Methods
Intermountain Healthcare patients with inflammatory heart disease from December 15, 2020, to June 15, 2021, and with or without preceding SARS-CoV-2 vaccinations were studied. Relative rates of inflammatory heart disease were examined for vaccinated patients compared to unvaccinated patients.
Results
Of 67 identified inflammatory heart disease patients, 21 (31.3%) had a SARS-Cov-2 vaccination within the previous 60 days. Overall, 914,611 Intermountain Healthcare patients received a SARS-CoV-2 vaccine, resulting in an inflammatory heart disease rate of 2.30 per 100,000 vaccinated patients. The relative risk of inflammatory heart disease for the vaccinated patients compared to the unvaccinated patients was 2.05 times higher rate within the 30-day window (p=0.01) and had a trend toward increase in the 60-day window (relative rate=1.63; p=0.07). All vaccinated patients with inflammatory heart disease were treated successfully with one death related to a pre-existing condition.
Conclusions
Though rare, the rate of inflammatory heart disease was greater in a SARS-CoV-2 vaccinated population than the unvaccinated population. This risk is eclipsed by the risk of contracting COVID-19 and its associated, commonly severe outcomes. Nevertheless, clinicians and patients should be informed of this risk to facilitate earlier recognition and treatment.
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Affiliation(s)
- Kirk U Knowlton
- Intermountain Medical Center, Salt Lake City, Utah, USA
- University of Utah School of Medicine, Salt Lake City, Utah, USA
| | - Stacey Knight
- Intermountain Medical Center, Salt Lake City, Utah, USA
- University of Utah School of Medicine, Salt Lake City, Utah, USA
| | - Joseph B Muhlestein
- Intermountain Medical Center, Salt Lake City, Utah, USA
- University of Utah School of Medicine, Salt Lake City, Utah, USA
| | - Viet T Le
- Intermountain Medical Center, Salt Lake City, Utah, USA
- Rocky Mountain University of Health Professions Physician Assistant Program, Provo, Utah, USA
| | - Benjamin D Horne
- Intermountain Medical Center, Salt Lake City, Utah, USA
- Stanford University School of Medicine, Stanford, CA, USA
| | - Heidi T May
- Intermountain Medical Center, Salt Lake City, Utah, USA
| | | | - Jeffrey L Anderson
- Intermountain Medical Center, Salt Lake City, Utah, USA
- University of Utah School of Medicine, Salt Lake City, Utah, USA
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21
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Varela DL, Burnham TS, May HT, Bair TL, Steinberg BA, Muhlestein JB, Anderson JL, Knowlton KU, Jared Bunch T. Economics and Outcomes of Sotalol In-Patient Dosing Approaches in Patients with Atrial Fibrillation. J Cardiovasc Electrophysiol 2021; 33:333-342. [PMID: 34953091 PMCID: PMC9305518 DOI: 10.1111/jce.15342] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/26/2021] [Revised: 10/22/2021] [Accepted: 10/27/2021] [Indexed: 11/30/2022]
Abstract
Introduction There exists variability in the administration of in‐patient sotalol therapy for symptomatic atrial fibrillation (AF). The impact of this variability on patient in‐hospital and 30‐day posthospitalization costs and outcomes is not known. Also, the cost impact of intravenous sotalol, which can accelerate drug loading to therapeutic levels, is unknown. Methods One hundred and thirty‐three AF patients admitted for oral sotalol initiation at an Intermountain Healthcare Hospital from January 2017 to December 2018 were included. Patient and dosing characteristics were described descriptively and the impact of dosing schedule was correlated with daily hospital costs/clinical outcomes during the index hospitalization and for 30 days. The Centers for Medicare and Medicaid Services reimbursement for 3‐day sotalol initiation is $9263.51. Projections of cost savings were made considering a 1‐day load using intravenous sotalol that costs $2500.00 to administer. Results The average age was 70.3 ± 12.3 years and 60.2% were male with comorbidities of hypertension (83%), diabetes (36%), and coronary artery disease (53%). The mean ejection fraction was 59.9 ± 7.8% and the median corrected QT interval was 453.7 ± 37.6 ms before sotalol dosing. No ventricular arrhythmias developed, but bradycardia (<60 bpm) was observed in 37.6% of patients. The average length of stay was 3.9 ± 4.6 (median: 2.2) days. Postdischarge outcomes and rehospitalization rates stratified by length of stay were similar. The cost per day was estimated at $2931.55 (1. $2931.55, 2. $5863.10, 3. $8794.65, 4. $11 726.20). Conclusions In‐patient oral sotalol dosing is markedly variable and results in the potential of both cost gain and loss to a hospital. In consideration of estimated costs, there is the potential for $871.55 cost savings compared to a 2‐day oral load and $3803.10 compared to a 3‐day oral load.
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Affiliation(s)
- Daniel L Varela
- University of Utah School of Medicine, Cardiology Division, 30 N 1900 E, Room 4A100, Salt Lake City, UT, USA, 84132
| | - Tyson S Burnham
- University of Utah School of Medicine, Cardiology Division, 30 N 1900 E, Room 4A100, Salt Lake City, UT, USA, 84132
| | - Heidi T May
- Intermountain Medical Center Heart Institute, 5169 Cottonwood, St #520, Murray, UT, USA, 84107
| | - Tami L Bair
- Intermountain Medical Center Heart Institute, 5169 Cottonwood, St #520, Murray, UT, USA, 84107
| | - Benjamin A Steinberg
- University of Utah School of Medicine, Cardiology Division, 30 N 1900 E, Room 4A100, Salt Lake City, UT, USA, 84132
| | - Joseph B Muhlestein
- University of Utah School of Medicine, Cardiology Division, 30 N 1900 E, Room 4A100, Salt Lake City, UT, USA, 84132
| | - Jeffrey L Anderson
- Intermountain Medical Center Heart Institute, 5169 Cottonwood, St #520, Murray, UT, USA, 84107
| | - Kirk U Knowlton
- Intermountain Medical Center Heart Institute, 5169 Cottonwood, St #520, Murray, UT, USA, 84107
| | - T Jared Bunch
- University of Utah School of Medicine, Cardiology Division, 30 N 1900 E, Room 4A100, Salt Lake City, UT, USA, 84132
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22
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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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23
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Horne BD, Muhlestein JB, May HT, Le VT, Bair TL, Bennett ST, Knowlton KU, Anderson JL. Preferential Metabolic Improvement by Intermittent Fasting in People with Elevated Baseline Red Cell Distribution Width: A Secondary Analysis of the WONDERFUL Randomized Controlled Trial. Nutrients 2021; 13:4407. [PMID: 34959959 PMCID: PMC8703681 DOI: 10.3390/nu13124407] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2021] [Revised: 12/03/2021] [Accepted: 12/03/2021] [Indexed: 12/26/2022] Open
Abstract
Red cell distribution width (RDW) predicts cardiovascular outcomes, but it is unstudied with regard to intermittent fasting. In WONDERFUL trial subjects, the effect of the interaction between baseline RDW and intermittent fasting on changes in insulin and other cardiometabolic endpoints and the effect of fasting on changes in RDW were evaluated. The subjects enrolled were aged 21-70 years and were free of statins, anti-diabetes medications, and chronic diseases, and had ≥1 metabolic syndrome feature, as well as elevated low-density lipoprotein cholesterol. Subjects were randomized to 24-h, water-only fasting (twice per week for 4 weeks, once per week for 22 weeks) or 26 weeks of ad libitum eating. Subjects (N = 71; n = 38 intermittent fasting, n = 33 controls) had more substantial changes in insulin in intermittent fasting vs. controls (-3.45 ± 2.27 vs. 0.48 ± 3.55 mIU/L) when baseline RDW size distribution (RDW-SD) was ≥median (42.6 fL) than
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Affiliation(s)
- Benjamin D. Horne
- Intermountain Medical Center Heart Institute, Salt Lake City, UT 84107, USA; (J.B.M.); (H.T.M.); (V.T.L.); (T.L.B.); (K.U.K.); (J.L.A.)
- Division of Cardiovascular Medicine, Department of Medicine, Stanford University, Stanford, CA 94305, USA
| | - Joseph B. Muhlestein
- Intermountain Medical Center Heart Institute, Salt Lake City, UT 84107, USA; (J.B.M.); (H.T.M.); (V.T.L.); (T.L.B.); (K.U.K.); (J.L.A.)
- Cardiology Division, Department of Internal Medicine, University of Utah, Salt Lake City, UT 84132, USA
| | - Heidi T. May
- Intermountain Medical Center Heart Institute, Salt Lake City, UT 84107, USA; (J.B.M.); (H.T.M.); (V.T.L.); (T.L.B.); (K.U.K.); (J.L.A.)
| | - Viet T. Le
- Intermountain Medical Center Heart Institute, Salt Lake City, UT 84107, USA; (J.B.M.); (H.T.M.); (V.T.L.); (T.L.B.); (K.U.K.); (J.L.A.)
- Department of Physician Assistant Studies, College of Medical and Health Professional Science, Rocky Mountain University of Health Professions, Provo, UT 84606, USA
| | - Tami L. Bair
- Intermountain Medical Center Heart Institute, Salt Lake City, UT 84107, USA; (J.B.M.); (H.T.M.); (V.T.L.); (T.L.B.); (K.U.K.); (J.L.A.)
| | - Sterling T. Bennett
- Intermountain Central Laboratory, Intermountain Medical Center, Salt Lake City, UT 84107, USA;
- Department of Pathology, University of Utah, Salt Lake City, UT 84132, USA
| | - Kirk U. Knowlton
- Intermountain Medical Center Heart Institute, Salt Lake City, UT 84107, USA; (J.B.M.); (H.T.M.); (V.T.L.); (T.L.B.); (K.U.K.); (J.L.A.)
- Division of Cardiovascular Medicine, Department of Medicine, University of California San Diego, San Diego, CA 92093, USA
| | - Jeffrey L. Anderson
- Intermountain Medical Center Heart Institute, Salt Lake City, UT 84107, USA; (J.B.M.); (H.T.M.); (V.T.L.); (T.L.B.); (K.U.K.); (J.L.A.)
- Cardiology Division, Department of Internal Medicine, University of Utah, Salt Lake City, UT 84132, USA
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24
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Anderson JL, Knight S, McCubrey RO, May HT, Mason S, Bunch TJ, Min DB, Cutler MJ, Le VT, Muhlestein JB, Knowlton KU. Absent or Mild Coronary Calcium Predicts Low-Risk Stress Test Results and Outcomes in Patients Considered for Flecainide Therapy. J Cardiovasc Pharmacol Ther 2021; 26:648-655. [PMID: 34546822 DOI: 10.1177/10742484211046671] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND Flecainide is a useful antiarrhythmic for atrial fibrillation (AF). However, because of ventricular proarrhythmia risk, a history of myocardial infarction (MI) or coronary artery disease (CAD) is a flecainide exclusion, and stress testing is used to exclude ischemia. We assessed whether absent/mild coronary artery calcium (CAC) can supplement or avoid the need for stress testing. METHODS We assessed ischemic burden using regadenoson Rb-82 PET/CT in 1372 AF patients ≥50 years old without symptoms or signs of clinical CAD. CAC was determined qualitatively by low dose attenuation computed tomography (CT) (n = 816) or by quantitative CT (n = 556). Ischemic burden and clinical outcomes were compared by CAC burden. RESULTS Patients with CAC absent or mild (n = 766, 57.2%) were younger, more frequently female, and had higher BMI but lower rates of diabetes, hypertension, and dyslipidemia. Average ischemic burden was lower in CAC-absent/mild patients, and CAC-absent/mild patients showed greater coronary flow reserve, had fewer referrals for coronary angiography, and less often had obstructive CAD. Revascularization at 90 days was lower, and the rate of longer-term major adverse cardiovascular events was favorable. CONCLUSIONS An easily administered, inexpensive, low radiation CAC scan can identify a subset of flecainide candidates with a low ischemic burden on PET stress testing that rarely needs coronary angiography/intervention and has favorable outcomes. Absent or mild CAC-burden combined with other clinical information may avoid or complement routine stress testing. However, additional, ideally randomized and multicenter trials are indicated to confirm these findings before replacing stress testing with CAC screening in selecting patients for flecainide therapy in clinical practice.
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Affiliation(s)
- Jeffrey L Anderson
- Intermountain Medical Center, 98078Intermountain Heart Institute, Salt Lake City, UT, USA.,14434University of Utah, School of Medicine, Salt Lake City, UT, USA
| | - Stacey Knight
- Intermountain Medical Center, 98078Intermountain Heart Institute, Salt Lake City, UT, USA
| | - Raymond O McCubrey
- Intermountain Medical Center, 98078Intermountain Heart Institute, Salt Lake City, UT, USA
| | - Heidi T May
- Intermountain Medical Center, 98078Intermountain Heart Institute, Salt Lake City, UT, USA
| | - Steve Mason
- Intermountain Medical Center, 98078Intermountain Heart Institute, Salt Lake City, UT, USA
| | - Thomas J Bunch
- 14434University of Utah, School of Medicine, Salt Lake City, UT, USA
| | - David B Min
- Intermountain Medical Center, 98078Intermountain Heart Institute, Salt Lake City, UT, USA
| | - Michael J Cutler
- Intermountain Medical Center, 98078Intermountain Heart Institute, Salt Lake City, UT, USA
| | - Viet T Le
- Intermountain Medical Center, 98078Intermountain Heart Institute, Salt Lake City, UT, USA.,Rocky Mountain University of Health Professionals, Provo, UT, USA
| | - Joseph B Muhlestein
- Intermountain Medical Center, 98078Intermountain Heart Institute, Salt Lake City, UT, USA.,14434University of Utah, School of Medicine, Salt Lake City, UT, USA
| | - Kirk U Knowlton
- Intermountain Medical Center, 98078Intermountain Heart Institute, Salt Lake City, UT, USA.,14434University of Utah, School of Medicine, Salt Lake City, UT, USA
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25
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Bartholomew CL, Muhlestein JB, May HT, Le VT, Galenko O, Garrett KD, Brunker C, Hopkins RO, Carlquist JF, Knowlton KU, Anderson JL, Bailey BW, Horne BD. Randomized controlled trial of once-per-week intermittent fasting for health improvement: the WONDERFUL trial. European Heart Journal Open 2021; 1:oeab026. [PMID: 35919268 PMCID: PMC9241570 DOI: 10.1093/ehjopen/oeab026] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 06/30/2021] [Revised: 07/27/2021] [Accepted: 08/31/2021] [Indexed: 12/17/2022]
Abstract
Abstract
Aims
Low-density lipoprotein cholesterol (LDL-C) predicts heart disease onset and may be reduced by intermittent fasting. Some studies, though, reported that fasting increased LDL-C; however, no study evaluated LDL-C as the primary endpoint. This randomized controlled trial evaluated the effect of low-frequency intermittent fasting on LDL-C and other biomarkers.
Methods and results
Adults aged 21–70 years were enrolled who were not taking a statin, had modestly elevated LDL-C, had ≥1 metabolic syndrome feature or type 2 diabetes, and were not taking anti-diabetic medication (N = 103). Water-only 24-h fasting was performed twice weekly for 4 weeks and then once weekly for 22 weeks; controls ate ad libitum. The primary outcome was 26-week LDL-C change score. Secondary outcomes (requiring P ≤ 0.01) were 26-week changes in homeostatic model assessment of insulin resistance (HOMA-IR), Metabolic Syndrome Score (MSS), brain-derived neurotrophic factor (BDNF), and MicroCog general cognitive proficiency index (GCPi). Intermittent fasting (n = 50) and control (n = 53) subjects were, respectively, aged 49.3 ± 12.0 and 47.0 ± 9.8 years, predominantly female (66.0% and 67.9%), and overweight (103 ± 24 and 100 ± 21 kg) and had modest LDL-C elevation (124 ± 19 and 128 ± 20 mg/dL). Drop-outs (n = 12 fasting, n = 20 control) provided an evaluable sample of n = 71 (n = 38 fasting, n = 33 control). Intermittent fasting did not change LDL-C (0.2 ± 16.7 mg/dL) vs. control (2.5 ± 19.4 mg/dL; P = 0.59), but it improved HOMA-IR (−0.75 ± 0.79 vs. −0.10 ± 1.06; P = 0.004) and MSS (−0.34 ± 4.72 vs. 0.31 ± 1.98, P = 0.006). BDNF (P = 0.58), GCPi (P = 0.17), and weight (−1.7 ± 4.7 kg vs. 0.2 ± 3.5 kg, P = 0.06) were unchanged.
Conclusions
A low-frequency intermittent fasting regimen did not reduce LDL-C or improve cognitive function but significantly reduced both HOMA-IR and MSS.
Trial registration
clinicaltrials.gov, NCT02770313.
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Affiliation(s)
| | - Joseph B Muhlestein
- Intermountain Medical Center Heart Institute , 5121 S. Cottonwood St. , Salt Lake City, UT 84107, USA
- Cardiology Division, Department of Internal Medicine, University of Utah , Salt Lake City, UT, USA
| | - Heidi T May
- Intermountain Medical Center Heart Institute , 5121 S. Cottonwood St. , Salt Lake City, UT 84107, USA
| | - Viet T Le
- Intermountain Medical Center Heart Institute , 5121 S. Cottonwood St. , Salt Lake City, UT 84107, USA
- Rocky Mountain University of Health Professions , Provo, UT, USA
| | - Oxana Galenko
- Intermountain Medical Center Heart Institute , 5121 S. Cottonwood St. , Salt Lake City, UT 84107, USA
| | - Kelly Davis Garrett
- Neuropsychology, Intermountain Medical Center , Salt Lake City, UT, USA
- Center for Aging, University of Utah , Salt Lake City, UT, USA
| | - Cherie Brunker
- Geriatric Medicine, Department of Internal Medicine, Intermountain Medical Center
- Division of Geriatrics, Department of Internal Medicine, University of Utah , Salt Lake City, UT, USA
| | - Ramona O Hopkins
- Pulmonary Division, Department of Internal Medicine, Intermountain Medical Center , Salt Lake City, UT, USA
- Psychology Department and Neuroscience Center, Brigham Young University , Provo, UT, USA
| | - John F Carlquist
- Intermountain Medical Center Heart Institute , 5121 S. Cottonwood St. , Salt Lake City, UT 84107, USA
- Cardiology Division, Department of Internal Medicine, University of Utah , Salt Lake City, UT, USA
| | - Kirk U Knowlton
- Intermountain Medical Center Heart Institute , 5121 S. Cottonwood St. , Salt Lake City, UT 84107, USA
- Division of Cardiovascular Medicine, Department of Medicine, University of California San Diego , La Jolla, CA, USA
| | - Jeffrey L Anderson
- Intermountain Medical Center Heart Institute , 5121 S. Cottonwood St. , Salt Lake City, UT 84107, USA
- Cardiology Division, Department of Internal Medicine, University of Utah , Salt Lake City, UT, USA
| | - Bruce W Bailey
- Department of Exercise Sciences, Brigham Young University , Provo, UT, USA
| | - Benjamin D Horne
- Intermountain Medical Center Heart Institute , 5121 S. Cottonwood St. , Salt Lake City, UT 84107, USA
- Division of Cardiovascular Medicine, Department of Medicine, Stanford University , Stanford, CA, USA
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26
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Rizzi SA, Knight S, May HT, Woller SC, Stevens SM, Steinberg BA, Bair TL, Anderson JL, Muhlestein JB, Knowlton KU, Bunch TJ. Depression as a Driving Force for Low Time in Therapeutic Range and Dementia in Patients With and Without Atrial Fibrillation. Am J Cardiol 2021; 153:58-64. [PMID: 34176597 DOI: 10.1016/j.amjcard.2021.05.021] [Citation(s) in RCA: 3] [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: 03/12/2021] [Revised: 05/07/2021] [Accepted: 05/14/2021] [Indexed: 11/28/2022]
Abstract
Both time in therapeutic range (TTR) for anticoagulation and depression are associated with dementia risk. The purposes of this study were to examine the impact of depression on TTR and to describe the partitioned contribution of depression and TTR on long-term dementia risk. We studied 14,953 patients anticoagulated with warfarin (target INR 2-3) for atrial fibrillation (AF), venous thromboembolism (VTE), or a mechanical heart valve from 2003 to 2015. We excluded patients with a diagnosis of dementia before or within 6 months of warfarin initiation. We examined the association of depression with TTR using finite mixture modeling and logistic regression and utilized multivariable Cox hazard regression to determine the association of TTR and depression with incident dementia at 3 and 13 years. Forty % (n = 6055) of patients were diagnosed with depression before or while on warfarin. Patients with depression had significantly lower TTR and were 1.37 times more likely to have TTR <50% than non-depressed patients (p <0.0001). During follow-up, 4.2% of patients received the diagnosis of dementia within 3 years as compared to 12% during all-time follow up. The 3-year risk of dementia was highest for patients with a ≤50% TTR regardless of depression status. The 3-year dementia risk was associated with TTR (p <0.0001) but not depression. However, for all-time dementia both TTR (p <0.0001) and depression (p <0.0001) as well as their interaction (p = 0.049) were associated with dementia. Depression increased the risk of long-term dementia by 1.69 fold (95% CI: 1.33, 2.15) for patients with the lowest TTR. Depression is prevalent in patients managed with warfarin and is associated with significant decreases in TTR. In conclusion, decreased TTR appears to increase 3-year dementia risk and both low TTR and depression interact to increase risk for all-time dementia in patients taking warfarin.
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Affiliation(s)
- Scott A Rizzi
- Department of Medicine, School of Medicine, University of Utah, Salt Lake City, Utah
| | - Stacey Knight
- Intermountain Medical Center Heart Institute, Intermountain Medical Center, Murray, Utah
| | - Heidi T May
- Intermountain Medical Center Heart Institute, Intermountain Medical Center, Murray, Utah
| | - Scott C Woller
- Department of Medicine, School of Medicine, University of Utah, Salt Lake City, Utah; Intermountain Medical Center Heart Institute, Intermountain Medical Center, Murray, Utah
| | - Scott M Stevens
- Department of Medicine, School of Medicine, University of Utah, Salt Lake City, Utah; Intermountain Medical Center Heart Institute, Intermountain Medical Center, Murray, Utah
| | - Benjamin A Steinberg
- Department of Medicine, School of Medicine, University of Utah, Salt Lake City, Utah
| | - Tami L Bair
- Intermountain Medical Center Heart Institute, Intermountain Medical Center, Murray, Utah
| | - Jeffrey L Anderson
- Department of Medicine, School of Medicine, University of Utah, Salt Lake City, Utah; Intermountain Medical Center Heart Institute, Intermountain Medical Center, Murray, Utah
| | - Joseph B Muhlestein
- Intermountain Medical Center Heart Institute, Intermountain Medical Center, Murray, Utah
| | - Kirk U Knowlton
- Intermountain Medical Center Heart Institute, Intermountain Medical Center, Murray, Utah
| | - T Jared Bunch
- Department of Medicine, School of Medicine, University of Utah, Salt Lake City, Utah.
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27
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Budoff MJ, Bhatt DL, Kinninger A, Lakshmanan S, Muhlestein JB, Le VT, May HT, Shaikh K, Shekar C, Roy SK, Tayek J, Nelson JR. Effect of icosapent ethyl on progression of coronary atherosclerosis in patients with elevated triglycerides on statin therapy: final results of the EVAPORATE trial. Eur Heart J 2021; 41:3925-3932. [PMID: 32860032 PMCID: PMC7654934 DOI: 10.1093/eurheartj/ehaa652] [Citation(s) in RCA: 228] [Impact Index Per Article: 76.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/01/2020] [Revised: 07/10/2020] [Accepted: 07/29/2020] [Indexed: 01/09/2023] Open
Abstract
Aims Despite the effects of statins in reducing cardiovascular events and slowing progression of coronary atherosclerosis, significant cardiovascular (CV) risk remains. Icosapent ethyl (IPE), a highly purified eicosapentaenoic acid ethyl ester, added to a statin was shown to reduce initial CV events by 25% and total CV events by 32% in the REDUCE-IT trial, with the mechanisms of benefit not yet fully explained. The EVAPORATE trial sought to determine whether IPE 4 g/day, as an adjunct to diet and statin therapy, would result in a greater change from baseline in plaque volume, measured by serial multidetector computed tomography (MDCT), than placebo in statin-treated patients. Methods and results A total of 80 patients were enrolled in this randomized, double-blind, placebo-controlled trial. Patients had to have coronary atherosclerosis as documented by MDCT (one or more angiographic stenoses with ≥20% narrowing), be on statin therapy, and have persistently elevated triglyceride (TG) levels. Patients underwent an interim scan at 9 months and a final scan at 18 months with coronary computed tomographic angiography. The pre-specified primary endpoint was change in low-attenuation plaque (LAP) volume at 18 months between IPE and placebo groups. Baseline demographics, vitals, and laboratory results were not significantly different between the IPE and placebo groups; the median TG level was 259.1 ± 78.1 mg/dL. There was a significant reduction in the primary endpoint as IPE reduced LAP plaque volume by 17%, while in the placebo group LAP plaque volume more than doubled (+109%) (P = 0.0061). There were significant differences in rates of progression between IPE and placebo at study end involving other plaque volumes including fibrous, and fibrofatty (FF) plaque volumes which regressed in the IPE group and progressed in the placebo group (P < 0.01 for all). When further adjusted for age, sex, diabetes status, hypertension, and baseline TG, plaque volume changes between groups remained significantly different, P < 0.01. Only dense calcium did not show a significant difference between groups in multivariable modelling (P = 0.053). Conclusions Icosapent ethyl demonstrated significant regression of LAP volume on MDCT compared with placebo over 18 months. EVAPORATE provides important mechanistic data on plaque characteristics that may have relevance to the REDUCE-IT results and clinical use of IPE.
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Affiliation(s)
- Matthew J Budoff
- Department of Medicine, Lundquist Institute at Harbor-UCLA Medical Center, 1124 W Carson Street, Torrance, CA 90502, USA
| | - Deepak L Bhatt
- Department of Medicine, Brigham and Women's Hospital Heart & Vascular Center and Harvard Medical School, Boston, MA, USA
| | - April Kinninger
- Department of Medicine, Lundquist Institute at Harbor-UCLA Medical Center, 1124 W Carson Street, Torrance, CA 90502, USA
| | - Suvasini Lakshmanan
- Department of Medicine, Lundquist Institute at Harbor-UCLA Medical Center, 1124 W Carson Street, Torrance, CA 90502, USA
| | - Joseph B Muhlestein
- Intermountain Heart Institute, Intermountain Medical Center, Salt Lake City, UT, USA
| | - Viet T Le
- Intermountain Heart Institute, Intermountain Medical Center, Salt Lake City, UT, USA.,Department of Medicine, Rocky Mountain University of Health Profession, Provo, UT, USA
| | - Heidi T May
- Intermountain Heart Institute, Intermountain Medical Center, Salt Lake City, UT, USA
| | - Kashif Shaikh
- Department of Medicine, Lundquist Institute at Harbor-UCLA Medical Center, 1124 W Carson Street, Torrance, CA 90502, USA
| | - Chandana Shekar
- Department of Medicine, Lundquist Institute at Harbor-UCLA Medical Center, 1124 W Carson Street, Torrance, CA 90502, USA
| | - Sion K Roy
- Department of Medicine, Lundquist Institute at Harbor-UCLA Medical Center, 1124 W Carson Street, Torrance, CA 90502, USA
| | - John Tayek
- Department of Medicine, Lundquist Institute at Harbor-UCLA Medical Center, 1124 W Carson Street, Torrance, CA 90502, USA
| | - John R Nelson
- California Cardiovascular Institute, Fresno, CA, USA
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28
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Anderson JL, May HT, Knight S, Bair TL, Muhlestein JB, Knowlton KU, Horne BD. Association of Sociodemographic Factors and Blood Group Type With Risk of COVID-19 in a US Population. JAMA Netw Open 2021; 4:e217429. [PMID: 33818622 PMCID: PMC8022215 DOI: 10.1001/jamanetworkopen.2021.7429] [Citation(s) in RCA: 21] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/02/2023] Open
Abstract
This case-control study examined the association of sociodemographic factors and blood group type with risk of SARS-CoV-2 infection and severity of COVID-19.
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Affiliation(s)
- Jeffrey L. Anderson
- Intermountain Medical Center Heart Institute, Salt Lake City, Utah
- University of Utah School of Medicine, Salt Lake City
| | - Heidi T. May
- Intermountain Medical Center Heart Institute, Salt Lake City, Utah
| | - Stacey Knight
- Intermountain Medical Center Heart Institute, Salt Lake City, Utah
- University of Utah School of Medicine, Salt Lake City
| | - Tami L. Bair
- Intermountain Medical Center Heart Institute, Salt Lake City, Utah
| | - Joseph B. Muhlestein
- Intermountain Medical Center Heart Institute, Salt Lake City, Utah
- University of Utah School of Medicine, Salt Lake City
| | - Kirk U. Knowlton
- Intermountain Medical Center Heart Institute, Salt Lake City, Utah
- University of Utah School of Medicine, Salt Lake City
| | - Benjamin D. Horne
- Intermountain Medical Center Heart Institute, Salt Lake City, Utah
- Stanford University, Stanford, California
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29
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May HT, Knowlton KU, Anderson JL, Lappé DL, Bair TL, Muhlestein JB. High Statin Adherence over 5 Years of Follow-up is Associated with Improved Cardiovascular Outcomes in Patients with Atherosclerotic Cardiovascular Disease: Results from the IMPRES Study. Eur Heart J Qual Care Clin Outcomes 2021; 8:352-360. [PMID: 33787865 DOI: 10.1093/ehjqcco/qcab024] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/01/2021] [Revised: 03/23/2021] [Accepted: 03/30/2021] [Indexed: 11/13/2022]
Abstract
AIMS Despite proven benefits of LDL-C lowering among those with atherosclerotic cardiovascular disease (ASCVD), statin adherence remains low. Very little real-world data exist on the effect of long-term statin adherence on cardiovascular outcomes. METHODS AND RESULTS A total of 7,339 patients ≥18 years first diagnosed with ASCVD with a statin prescription within 12-months of diagnosis who had 5-years of continuous Select Health insurance or died during years 2-5 while a member were studied. The proportion of days covered (PDC) was calculated using pharmacy claims for statin use by year, and patients were stratified into pre-defined categories: Fully-adherent (PDC≥80% for years 1-5 or until death, n = 353[4.8%]), Short-term-adherent (PDC≥80% for years 1-3, n = 330[4.5%]), Early-adherent-only (PDC≥80% for year 1, n = 890[12.1%]), Complex-adherent (PDC≥80% in any of years 2-5, but not year 1, n = 1,292[17.6%]), and Non-adherent (PDC<80% for years 1-5 or until death, n = 3,942[72.1%]). Patients were followed for major adverse clinical events (MACE=death, MI, and stroke). Patients averaged 56.4±9.6 years and 76.5% were male. During year 1, statin adherence was poor, with PDC<20% in 4,007 (54.6%) patients and PDC ≥80% in 1,573 (21.4%) patients, which dropped to 16.9% by year 5. Increased adherence was associated with significantly fewer MACE (11.6%, 17.9%, 21.9%, 21.1%, and 26.4% for those fully-adherent, short-term-adherent, early-adherent only, complex-adherent, and non-adherent, respectively, p-trend<0.0001). After adjustment, fully-adherent was associated with a significant decrease in MACE (HR = 0.51 [0.37, 0.71]). CONCLUSION Among ASCVD patients with at least 5-years of continuous pharmacy benefits, long-term adherence to statins was associated with decreased long-term MACE in a linear-fashion.
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Affiliation(s)
- Heidi T May
- Intermountain Medical Center Heart Institute, 5121 S Cottonwood Dr, Murray UT 84157
| | - Kirk U Knowlton
- Intermountain Medical Center Heart Institute, 5121 S Cottonwood Dr, Murray UT 84157.,University of Utah School of Medicine, 30 N Medical Dr, Salt Lake City, Utah 84132
| | - Jeffrey L Anderson
- Intermountain Medical Center Heart Institute, 5121 S Cottonwood Dr, Murray UT 84157.,University of Utah School of Medicine, 30 N Medical Dr, Salt Lake City, Utah 84132
| | - Donald L Lappé
- Intermountain Medical Center Heart Institute, 5121 S Cottonwood Dr, Murray UT 84157
| | - Tami L Bair
- Intermountain Medical Center Heart Institute, 5121 S Cottonwood Dr, Murray UT 84157
| | - Joseph B Muhlestein
- Intermountain Medical Center Heart Institute, 5121 S Cottonwood Dr, Murray UT 84157.,University of Utah School of Medicine, 30 N Medical Dr, Salt Lake City, Utah 84132
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30
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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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31
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Muhlestein JB, Kammerer J, Bair TL, Knowlton KU, Le VT, Anderson JL, Lappé DL, May HT. Frequency and clinical impact of hyperkalaemia within a large, modern, real-world heart failure population. ESC Heart Fail 2020; 8:691-696. [PMID: 33331114 PMCID: PMC7835576 DOI: 10.1002/ehf2.13164] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/19/2020] [Revised: 11/12/2020] [Accepted: 11/24/2020] [Indexed: 11/07/2022] Open
Abstract
AIMS This analysis qualitatively describes the impact of hyperkalaemia (HK) and renin-angiotensin-aldosterone system inhibitor (RAASi) use on clinical outcomes in patients with heart failure (HF). METHODS AND RESULTS Patients were included if they were ≥18 years old; had a serum potassium result between 1 January 2003 and 3 December 2018; had ≥2 separate, non-urgent care or emergency department encounters; and had an HF diagnosis. Criteria were met by 52 253 patients; 48 333 had sufficient follow-up for analysis. Patients were stratified by the presence/absence of HK (serum potassium >5.0 mmol/L) (n = 31 619 and n = 20 634, respectively) and by baseline left ventricular ejection fraction (LVEF) ≤40% or >40%. Compared with patients without HK (no-HK), those with HK had significantly higher rates of baseline cardiovascular risk factors, prior diagnoses, and greater RAASi use in both baseline and follow-up periods. Assessed outcomes included RAASi use, rate of 3 year major adverse cardiovascular events (MACE), and individual component rates. Between baseline and follow-up analyses, the proportion of patients on RAASi decreased by 5% in patients with HK but increased by 20% in no-HK patients. Overall, MACE and death were consistently highest in the presence of HK without RAASi treatment (63% and 62%, respectively) and lowest in no-HK but on RAASi (25% and 21%, respectively). After complete multivariable adjustment, these trends were consistent regardless of baseline LVEF. CONCLUSIONS In this large, real-world HF population, HK was common and linked to baseline clinical risk factors, declining use of RAASi treatment, and an increase in future MACE, regardless of baseline LVEF. Both HK and reduced RAASi use were independent predictors of future MACE.
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Affiliation(s)
- Joseph B. Muhlestein
- Department of CardiologyIntermountain Medical Center Heart Institute5121 S. Cottonwood StreetSalt Lake CityUT84157USA
- Department of CardiologyUniversity of UtahSalt Lake CityUTUSA
| | - Jennifer Kammerer
- Managed Care Health OutcomesRelypsa, Inc., a Vifor Pharma Group CompanyRedwood CityCAUSA
| | - Tami L. Bair
- BioinformaticsIntermountain Medical Center Heart InstituteSalt Lake CityUTUSA
| | - Kirk U. Knowlton
- Department of CardiologyIntermountain Medical Center Heart Institute5121 S. Cottonwood StreetSalt Lake CityUT84157USA
- Department of CardiologyUniversity of UtahSalt Lake CityUTUSA
| | - Viet T. Le
- Department of CardiologyIntermountain Medical Center Heart Institute5121 S. Cottonwood StreetSalt Lake CityUT84157USA
| | - Jeffrey L. Anderson
- Department of CardiologyIntermountain Medical Center Heart Institute5121 S. Cottonwood StreetSalt Lake CityUT84157USA
- Department of CardiologyUniversity of UtahSalt Lake CityUTUSA
| | - Donald L. Lappé
- Department of CardiologyIntermountain Medical Center Heart Institute5121 S. Cottonwood StreetSalt Lake CityUT84157USA
| | - Heidi T. May
- EpidemiologyIntermountain Medical Center Heart InstituteSalt Lake CityUTUSA
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32
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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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May HT, Anderson JL, Muhlestein JB, Knowlton KU, Horne BD. Intermountain chronic disease risk score (ICHRON) validation for prediction of incident chronic disease diagnoses in an australian primary prevention population. Eur J Intern Med 2020; 79:81-87. [PMID: 32563688 DOI: 10.1016/j.ejim.2020.06.009] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/11/2020] [Revised: 05/25/2020] [Accepted: 06/06/2020] [Indexed: 11/28/2022]
Abstract
BACKGROUND The Intermountain Chronic Disease Risk Score (ICHRON) is a primary prevention risk prediction tool that uses commonly ordered blood tests and is designed to be calculated by the electronic health record. ICHRON was highly predictive of 3-year chronic disease (ChrD) diagnosis in an internal validation; however, external validation is needed. METHODS ICHRON was calculated among patients from a region of Australia using sex-specific weightings of age and components of the comprehensive metabolic panel and the complete blood count. Original ICHRON weightings and risk stratification thresholds from the US-based derivation at Intermountain Healthcare were used. ICHRON was evaluated as a predictor of an incident 3-year ChrD diagnosis (coronary artery disease, myocardial infarction, heart failure, atrial fibrillation, stroke, dementia, diabetes, renal failure, chronic obstructive pulmonary disease, and peripheral vascular disease). RESULTS A total 5,512 females (49.6 ± 19.2) and 3,461 males (53.0 ± 18.6) were studied. Among females, 50.3%, 33.7% and 16.0% were low, moderate, and high-risk, respectively; and for males, 39.6%, 35.0%, and 25.4%. Frequency of a 3-year ChrD diagnosis among females was 2.2%, 8.5%, and 15.9% for low, moderate, and high-risk groups, respectively, and 4.7%, 9.7%, and 20.0% among males. C-statistics were 0.726 (0.700, 0.752) for females and 0.694 (0.665, 0.724) for males. CONCLUSION ICHRON predicted ChrD diagnosis at 3-years among an external, geographically distant validation cohort. These findings show the value of ICHRON for primary care patients in distinct locales. Additionally, electronic calculation of ICHRON empowers the clinical use of this tool to identify and differentially manage and treat high-risk patients.
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Affiliation(s)
- Heidi T May
- Intermountain Medical Center Heart Institute, Salt Lake City, UT, USA.
| | - Jeffrey L Anderson
- Intermountain Medical Center Heart Institute, Salt Lake City, UT, USA; University of Utah School of Medicine, Salt Lake City, UT, USA
| | - Joseph B Muhlestein
- Intermountain Medical Center Heart Institute, Salt Lake City, UT, USA; University of Utah School of Medicine, Salt Lake City, UT, USA
| | - Kirk U Knowlton
- Intermountain Medical Center Heart Institute, Salt Lake City, UT, USA; Division of Cardiovascular Medicine, Department of Medicine, University of California San Diego, San Diego, CA, USA
| | - Benjamin D Horne
- Intermountain Medical Center Heart Institute, Salt Lake City, UT, USA; Division of Cardiovascular Medicine, Department of Medicine, Stanford University School of Medicine, Stanford, CA, USA
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Muhlestein JB, Muhlestein JB, Anderson JL, Bethea CF, Severance HW, Mentz RJ, Barsness GW, Barbagelata A, Albert D, Le VT, Bunch TJ, Yanowitz F, May HT, Chisum B, Ronnow BS. Smartphone 12-lead ECG-Exciting but must be handled with care. Am Heart J 2020; 226:269. [PMID: 32811641 DOI: 10.1016/j.ahj.2020.03.004] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
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Budoff MJ, Muhlestein JB, Bhatt DL, Le Pa VT, May HT, Shaikh K, Shekar C, Kinninger A, Lakshmanan S, Roy SK, Tayek J, Nelson JR. Effect of icosapent ethyl on progression of coronary atherosclerosis in patients with elevated triglycerides on statin therapy: a prospective, placebo-controlled randomized trial (EVAPORATE): interim results. Cardiovasc Res 2020; 117:1070-1077. [PMID: 32609331 DOI: 10.1093/cvr/cvaa184] [Citation(s) in RCA: 37] [Impact Index Per Article: 9.3] [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] [Accepted: 06/23/2020] [Indexed: 12/30/2022] Open
Abstract
AIMS Though statin therapy is known to slow coronary atherosclerosis progression and reduce cardiovascular (CV) events, significant CV risk still remains. In the REDUCE-IT study, icosapent ethyl (IPE) added to statin therapy reduced initial CV events by 25% and total CV events by 30%, but its effects on coronary atherosclerosis progression have not yet been fully investigated. Therefore, this study is to determine whether IPE 4 g/day will result in a greater change from baseline in plaque volume measured by serial multidetector computed tomography than placebo in statin-treated patients. METHODS AND RESULTS EVAPORATE is a randomized, double-blind, placebo-controlled trial. Patients had to have coronary atherosclerosis by coronary computed tomographic angiography (CCTA) (≥1 angiographic stenoses with ≥20% narrowing), on stable statin therapy with low-density lipoprotein cholesterol levels 40-115 mg/dL, and persistently high triglyceride levels (135-499 mg/dL). Patients underwent an interim scan at 9 months and were followed for an additional 9 months with CCTA at 0, 9, and 18 months. Here, we present the protocol-specified interim efficacy results. A total of 80 patients were enrolled, with 67 completing the 9-month visit and having interpretable CCTA at baseline and at 9 months (age = 57 ± 6 years, male = 36, 63%). At the 9-month interim analysis, there was no significant change in low attenuation plaque (LAP) between active and placebo groups (74% vs. 94%, P = 0.469). However, there was slowing of total non-calcified plaque (sum of LAP, fibrofatty, and fibrous plaque) (35% vs. 43%, P = 0.010), total plaque (non-calcified + calcified plaque) (15% vs. 26%, P = 0.0004), fibrous plaque (17% vs. 40%, P = 0.011), and calcified plaque (-1% vs. 9%, P = 0.001), after adjustment by baseline plaque, age, sex, diabetes, baseline triglyceride levels, and statin use. CONCLUSION EVAPORATE is the first study using CCTA to evaluate the effects of IPE as an adjunct to statin therapy on atherosclerotic plaque characteristics in a high-risk CV population with persistently high triglyceride levels. It provides important mechanistic data in regards to the reduction in CV events in the REDUCE-IT clinical trial. CLINICALTRIALS. GOVIDENTIFIER NCT029226027.
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Affiliation(s)
- Matthew J Budoff
- Department of Medicine, Lundquist Institute at Harbor-UCLA Medical Center, 1124 W Carson Street, CDCRC, Torrance, CA 90502, USA
| | - Joseph B Muhlestein
- Department of Internal Medicine, Intermountain Heart Institute, Intermountain Medical Center, Salt Lake City, UT, USA
| | - Deepak L Bhatt
- Department of Internal Medicine, Brigham and Women's Hospital Heart & Vascular Center and Harvard Medical School, Boston, MA, USA
| | - Viet T Le Pa
- Department of Internal Medicine, Intermountain Heart Institute, Intermountain Medical Center, Salt Lake City, UT, USA.,Department of Internal Medicine, Rocky Mountain University of Health Profession, Provo, UT, USA
| | - Heidi T May
- Department of Internal Medicine, Intermountain Heart Institute, Intermountain Medical Center, Salt Lake City, UT, USA
| | - Kashif Shaikh
- Department of Medicine, Lundquist Institute at Harbor-UCLA Medical Center, 1124 W Carson Street, CDCRC, Torrance, CA 90502, USA
| | - Chandana Shekar
- Department of Medicine, Lundquist Institute at Harbor-UCLA Medical Center, 1124 W Carson Street, CDCRC, Torrance, CA 90502, USA
| | - April Kinninger
- Department of Medicine, Lundquist Institute at Harbor-UCLA Medical Center, 1124 W Carson Street, CDCRC, Torrance, CA 90502, USA
| | - Suvasini Lakshmanan
- Department of Medicine, Lundquist Institute at Harbor-UCLA Medical Center, 1124 W Carson Street, CDCRC, Torrance, CA 90502, USA
| | - Sion K Roy
- Department of Medicine, Lundquist Institute at Harbor-UCLA Medical Center, 1124 W Carson Street, CDCRC, Torrance, CA 90502, USA
| | - John Tayek
- Department of Medicine, Lundquist Institute at Harbor-UCLA Medical Center, 1124 W Carson Street, CDCRC, Torrance, CA 90502, USA
| | - John R Nelson
- Department of Internal Medicine, California Cardiovascular Institute, Fresno, CA, USA
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Muhlestein JB, Anderson JL, Bethea CF, Severance HW, Mentz RJ, Barsness GW, Barbagelata A, Albert D, Le VT, Bunch TJ, Yanowitz F, May HT, Chisum B, Ronnow BS, Muhlestein JB. Feasibility of combining serial smartphone single-lead electrocardiograms for the diagnosis of ST-elevation myocardial infarction. Am Heart J 2020; 221:125-135. [PMID: 31986289 DOI: 10.1016/j.ahj.2019.12.016] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [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: 09/27/2019] [Accepted: 12/21/2019] [Indexed: 11/30/2022]
Abstract
BACKGROUND The rate-limiting step in STEMI diagnosis often is the availability of a 12-lead electrocardiogram (ECG) and its interpretation. The potential may exist to speed the availability of 12-lead ECG information by using commonly available mobile technologies. We sought to test whether combining serial smartphone single-lead ECGs to create a virtual 12-lead ECG can accurately diagnose STEMI. METHODS Consenting patients presenting with symptoms consistent with a possible STEMI had contemporaneous standard 12-lead and smartphone '12-lead equivalent' ECG (produced by electronically combining serial single-lead ECGs) recordings obtained. Matched ECGs were evaluated qualitatively and quantitatively by a panel of blinded readers and classified as STEMI/STEMI equivalent (LBBB), Not-STEMI, or uninterpretable. Interpretable ECG pairs were graded as showing good, fair, or poor correlation. RESULTS Two hundred four subjects (age = 60 years, males = 57%, STEMI activation = 45%) were enrolled from 5 international sites. Smartphone ECG quality was graded as good in 151 (74.0%), fair in 32 (15.7%), poor in 8 (3.9%), and uninterpretable in 13 (6.4%). A STEMI/STEMI equivalent diagnosis was identified by standard 12-lead ECG in 57/204 (27.9%) recordings. For all interpretable pairs of smartphone ECGs compared with standard ECGs (n = 190), the sensitivity, specificity, and positive and negative predictive values for STEMI/STEMI equivalent by smartphone were 0.89, 0.84, 0.70 and 0.95, respectively. CONCLUSIONS A '12-lead equivalent' ECG obtained from multiple serial single-lead ECGs from a smartphone can identify STEMI with good correlation to a standard 12-lead ECG. This technology holds promise to improve outcomes in STEMI by enhancing the reach and speed of diagnosis and thereby early treatment.
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Affiliation(s)
- Joseph Boone Muhlestein
- Intermountain Medical Center, Intermountain Heart Institute, Salt Lake City, Utah; University of Utah, Department of Internal Medicine, Salt Lake City, Utah
| | - Jeffrey L Anderson
- Intermountain Medical Center, Intermountain Heart Institute, Salt Lake City, Utah; University of Utah, Department of Internal Medicine, Salt Lake City, Utah
| | | | - Harry W Severance
- Erlanger Institute for Clinical Research, UT College of Medicine, Chattanooga, Tennessee; Duke University, Durham, North Carolina
| | | | | | | | - David Albert
- AliveCor™ Corporation, San Franscisco, California
| | - Viet T Le
- Intermountain Medical Center, Intermountain Heart Institute, Salt Lake City, Utah; Rocky Mountain University of Health Professions, Masters of Physician Assistant Studies Program, Provo, Utah
| | - T Jared Bunch
- Intermountain Medical Center, Intermountain Heart Institute, Salt Lake City, Utah; Stanford University, Department of Internal Medicine, Palo Alto, California
| | - Frank Yanowitz
- Intermountain Medical Center, Intermountain Heart Institute, Salt Lake City, Utah; University of Utah, Department of Internal Medicine, Salt Lake City, Utah
| | - Heidi T May
- Intermountain Medical Center, Intermountain Heart Institute, Salt Lake City, Utah
| | - Benjamin Chisum
- Intermountain Medical Center, Intermountain Heart Institute, Salt Lake City, Utah
| | - Brianna S Ronnow
- Intermountain Medical Center, Intermountain Heart Institute, Salt Lake City, Utah
| | - Joseph Brent Muhlestein
- Intermountain Medical Center, Intermountain Heart Institute, Salt Lake City, Utah; University of Utah, Department of Internal Medicine, Salt Lake City, Utah.
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Bunch TJ, May HT, Bair TL, Crandall BG, Cutler MJ, Mallender C, Weiss JP, Osborn JS, Day JD. Long-term outcomes after low power, slower movement versus high power, faster movement irrigated-tip catheter ablation for atrial fibrillation. Heart Rhythm 2020; 17:184-189. [DOI: 10.1016/j.hrthm.2019.08.001] [Citation(s) in RCA: 35] [Impact Index Per Article: 8.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/02/2019] [Indexed: 01/22/2023]
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Bunch TJ, Bair TL, Crandall BG, Cutler MJ, Day JD, Graves KG, Jacobs V, Mallender C, Osborn JS, Weiss JP, May HT. Stroke and dementia risk in patients with and without atrial fibrillation and carotid arterial disease. Heart Rhythm 2020; 17:20-26. [DOI: 10.1016/j.hrthm.2019.07.007] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/14/2019] [Indexed: 11/28/2022]
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Timmis A, Townsend N, Gale CP, Torbica A, Lettino M, Petersen SE, Mossialos EA, Maggioni AP, Kazakiewicz D, May HT, De Smedt D, Flather M, Zuhlke L, Beltrame JF, Huculeci R, Tavazzi L, Hindricks G, Bax J, Casadei B, Achenbach S, Wright L, Vardas P. European Society of Cardiology: Cardiovascular Disease Statistics 2019 (Executive Summary). Eur Heart J Qual Care Clin Outcomes 2020; 6:7-9. [PMID: 31957796 DOI: 10.1093/ehjqcco/qcz065] [Citation(s) in RCA: 26] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Affiliation(s)
| | | | | | - Adam Timmis
- Barts Heart Centre and Queen Mary University London, London, UK
| | - N Townsend
- Department for Health, University of Bath, Bath, UK
| | - C P Gale
- Medical Research Council Bioinformatics Centre, Leeds Institute for Cardiovascular and Metabolic Medicine, University of Leeds, Leeds, UK
| | - A Torbica
- Centre for Research on Health and Social Care Management (CERGAS), Bocconi University, Milan, Italy
| | | | - S E Petersen
- Barts Heart Centre and Queen Mary University London, London, UK
| | - E A Mossialos
- Department of Health Policy, London School of Economics, London, UK
| | - A P Maggioni
- Research Center of Italian Association of Hospital Cardiologists (ANMCO), Florence, Italy
| | - D Kazakiewicz
- European Society of Cardiology Health Policy Unit, European Heart Health Institute, European Heart Agency, Brussels, Belgium
| | - H T May
- Intermountain Medical Center Heart Institute, Salt Lake City, UT, USA
| | - D De Smedt
- Department of Public Health, Ghent University, Ghent, Belgium
| | - M Flather
- Norwich Medical School, University of East Anglia, Norwich, UK
| | - L Zuhlke
- Red Cross Children's Hospital, University of Cape Town, Cape Town, South Africa
| | - J F Beltrame
- University of Adelaide, Central Adelaide Local Health Network, The Queen Elizabeth Hospital, Adelaide, Australia
| | - R Huculeci
- European Society of Cardiology Health Policy Unit, European Heart Health Institute, European Heart Agency, Brussels, Belgium
| | - L Tavazzi
- Maria Cecilia Hospital-GVM Care&Research, Cotignola, Italy
| | | | - J Bax
- Leiden University Medical Center, Leiden, The Netherlands
| | - B Casadei
- Division of Cardiovascular Medicine, Radcliffe Department of Medicine, John Radcliffe Hospital, University of Oxford, Level 6, West Wing, Oxford, UK
| | - S Achenbach
- Friedrich-Alexander-Universität Erlangen-Nürnberg (FAU), Erlangen, Germany
| | - L Wright
- Nuffield Department of Population Health, University of Oxford, Headington, Oxford, UK
| | - P Vardas
- European Society of Cardiology Health Policy Unit, European Heart Health Institute, European Heart Agency, Brussels, Belgium
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40
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Timmis A, Townsend N, Gale CP, Torbica A, Lettino M, Petersen SE, Mossialos EA, Maggioni AP, Kazakiewicz D, May HT, De Smedt D, Flather M, Zuhlke L, Beltrame JF, Huculeci R, Tavazzi L, Hindricks G, Bax J, Casadei B, Achenbach S, Wright L, Vardas P. European Society of Cardiology: Cardiovascular Disease Statistics 2019. Eur Heart J 2020; 41:12-85. [PMID: 31820000 DOI: 10.1093/eurheartj/ehz859] [Citation(s) in RCA: 571] [Impact Index Per Article: 142.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/08/2019] [Accepted: 11/26/2019] [Indexed: 02/06/2023] Open
Abstract
AIMS The 2019 report from the European Society of Cardiology (ESC) Atlas provides a contemporary analysis of cardiovascular disease (CVD) statistics across 56 member countries, with particular emphasis on international inequalities in disease burden and healthcare delivery together with estimates of progress towards meeting 2025 World Health Organization (WHO) non-communicable disease targets. METHODS AND RESULTS In this report, contemporary CVD statistics are presented for member countries of the ESC. The statistics are drawn from the ESC Atlas which is a repository of CVD data from a variety of sources including the WHO, the Institute for Health Metrics and Evaluation, and the World Bank. The Atlas also includes novel ESC sponsored data on human and capital infrastructure and cardiovascular healthcare delivery obtained by annual survey of the national societies of ESC member countries. Across ESC member countries, the prevalence of obesity (body mass index ≥30 kg/m2) and diabetes has increased two- to three-fold during the last 30 years making the WHO 2025 target to halt rises in these risk factors unlikely to be achieved. More encouraging have been variable declines in hypertension, smoking, and alcohol consumption but on current trends only the reduction in smoking from 28% to 21% during the last 20 years appears sufficient for the WHO target to be achieved. The median age-standardized prevalence of major risk factors was higher in middle-income compared with high-income ESC member countries for hypertension {23.8% [interquartile range (IQR) 22.5-23.1%] vs. 15.7% (IQR 14.5-21.1%)}, diabetes [7.7% (IQR 7.1-10.1%) vs. 5.6% (IQR 4.8-7.0%)], and among males smoking [43.8% (IQR 37.4-48.0%) vs. 26.0% (IQR 20.9-31.7%)] although among females smoking was less common in middle-income countries [8.7% (IQR 3.0-10.8) vs. 16.7% (IQR 13.9-19.7%)]. There were associated inequalities in disease burden with disability-adjusted life years per 100 000 people due to CVD over three times as high in middle-income [7160 (IQR 5655-8115)] compared with high-income [2235 (IQR 1896-3602)] countries. Cardiovascular disease mortality was also higher in middle-income countries where it accounted for a greater proportion of potential years of life lost compared with high-income countries in both females (43% vs. 28%) and males (39% vs. 28%). Despite the inequalities in disease burden across ESC member countries, survey data from the National Cardiac Societies of the ESC showed that middle-income member countries remain severely under-resourced compared with high-income countries in terms of cardiological person-power and technological infrastructure. Under-resourcing in middle-income countries is associated with a severe procedural deficit compared with high-income countries in terms of coronary intervention, device implantation and cardiac surgical procedures. CONCLUSION A seemingly inexorable rise in the prevalence of obesity and diabetes currently provides the greatest challenge to achieving further reductions in CVD burden across ESC member countries. Additional challenges are provided by inequalities in disease burden that now require intensification of policy initiatives in order to reduce population risk and prioritize cardiovascular healthcare delivery, particularly in the middle-income countries of the ESC where need is greatest.
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Affiliation(s)
- Adam Timmis
- Barts Heart Centre and Queen Mary University London, London, UK
| | | | - Chris P Gale
- Medical Research Council Bioinformatics Centre, Leeds Institute for Cardiovascular and Metabolic Medicine, University of Leeds, Leeds, UK
| | - Aleksandra Torbica
- Centre for Research on Health and Social Care Management (CERGAS), Bocconi University, Milan, Italy
| | | | | | | | - Aldo P Maggioni
- Research Center of Italian Association of Hospital Cardiologists (ANMCO), Florence, Italy
| | - Dzianis Kazakiewicz
- European Society of Cardiology Health Policy Unit, European Heart Health Institute, European Heart Agency, Brussels, Belgium
| | - Heidi T May
- Intermountain Medical Center Heart Institute, Salt Lake City, UT, USA
| | - Delphine De Smedt
- Department of Public Health and Primary Care, Ghent University, Ghent, Belgium
| | - Marcus Flather
- Norwich Medical School, University of East Anglia, Norwich, UK
| | - Liesl Zuhlke
- Red Cross Children's Hospital, University of Cape Town, Cape Town, South Africa
| | - John F Beltrame
- University of Adelaide, Central Adelaide Local Health Network, The Queen Elizabeth Hospital, Adelaide, Australia
| | - Radu Huculeci
- European Society of Cardiology Health Policy Unit, European Heart Health Institute, European Heart Agency, Brussels, Belgium
| | - Luigi Tavazzi
- Maria Cecilia Hospital-GVM Care&Research, Cotignola, Italy
| | | | - Jeroen Bax
- Leiden University Medical Center, Leiden, The Netherlands
| | - Barbara Casadei
- Division of Cardiovascular Medicine, Radcliffe Department of Medicine, John Radcliffe Hospital, University of Oxford, Level 6, West Wing, Oxford, UK
| | - Stephan Achenbach
- Friedrich-Alexander-Universität Erlangen-Nürnberg (FAU), Erlangen, Germany
| | - Lucy Wright
- Nuffield Department of Population Health, University of Oxford, Headington, Oxford, UK
| | - Panos Vardas
- European Society of Cardiology Health Policy Unit, European Heart Health Institute, European Heart Agency, Brussels, Belgium
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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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Jacobs V, T May H, L Bair T, G Crandall B, J Cutler DO M, D Day J, Le V, Mallender C, S Osborn J, Weiss JP, Bunch TJ. The Impact of Repeated Cardioversions for Atrial Fibrillation on Stroke, Hospitalizations, and Catheter Ablation Outcomes. J Atr Fibrillation 2019; 11:2164. [PMID: 31384369 DOI: 10.4022/jafib.2164] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2018] [Revised: 09/16/2018] [Accepted: 12/16/2018] [Indexed: 11/10/2022]
Abstract
BACKGROUND Long-term outcomes after direct current cardioversion (DCCV) in patients that receive anticoagulation have demonstrated to have no adverse sequela. Less is known about the impact on atrial fibrillation (AF) outcomes and resource utilization of repeated DCCVs that are often required for long-term rhythm control. METHODS A total of 4,135 AF patients >18 years of age that underwent DCCV with long-term system follow-up were evaluated. Patients were stratified by the number of DCCVs received: 1 (n=2,201), 2-4 (n=1,748), and ≥5 (n=186). Multivariable Cox hazard regression was used to determine the association of DCCV categories to the outcomes of death, AF hospitalization, AF ablation, DCCVs, and stroke/transient ischemic attack. RESULTS The average follow-up of the patient population was 1,633.1±1,232.9 (median: 1,438.0) days. Patients who underwent 2-4 and ≥5 DCCVs had more comorbidities, namely hypertension, hyperlipidemia and heart failure. Anticoagulation use was common at the time of DCCV in all groups (89.1%, 91.2%, 91.9%, p=0.06) and amiodarone use increased with increasing DCCV category (30.1%, 43.4%, 52.2, p<0.0001). At 5 years, patients that received more DCCVs had higher rates of repeat DCCVs, AF hospitalizations, and ablations. Stroke rates were not increased. Though not statistically significant, 5-year death was increased when comparing DCCV >5 vs. 1, (HR=1.32 [0.89-1.94], p=0.17). CONCLUSIONS This study found that the increasing number of DCCVs, despite escalation of other pharmacologic and nonpharmacologic therapies, is a long-term independent risk factor for repeat DCCVs, ablations, and AF hospitalizations among AF patients.
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Affiliation(s)
- Victoria Jacobs
- Intermountain Medical Center Heart Institute, Intermountain Medical Center, Murray, Utah
| | - Heidi T May
- Intermountain Medical Center Heart Institute, Intermountain Medical Center, Murray, Utah
| | - Tami L Bair
- Intermountain Medical Center Heart Institute, Intermountain Medical Center, Murray, Utah
| | - Brian G Crandall
- Intermountain Medical Center Heart Institute, Intermountain Medical Center, Murray, Utah
| | - Michael J Cutler DO
- Intermountain Medical Center Heart Institute, Intermountain Medical Center, Murray, Utah
| | - John D Day
- Intermountain Medical Center Heart Institute, Intermountain Medical Center, Murray, Utah
| | - Viet Le
- Intermountain Medical Center Heart Institute, Intermountain Medical Center, Murray, Utah
| | - Charles Mallender
- Intermountain Medical Center Heart Institute, Intermountain Medical Center, Murray, Utah
| | - Jeffrey S Osborn
- Intermountain Medical Center Heart Institute, Intermountain Medical Center, Murray, Utah
| | - J Peter Weiss
- Intermountain Medical Center Heart Institute, Intermountain Medical Center, Murray, Utah
| | - T Jared Bunch
- Intermountain Medical Center Heart Institute, Intermountain Medical Center, Murray, Utah.,Stanford University, Department of Internal Medicine, Palo Alto, California
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May HT, Lappé DL, Knowlton KU, Muhlestein JB, Anderson JL, Horne BD. Prediction of Long-Term Incidence of Chronic Cardiovascular and Cardiopulmonary Diseases in Primary Care Patients for Population Health Monitoring: The Intermountain Chronic Disease Model (ICHRON). Mayo Clin Proc 2019; 94:1221-1230. [PMID: 30577973 DOI: 10.1016/j.mayocp.2018.06.029] [Citation(s) in RCA: 5] [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: 03/22/2018] [Revised: 05/30/2018] [Accepted: 06/14/2018] [Indexed: 11/13/2022]
Abstract
OBJECTIVE To apply the practical parsimonious modeling method of the Intermountain Mortality Risk Score in a primary care environment to predict chronic disease (ChrD) onset. PATIENTS AND METHODS Primary care patients free of ChrD (women: n=98,711; men: n=45,543) were evaluated to develop (70% [n=95,882] of patients) and validate (the other 30% [n=48,372]) the sex-specific Intermountain Chronic Disease Risk Score (ICHRON) if seen initially between January 1, 2003, and December 31, 2005. The sex-specific ICHRON was composed of comprehensive metabolic profile and complete blood count components and age. The primary outcome was the first diagnosis of coronary artery disease, myocardial infarction, heart failure, atrial fibrillation, stroke, diabetes, renal failure, chronic obstructive pulmonary disease, peripheral vascular disease, or dementia within 3 years of baseline. RESULTS At 3 years, 9.0% of men (mean age, 44±16 years) and 6.6% of women (mean age, 42±16 years) received a diagnosis of ChrD. In the derivation population, C-statistics were 0.783 (95% CI, 0.774-0.791) for men and 0.774 (95% CI, 0.767-0.781) for women. In the validation population, C-statistics were 0.774 (95% CI, 0.762-0.786) for men and 0.762 (95% CI, 0.752-0.772) for women. Evaluation of 10-year outcomes for ICHRON and analysis of its association with each outcome individually at 3 years revealed similar predictive ability. CONCLUSION An augmented intelligence clinical decision tool for primary care, ICHRON, is developed using common laboratory parameters, which provides good discrimination of ChrD risk at 3 and 10 years.
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Affiliation(s)
- Heidi T May
- Intermountain Medical Center Heart Institute, Salt Lake City, UT.
| | - Donald L Lappé
- Intermountain Medical Center Heart Institute, Salt Lake City, UT
| | - Kirk U Knowlton
- Intermountain Medical Center Heart Institute, Salt Lake City, UT; Department of Medicine, University of Utah, Salt Lake City, UT
| | - Joseph B Muhlestein
- Intermountain Medical Center Heart Institute, Salt Lake City, UT; Department of Medicine, University of Utah, Salt Lake City, UT
| | - Jeffrey L Anderson
- Intermountain Medical Center Heart Institute, Salt Lake City, UT; Department of Medicine, University of Utah, Salt Lake City, UT
| | - Benjamin D Horne
- Intermountain Medical Center Heart Institute, Salt Lake City, UT; Department of Medicine, University of Utah, Salt Lake City, UT
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Muhlestein JB, Hackett IS, May HT, Bair TL, Le VT, Anderson JL, Whisenant B, Knowlton KU, Lappé DL. Safety and Efficacy of Periprocedural Heparin Plus a Short-Term Infusion of Tirofiban Versus Bivalirudin Monotherapy in Patients Who Underwent Percutaneous Coronary Intervention (from the Intermountain Heart Institute STAIR Observational Registry). Am J Cardiol 2019; 123:1927-1934. [PMID: 30981419 DOI: 10.1016/j.amjcard.2019.03.025] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [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] [Received: 11/29/2018] [Revised: 03/02/2019] [Accepted: 03/05/2019] [Indexed: 11/27/2022]
Abstract
Glycoprotein IIb/IIIa inhibitors, used as a standard intravenous bolus followed by a prolonged infusion for 12 to 18 hours, reduces ischemic complications during percutaneous coronary interventions (PCI) but often at a cost of increased bleeding. Today, when dual oral antiplatelet therapy is routine, heparin use plus short-term (bolus alone or with a <6 hours infusion) glycoprotein IIb/IIIa inhibitors, or bivalirudin monotherapy, have been proposed as potentially superior alternatives. This observational study evaluated the safety and efficacy of heparin plus short-term tirofiban versus bivalirudin monotherapy during PCI. Patients with successful PCI and no cardiogenic shock who were anticoagulated with either of the above regimens were followed for 30-day major bleeding and major adverse cardiovascular events (death, nonfatal myocardial infarction, and urgent target vessel revascularization) at 30 days, 1 year, and long term. A total of 727 patients receiving tirofiban (age = 63 ± 13 years, males = 76%, ACS presentation = 75%, radial access = 51%) and 459 patients receiving bivalirudin, (age = 65 ± 13 years, males = 71%, ACS presentation = 78%, radial access = 18%) were included. Thirty-day major bleeding was 0.7% and 4.1% for tirofiban and bivalirudin, respectively (adjusted odds ratio = 0.17 [0.06, 0.46], p = 0.001). During 30-day, 1-year, and long-term (1.7 ± 0.9 years) follow-up, major adverse cardiovascular events risk did not differ significantly between tirofiban and bivalirudin. However, long-term death was significantly lower in those receiving tirofiban (adjusted hazard ratio = 0.58 [0.34, 1.00], p = 0.05). In conclusion, in this observational study, PCI patients receiving heparin plus short-term tirofiban experienced significantly lower 30-day major bleeding, and improved long-term survival, than those receiving bivalirudin monotherapy.
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Affiliation(s)
- Joseph B Muhlestein
- Department of Internal Medicine, University of Utah, Salt Lake City, Utah; Department of Cardiology, Intermountain Heart Institute, Murray, Utah.
| | - Ian S Hackett
- Department of Internal Medicine, University of Utah, Salt Lake City, Utah
| | - Heidi T May
- Department of Cardiology, Intermountain Heart Institute, Murray, Utah
| | - Tami L Bair
- Department of Cardiology, Intermountain Heart Institute, Murray, Utah
| | - Viet T Le
- Department of Cardiology, Intermountain Heart Institute, Murray, Utah; Rocky Mountain University of Health Professions, Provo, Utah
| | - Jeffrey L Anderson
- Department of Internal Medicine, University of Utah, Salt Lake City, Utah; Department of Cardiology, Intermountain Heart Institute, Murray, Utah
| | - Brian Whisenant
- Department of Cardiology, Intermountain Heart Institute, Murray, Utah
| | - Kirk U Knowlton
- Department of Cardiology, Intermountain Heart Institute, Murray, Utah
| | - Donald L Lappé
- Department of Cardiology, Intermountain Heart Institute, Murray, Utah
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46
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Horne BD, Jacobs V, May HT, Graves KG, Bunch TJ. Augmented intelligence decision tool for stroke prediction combines factors from CHA 2 DS 2 -VASc and the intermountain risk score for patients with atrial fibrillation. J Cardiovasc Electrophysiol 2019; 30:1452-1461. [PMID: 31115939 DOI: 10.1111/jce.13999] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/14/2019] [Revised: 04/11/2019] [Accepted: 04/26/2019] [Indexed: 11/27/2022]
Abstract
INTRODUCTION CHA2 DS2 -VASc and CHADS2 are computationally simple risk prediction tools used to guide anticoagulation decisions for stroke prophylaxis, but they have modest risk discrimination ability and use static dichotomous variables. The Intermountain Mortality Risk Scores (IMRS) are dynamic decision tools using standard clinical laboratory tests. This study derived new stroke prediction scores using variables from both CHA2 DS2 -VASc and IMRS. METHODS AND RESULTS In outpatients with first atrial fibrillation (AF) diagnosis at the Intermountain Healthcare (females, n = 26 063 males, n = 29 807), sex-specific "IMRS-VASc" scores were derived using variables from CHA2 DS2 -VASc, warfarin use, the complete blood count, and the comprehensive metabolic profile. Validation was performed in an independent Intermountain outpatient AF cohort (females, n = 11 021; males, n = 12 641). Stroke occurred among 3.1% and 3.1% of females and 2.3% and 2.5% of males in derivation and validation groups, respectively. IMRS-VASc stratified stroke with similar ability in derivation (c-statistics, females: c = 0.703, males: c = 0.697) and validation groups (females: c = 0.681, males: c = 0.685). CHA2 DS2 -VASc (females: c = 0.581 and c = 0.605; males: c = 0.616 and c = 0.613 in derivation and validation, respectively) and CHADS2 (females: c = 0.581 and c = 0.608; males: c = 0.620 and c = 0.621 in derivation and validation, respectively) were substantially weaker stroke predictors. IMRS was the strongest mortality predictor (females: c = 0.783 and c = 0.782; males: c = 0.796 and c = 0.794 in derivation and validation, respectively) and all scores were poor at predicting bleeding risk. CONCLUSIONS A temporally dynamic risk score, IMRS-VASc was derived and validated as a predictor of stroke in outpatients with AF. IMRS-VASc requires further validation and the evaluation of its use in guiding care and treatment decisions for patients with AF.
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Affiliation(s)
- Benjamin D Horne
- Intermountain Medical Center, Intermountain Heart Institute, Salt Lake, Utah.,Department of Biomedical Informatics, University of Utah School of Medicine, Salt Lake, Utah
| | - Victoria Jacobs
- Intermountain Medical Center, Intermountain Heart Institute, Salt Lake, Utah
| | - Heidi T May
- Intermountain Medical Center, Intermountain Heart Institute, Salt Lake, Utah
| | - Kevin G Graves
- Intermountain Medical Center, Intermountain Heart Institute, Salt Lake, Utah
| | - T Jared Bunch
- Intermountain Medical Center, Intermountain Heart Institute, Salt Lake, Utah.,Department of Internal Medicine, Stanford University, Palo Alto, California
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Abstract
AF is strongly associated with a spectrum of cranial injuries including stroke and dementia. Dementia risk is seen in patients with and without a prior stroke and includes idiopathic forms of dementia, such as Alzheimer’s disease. The initiation, use and efficacy of anticoagulation have been shown in multiple observational trials to have an impact on dementia risk. Cerebral hypoperfusion during AF can result in cognitive decline and patients with cranial atherosclerosis may have unique susceptibility. Therapies to carefully control the ventricular rate and catheter ablation have been shown in observational trials to lower dementia risk. There is a need for further research in multiple areas and the observational trials will require prospective trials confirmation. Recent guidelines for AF have advocated the initiation of effective anticoagulation, the treatment of associated disease conditions that may influence the progression of AF and catheter ablation, with long-term management of risk factors to lower risk of dementia.
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Affiliation(s)
- T Jared Bunch
- Intermountain Medical Center Heart Institute Murray, UT, US.,Department of Internal Medicine Stanford University, Palo Alto, CA, US
| | - Oxana Galenko
- Intermountain Medical Center Heart Institute Murray, UT, US
| | | | | | - Heidi T May
- Intermountain Medical Center Heart Institute Murray, UT, US
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May HT, Muhlestein JB, Ma Y, López JAG, Coll B, Nelson J. Effects of Evolocumab on the ApoA1 Remnant Ratio: A Pooled Analysis of Phase 3 Studies. Cardiol Ther 2019; 8:91-102. [PMID: 30852766 PMCID: PMC6525215 DOI: 10.1007/s40119-019-0133-6] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2019] [Indexed: 12/05/2022] Open
Abstract
Introduction The apolipoprotein A1 (apoA1) remnant ratio has been identified as an independent cardiovascular (CV) risk factor. Higher apoA1 remnant ratios may predict lower CV risk in some patients. This analysis aimed to evaluate the effects of evolocumab on the change from baseline in the apoA1 remnant ratio compared with placebo. Methods This pooled post hoc analysis included 2464 patients with mixed dyslipidemia treated with evolocumab 140 mg every 2 weeks (Q2W) or 420 mg once monthly (QM) in three phase 3 evolocumab trials. The apoA1 remnant ratio was calculated by dividing apoA1 by the difference between non-high-density lipoprotein cholesterol (non-HDL-C) and low-density lipoprotein cholesterol (LDL-C). ApoA1 remnant ratio strata were generated using previously published tertile (< 4.7, 4.7–6.8, and > 6.8) and partitioning categories (< 3.6, 3.6–6.0, and > 6.0). Results The baseline apoA1 remnant ratio in evolocumab and placebo treatment arms was 7.1 and 7.3, respectively. At week 12, evolocumab 140 mg Q2W and 420 mg QM increased the apoA1 remnant ratio by 25.0% and 33.6%, respectively, versus placebo (p < 0.0001 for both groups). When patients were categorized by week 12 apoA1 remnant ratio thresholds (< 3.6 vs. > 3.6, and < 4.7 vs. > 4.7), those with higher week 12 apoA1 remnant ratios were significantly more likely to have also achieved a target non-HDL-C level of < 100 mg/dl. In the subset of women > 50 years of age, the proportion of patients at apoA1 remnant ratio thresholds < 3.6, 3.6–6.0, and > 6.0 at baseline shifted toward or remained at higher thresholds at week 12. Conclusions This post hoc analysis suggests that evolocumab increases the apoA1 remnant ratio. Funding Amgen Inc. Plain Language Summary Plain language summary available for this article. Electronic supplementary material The online version of this article (10.1007/s40119-019-0133-6) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Heidi T May
- Intermountain Heart Institute, Intermountain Medical Center, Murray, UT, USA.
| | - Joseph B Muhlestein
- Intermountain Heart Institute, Intermountain Medical Center, Murray, UT, USA.,Department of Medicine, University of Utah, Salt Lake City, UT, USA
| | - Yuhui Ma
- Amgen Inc., Thousand Oaks, CA, USA
| | | | | | - John Nelson
- California Cardiovascular Institute, Fresno, CA, USA
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Graves KG, May HT, Knowlton KU, Muhlestein JB, Jacobs V, Lappé DL, Anderson JL, Horne BD, Bunch TJ. Improving CHA 2DS 2-VASc stratification of non-fatal stroke and mortality risk using the Intermountain Mortality Risk Score among patients with atrial fibrillation. Open Heart 2018; 5:e000907. [PMID: 30564375 PMCID: PMC6269639 DOI: 10.1136/openhrt-2018-000907] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/10/2018] [Revised: 09/27/2018] [Accepted: 10/04/2018] [Indexed: 02/04/2023] Open
Abstract
Background Oral anticoagulation (OAC) therapy guidelines recommend using CHA2DS2-VASc to determine OAC need in atrial fibrillation (AF). A usable tool, CHA2DS2-VASc is challenged by its predictive ability. Applying components of the complete blood count and basic metabolic profile, the Intermountain Mortality Risk Score (IMRS) has been extensively validated. This study evaluated whether use of IMRS with CHA2DS2-VASc in patients with AF improves prediction. Methods Patients with AF undergoing cardiac catheterisation (N=10 077) were followed for non-fatal stroke and mortality (mean 5.8±4.1 years, maximum 19 years). CHA2DS2-VASc and IMRS were calculated at baseline. IMRS categories were defined based on previously defined criteria. Cox regression was adjusted for demographic, clinical and treatment variables not included in IMRS or CHA2DS2-VASc. Results In women (n=4122, mean age 71±12 years), the composite of non-fatal stroke/mortality was stratified (all p-trend <0.001) by CHA2DS2-VASc (1: 12.6%, 2: 22.8%, >2: 48.1%) and IMRS (low: 17.8%, moderate: 40.9%, high risk: 64.5%), as it was for men (n=5955, mean age 68±12 years) by CHA2DS2-VASc (<2: 15.7%, 2: 30.3%, >2: 51.8%) and IMRS (low: 19.0%, moderate: 42.0%, high risk: 65.9%). IMRS stratified stroke/mortality (all p-trend <0.001) in each CHA2DS2-VASc category. Conclusions Using IMRS jointly with CHA2DS2-VASc in patients with AF improved the prediction of stroke and mortality. For example, in patients at the OAC treatment threshold (CHA2DS2 -VASc = 2), IMRS provided ≈4-fold separation between low and high risk. IMRS provides an enhancing marker for risk in patients with AF that reflects the underlying systemic nature of this disease that may be considered in combination with the CHA2DS2-VASc score.
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Affiliation(s)
- Kevin G Graves
- Intermountain Heart Institute, Intermountain Medical Center, Murray, Utah, USA
| | - Heidi T May
- Intermountain Heart Institute, Intermountain Medical Center, Murray, Utah, USA
| | - Kirk U Knowlton
- Intermountain Heart Institute, Intermountain Medical Center, Murray, Utah, USA
| | - Joseph B Muhlestein
- Intermountain Heart Institute, Intermountain Medical Center, Murray, Utah, USA.,Cardiology Division, Department of Internal Medicine, University of Utah, Murray, Utah, USA
| | - Victoria Jacobs
- Intermountain Heart Institute, Intermountain Medical Center, Murray, Utah, USA
| | - Donald L Lappé
- Intermountain Heart Institute, Intermountain Medical Center, Murray, Utah, USA.,Cardiology Division, Department of Internal Medicine, University of Utah, Murray, Utah, USA
| | - Jeffrey L Anderson
- Intermountain Heart Institute, Intermountain Medical Center, Murray, Utah, USA.,Cardiology Division, Department of Internal Medicine, University of Utah, Murray, Utah, USA
| | - Benjamin D Horne
- Intermountain Heart Institute, Intermountain Medical Center, Murray, Utah, USA.,Department of Biomedical Informatics, University of Utah, Salt Lake City, Utah, USA
| | - Thomas Jared Bunch
- Intermountain Heart Institute, Intermountain Medical Center, Murray, Utah, USA.,Department of Internal Medicine, Stanford University, Palo Alto, California, USA
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50
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Golive A, May HT, Bair TL, Jacobs V, Crandall BG, Cutler MJ, Day JD, Mallender C, Osborn JS, Weiss JP, Bunch TJ. The Impact of Gender on Atrial Fibrillation Incidence and Progression to Dementia. Am J Cardiol 2018; 122:1489-1495. [PMID: 30195396 DOI: 10.1016/j.amjcard.2018.07.031] [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] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/08/2018] [Revised: 07/18/2018] [Accepted: 07/23/2018] [Indexed: 11/18/2022]
Abstract
There are a paucity of data regarding the role of gender and atrial fibrillation (AF) on cognitive decline and incidence of dementia. Such data may provide insight into the disproportionate incidence of dementia in women and may help identify high-risk characteristics to target for prevention. We examined patients who underwent coronary angiography at an Intermountain Healthcare Medical Center and enrolled in a prospective cardiovascular database. To be included, patients could not have a previous diagnosis of AF or dementia and had to have 5years of follow-up. Endpoints included incident AF and dementia. Study cohort consisted of 35,608 patients without a previous history of AF or dementia, with 14,377 (40.4%) being woman. Women had lower rates of hypertension, diabetes, coronary artery disease, and prior myocardial infarction, but higher rates of prior stroke. Men had a higher incidence of 5-year and long-term AF. However, women trended toward a higher incidence of 5-year and long-term dementia and stroke compared with men. In all groups of patients with and without AF, prior stroke predicted cognitive decline. In patients without a history of or development of AF, diabetes significantly increased risk of dementia. Women have higher rates of dementia over time than men, driven by higher baseline stroke rates and nontraditional cardiovascular risk factors. The higher dementia rates were in the setting of lower AF rates. However, in both men and women who develop AF, dementia rates are increased and do not show gender-based differences in risk.
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Affiliation(s)
- Anjani Golive
- Intermountain Medical Center Heart Institute, Intermountain Medical Center, Murray, Utah
| | - Heidi T May
- Intermountain Medical Center Heart Institute, Intermountain Medical Center, Murray, Utah
| | - Tami L Bair
- Intermountain Medical Center Heart Institute, Intermountain Medical Center, Murray, Utah
| | - Victoria Jacobs
- Intermountain Medical Center Heart Institute, Intermountain Medical Center, Murray, Utah
| | - Brian G Crandall
- Intermountain Medical Center Heart Institute, Intermountain Medical Center, Murray, Utah
| | - Michael J Cutler
- Intermountain Medical Center Heart Institute, Intermountain Medical Center, Murray, Utah
| | - John D Day
- Intermountain Medical Center Heart Institute, Intermountain Medical Center, Murray, Utah
| | - Charles Mallender
- Intermountain Medical Center Heart Institute, Intermountain Medical Center, Murray, Utah
| | - Jeffrey S Osborn
- Intermountain Medical Center Heart Institute, Intermountain Medical Center, Murray, Utah
| | - J Peter Weiss
- Intermountain Medical Center Heart Institute, Intermountain Medical Center, Murray, Utah
| | - T Jared Bunch
- Intermountain Medical Center Heart Institute, Intermountain Medical Center, Murray, Utah; Stanford University, Department of Internal Medicine, Palo Alto, California.
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