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Mao J, Chang AK, Chin S, Preet K, Torosyan N, Sarkissian S, Ebinger J. Polymorphic ventricular tachycardia and cardiac arrest from abiraterone-induced hypokalemia: a case report. J Med Case Rep 2024; 18:186. [PMID: 38622681 PMCID: PMC11020456 DOI: 10.1186/s13256-024-04513-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2022] [Accepted: 03/15/2024] [Indexed: 04/17/2024] Open
Abstract
BACKGROUND Polymorphic ventricular tachycardia (PMVT) is an unstable and often fatal cardiac tachyarrhythmia. While there are many causes of this rhythm, including electrolyte imbalances, ischemia, and genetic disorders, iatrogenic etiologies are important to recognize. Abiraterone is an androgen synthesis antagonist effective in treating prostate cancer, but here we describe a case of severe hypokalemia secondary to abiraterone resulting in polymorphic ventricular tachycardia and cardiac arrest. While this is a potential adverse effect of the medication, severe hypokalemia causing polymorphic ventricular tachycardia and cardiac arrest, as seen in our patient's case, has not been described. CASE PRESENTATION A 78-year-old African-American man with history of prostate cancer presents with polymorphic ventricular tachycardia and cardiac arrest. After resuscitation, he was found to be severely hypokalemic and refractory to large doses of repletion. Evaluation of secondary causes of hypokalemia identified the likely culprit to be adverse effects from prostate cancer treatment. CONCLUSION A broad differential diagnosis for polymorphic ventricular tachycardia is essential in identifying and treating patients presenting in this rhythm. Here we present a case of iatrogenic polymorphic ventricular tachycardia secondary to oncologic treatment.
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Affiliation(s)
- Jessica Mao
- Department of Cardiology, Smidt Heart Institute, Cedars-Sinai Medical Center, Los Angeles, CA, USA
| | | | - Stephen Chin
- Department of Internal Medicine, Cedars-Sinai Medical Center, Los Angeles, CA, USA
| | - Komal Preet
- David Geffen School of Medicine at the University of California, Los Angeles, Los Angeles, CA, USA
| | - Nare Torosyan
- Department of Internal Medicine, Cedars-Sinai Medical Center, Los Angeles, CA, USA
| | - Sarmen Sarkissian
- Department of Hematology-Oncology, Memorial Care, Long Beach, CA, USA
| | - Joseph Ebinger
- Department of Cardiology, Smidt Heart Institute, Cedars-Sinai Medical Center, Los Angeles, CA, USA.
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Mujukian A, Kumar R, Li D, Debbas P, Botwin GJ, Cheng S, Ebinger J, Braun J, McGovern D, Melmed GY. Postvaccination Symptoms After SARS-CoV-2 mRNA Vaccination Among Patients With Inflammatory Bowel Disease: A Prospective, Comparative Study. Inflamm Bowel Dis 2024; 30:602-616. [PMID: 37556401 DOI: 10.1093/ibd/izad114] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/22/2022] [Indexed: 08/11/2023]
Abstract
BACKGROUND Vaccine hesitancy is prevalent among people with IBD, in part due to insufficient evidence regarding comparative safety of vaccines in this population. METHODS We conducted a nationwide comparative study of postvaccination symptoms among those with IBD and health care workers (HCWs) without IBD. Symptom frequency, severity, and duration were measured. Continuous and categorical data were analyzed using Wilcoxon rank-sum and Fisher's exact test. Regression analysis was used to adjust for confounding variables. RESULTS We had 2910 and 2746 subjects who completed a survey after dose 1 (D1) and dose 2 (D2) respectively (D1: HCW = 933, IBD = 1977; D2: HCW = 884, IBD = 1862). Mean age was 43 years, 67% were female, and 23% were nonwhite; 73% received BNT162b2 (Pfizer) including almost all HCWs and 60% of IBD patients. Most postvaccine symptoms were mild and lasted ≤2 days after both doses in both groups. Health care workers experienced more postvaccination symptoms overall than IBD patients after each dose (D1: 57% vs 35%, P < .001; D2: 73% vs 50%, P < .001). Gastrointestinal symptoms were noted in IBD more frequently after D1 (5.5% vs 3%, P = .003) but not after D2 (10% vs 13%, P = .07). Inflammatory bowel disease subjects who received mRNA-1273 (Moderna) reported more overall symptoms compared with BNT162b2 (57% vs 46%, P < .001) including gastrointestinal symptoms (12% vs 8%, P = .002) after D2. CONCLUSIONS People with IBD had fewer postvaccination symptoms following the first 2 doses of SARS-CoV-2 mRNA vaccines than HCWs. Among those with symptoms, most symptoms were mild and of short duration.
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Affiliation(s)
- Angela Mujukian
- Inflammatory Bowel and Immunobiology Research Institute, Karsh Division of Digestive and Liver Diseases, Department of Medicine, Cedars-Sinai Medical Center, Los Angeles, CA, USA
| | - Rashmi Kumar
- Inflammatory Bowel and Immunobiology Research Institute, Karsh Division of Digestive and Liver Diseases, Department of Medicine, Cedars-Sinai Medical Center, Los Angeles, CA, USA
| | - Dalin Li
- Inflammatory Bowel and Immunobiology Research Institute, Karsh Division of Digestive and Liver Diseases, Department of Medicine, Cedars-Sinai Medical Center, Los Angeles, CA, USA
| | - Philip Debbas
- Inflammatory Bowel and Immunobiology Research Institute, Karsh Division of Digestive and Liver Diseases, Department of Medicine, Cedars-Sinai Medical Center, Los Angeles, CA, USA
| | - Gregory J Botwin
- Inflammatory Bowel and Immunobiology Research Institute, Karsh Division of Digestive and Liver Diseases, Department of Medicine, Cedars-Sinai Medical Center, Los Angeles, CA, USA
| | - Susan Cheng
- Smidt Heart Institute, Department of Medicine, Cedars-Sinai, Los Angeles, CA, USA
| | - Joseph Ebinger
- Inflammatory Bowel and Immunobiology Research Institute, Karsh Division of Digestive and Liver Diseases, Department of Medicine, Cedars-Sinai Medical Center, Los Angeles, CA, USA
| | - Jonathan Braun
- Inflammatory Bowel and Immunobiology Research Institute, Karsh Division of Digestive and Liver Diseases, Department of Medicine, Cedars-Sinai Medical Center, Los Angeles, CA, USA
| | - Dermot McGovern
- Inflammatory Bowel and Immunobiology Research Institute, Karsh Division of Digestive and Liver Diseases, Department of Medicine, Cedars-Sinai Medical Center, Los Angeles, CA, USA
| | - Gil Y Melmed
- Inflammatory Bowel and Immunobiology Research Institute, Karsh Division of Digestive and Liver Diseases, Department of Medicine, Cedars-Sinai Medical Center, Los Angeles, CA, USA
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Ouyang D, Theurer J, Stein NR, Hughes JW, Elias P, He B, Yuan N, Duffy G, Sandhu RK, Ebinger J, Botting P, Jujjavarapu M, Claggett B, Tooley JE, Poterucha T, Chen JH, Nurok M, Perez M, Perotte A, Zou JY, Cook NR, Chugh SS, Cheng S, Albert CM. Electrocardiographic deep learning for predicting post-procedural mortality: a model development and validation study. Lancet Digit Health 2024; 6:e70-e78. [PMID: 38065778 DOI: 10.1016/s2589-7500(23)00220-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/15/2022] [Revised: 10/01/2023] [Accepted: 10/18/2023] [Indexed: 12/22/2023]
Abstract
BACKGROUND Preoperative risk assessments used in clinical practice are insufficient in their ability to identify risk for postoperative mortality. Deep-learning analysis of electrocardiography can identify hidden risk markers that can help to prognosticate postoperative mortality. We aimed to develop a prognostic model that accurately predicts postoperative mortality in patients undergoing medical procedures and who had received preoperative electrocardiographic diagnostic testing. METHODS In a derivation cohort of preoperative patients with available electrocardiograms (ECGs) from Cedars-Sinai Medical Center (Los Angeles, CA, USA) between Jan 1, 2015 and Dec 31, 2019, a deep-learning algorithm was developed to leverage waveform signals to discriminate postoperative mortality. We randomly split patients (8:1:1) into subsets for training, internal validation, and final algorithm test analyses. Model performance was assessed using area under the receiver operating characteristic curve (AUC) values in the hold-out test dataset and in two external hospital cohorts and compared with the established Revised Cardiac Risk Index (RCRI) score. The primary outcome was post-procedural mortality across three health-care systems. FINDINGS 45 969 patients had a complete ECG waveform image available for at least one 12-lead ECG performed within the 30 days before the procedure date (59 975 inpatient procedures and 112 794 ECGs): 36 839 patients in the training dataset, 4549 in the internal validation dataset, and 4581 in the internal test dataset. In the held-out internal test cohort, the algorithm discriminates mortality with an AUC value of 0·83 (95% CI 0·79-0·87), surpassing the discrimination of the RCRI score with an AUC of 0·67 (0·61-0·72). The algorithm similarly discriminated risk for mortality in two independent US health-care systems, with AUCs of 0·79 (0·75-0·83) and 0·75 (0·74-0·76), respectively. Patients determined to be high risk by the deep-learning model had an unadjusted odds ratio (OR) of 8·83 (5·57-13·20) for postoperative mortality compared with an unadjusted OR of 2·08 (0·77-3·50) for postoperative mortality for RCRI scores of more than 2. The deep-learning algorithm performed similarly for patients undergoing cardiac surgery (AUC 0·85 [0·77-0·92]), non-cardiac surgery (AUC 0·83 [0·79-0·88]), and catheterisation or endoscopy suite procedures (AUC 0·76 [0·72-0·81]). INTERPRETATION A deep-learning algorithm interpreting preoperative ECGs can improve discrimination of postoperative mortality. The deep-learning algorithm worked equally well for risk stratification of cardiac surgeries, non-cardiac surgeries, and catheterisation laboratory procedures, and was validated in three independent health-care systems. This algorithm can provide additional information to clinicians making the decision to perform medical procedures and stratify the risk of future complications. FUNDING National Heart, Lung, and Blood Institute.
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Affiliation(s)
- David Ouyang
- Department of Cardiology, Smidt Heart Institute, Cedars-Sinai Medical Center, Los Angeles, CA, USA; Division of Artificial Intelligence in Medicine, Department of Medicine, Cedars-Sinai Medical Center, Los Angeles, CA, USA.
| | - John Theurer
- Department of Cardiology, Smidt Heart Institute, Cedars-Sinai Medical Center, Los Angeles, CA, USA
| | - Nathan R Stein
- Department of Cardiology, Smidt Heart Institute, Cedars-Sinai Medical Center, Los Angeles, CA, USA
| | - J Weston Hughes
- Department of Computer Science, Stanford University, Palo Alto, CA, USA
| | - Pierre Elias
- Milstein Division of Cardiology, Department of Medicine, Columbia University Irving Medical Center, New York, NY, USA; Department of Biomedical Informatics, Columbia University Irving Medical Center, New York, NY, USA
| | - Bryan He
- Department of Computer Science, Stanford University, Palo Alto, CA, USA
| | - Neal Yuan
- Department of Cardiology, Smidt Heart Institute, Cedars-Sinai Medical Center, Los Angeles, CA, USA
| | - Grant Duffy
- Department of Cardiology, Smidt Heart Institute, Cedars-Sinai Medical Center, Los Angeles, CA, USA
| | - Roopinder K Sandhu
- Department of Cardiology, Smidt Heart Institute, Cedars-Sinai Medical Center, Los Angeles, CA, USA
| | - Joseph Ebinger
- Department of Cardiology, Smidt Heart Institute, Cedars-Sinai Medical Center, Los Angeles, CA, USA
| | - Patrick Botting
- Department of Cardiology, Smidt Heart Institute, Cedars-Sinai Medical Center, Los Angeles, CA, USA
| | - Melvin Jujjavarapu
- Department of Cardiology, Smidt Heart Institute, Cedars-Sinai Medical Center, Los Angeles, CA, USA
| | - Brian Claggett
- Division of Cardiovascular Medicine, Department of Medicine, Brigham and Women's Hospital, Boston, MA, USA
| | - James E Tooley
- Division of Cardiology, Stanford University, Palo Alto, CA, USA
| | - Tim Poterucha
- Milstein Division of Cardiology, Department of Medicine, Columbia University Irving Medical Center, New York, NY, USA
| | - Jonathan H Chen
- Division of Bioinformatics Research, Stanford University, Palo Alto, CA, USA
| | - Michael Nurok
- Division of Anesthesia, Department of Surgery, Cedars-Sinai Medical Center, Los Angeles, CA, USA
| | - Marco Perez
- Division of Cardiology, Stanford University, Palo Alto, CA, USA
| | - Adler Perotte
- Milstein Division of Cardiology, Department of Medicine, Columbia University Irving Medical Center, New York, NY, USA
| | - James Y Zou
- Department of Computer Science, Stanford University, Palo Alto, CA, USA; Department of Medicine, and Department of Biomedical Data Science, Stanford University, Palo Alto, CA, USA
| | - Nancy R Cook
- Division of Preventive Medicine, Department of Medicine, Brigham and Women's Hospital, Boston, MA, USA
| | - Sumeet S Chugh
- Department of Cardiology, Smidt Heart Institute, Cedars-Sinai Medical Center, Los Angeles, CA, USA; Division of Artificial Intelligence in Medicine, Department of Medicine, Cedars-Sinai Medical Center, Los Angeles, CA, USA
| | - Susan Cheng
- Department of Cardiology, Smidt Heart Institute, Cedars-Sinai Medical Center, Los Angeles, CA, USA
| | - Christine M Albert
- Department of Cardiology, Smidt Heart Institute, Cedars-Sinai Medical Center, Los Angeles, CA, USA
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Malas J, Chen Q, Shen T, Emerson D, Gunn T, Megna D, Catarino P, Nurok M, Bowdish M, Chikwe J, Cheng S, Ebinger J, Kumaresan A. Outcomes of Extremely Prolonged (> 50 d) Venovenous Extracorporeal Membrane Oxygenation Support. Crit Care Med 2023; 51:e140-e144. [PMID: 36927927 PMCID: PMC10272086 DOI: 10.1097/ccm.0000000000005860] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/18/2023]
Abstract
OBJECTIVES There has been a sustained increase in the utilization of venovenous extracorporeal membrane oxygenation (ECMO) over the last decade, further exacerbated by the COVID-19 pandemic. We set out to describe our institutional experience with extremely prolonged (> 50 d) venovenous ECMO support for recovery or bridge to lung transplant candidacy in patients with acute respiratory failure. DESIGN Retrospective cohort study. SETTING A large tertiary urban care center. PATIENTS Patients 18 years or older receiving venovenous ECMO support for greater than 50 days, with initial cannulation between January 2018 and January 2022. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS One hundred thirty patients were placed on venovenous ECMO during the study period. Of these, 12 received prolonged (> 50 d) venovenous ECMO support. Eleven patients (92%) suffered from adult respiratory distress syndrome (ARDS) secondary to COVID-19, while one patient with prior bilateral lung transplant suffered from ARDS secondary to bacterial pneumonia. The median age of patients was 39 years (interquartile range [IQR], 35-51 yr). The median duration of venovenous ECMO support was 94 days (IQR, 70-128 d), with a maximum of 180 days. Median time from intubation to cannulation was 5 days (IQR, 2-14 d). Nine patients (75%) were successfully mobilized while on venovenous ECMO support. Successful weaning of venovenous ECMO support occurred in eight patients (67%); 6 (50%) were bridged to lung transplantation and 2 (17%) were bridged to recovery. Of those successfully weaned, seven patients (88%) were discharged from the hospital. All seven patients discharged from the hospital were alive 6 months post-decannulation; 83% (5/6) with sufficient follow-up time were alive 1-year after decannulation. CONCLUSIONS Our experience suggests that extremely prolonged venovenous ECMO support to allow native lung recovery or optimization for lung transplantation may be a feasible strategy in select critically ill patients, further supporting the expanded utilization of venovenous ECMO for refractory respiratory failure.
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Affiliation(s)
- Jad Malas
- Department of Cardiac Surgery, Smidt Heart Institute, Cedars-Sinai Medical Center, Los Angeles, CA
| | - Qiudong Chen
- Department of Cardiac Surgery, Smidt Heart Institute, Cedars-Sinai Medical Center, Los Angeles, CA
| | - Tao Shen
- Department of Cardiac Surgery, Smidt Heart Institute, Cedars-Sinai Medical Center, Los Angeles, CA
- Department of Anesthesiology, Cedars-Sinai Medical Center, Los Angeles, CA
| | - Dominic Emerson
- Department of Cardiac Surgery, Smidt Heart Institute, Cedars-Sinai Medical Center, Los Angeles, CA
| | - Tyler Gunn
- Department of Cardiac Surgery, Smidt Heart Institute, Cedars-Sinai Medical Center, Los Angeles, CA
| | - Dominick Megna
- Department of Cardiac Surgery, Smidt Heart Institute, Cedars-Sinai Medical Center, Los Angeles, CA
| | - Pedro Catarino
- Department of Cardiac Surgery, Smidt Heart Institute, Cedars-Sinai Medical Center, Los Angeles, CA
| | - Michael Nurok
- Department of Cardiac Surgery, Smidt Heart Institute, Cedars-Sinai Medical Center, Los Angeles, CA
| | - Michael Bowdish
- Department of Cardiac Surgery, Smidt Heart Institute, Cedars-Sinai Medical Center, Los Angeles, CA
| | - Joanna Chikwe
- Department of Cardiac Surgery, Smidt Heart Institute, Cedars-Sinai Medical Center, Los Angeles, CA
| | - Susan Cheng
- Department of Cardiology, Smidt Heart Institute, Cedars-Sinai Medical Center, Los Angeles, CA
| | - Joseph Ebinger
- Department of Cardiology, Smidt Heart Institute, Cedars-Sinai Medical Center, Los Angeles, CA
| | - Abirami Kumaresan
- Department of Cardiac Surgery, Smidt Heart Institute, Cedars-Sinai Medical Center, Los Angeles, CA
- Department of Anesthesiology, Cedars-Sinai Medical Center, Los Angeles, CA
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Holmstrom L, Christensen M, Yuan N, Weston Hughes J, Theurer J, Jujjavarapu M, Fatehi P, Kwan A, Sandhu RK, Ebinger J, Cheng S, Zou J, Chugh SS, Ouyang D. Deep learning-based electrocardiographic screening for chronic kidney disease. Commun Med (Lond) 2023; 3:73. [PMID: 37237055 DOI: 10.1038/s43856-023-00278-w] [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: 08/22/2022] [Accepted: 03/10/2023] [Indexed: 05/28/2023] Open
Abstract
BACKGROUND Undiagnosed chronic kidney disease (CKD) is a common and usually asymptomatic disorder that causes a high burden of morbidity and early mortality worldwide. We developed a deep learning model for CKD screening from routinely acquired ECGs. METHODS We collected data from a primary cohort with 111,370 patients which had 247,655 ECGs between 2005 and 2019. Using this data, we developed, trained, validated, and tested a deep learning model to predict whether an ECG was taken within one year of the patient receiving a CKD diagnosis. The model was additionally validated using an external cohort from another healthcare system which had 312,145 patients with 896,620 ECGs between 2005 and 2018. RESULTS Using 12-lead ECG waveforms, our deep learning algorithm achieves discrimination for CKD of any stage with an AUC of 0.767 (95% CI 0.760-0.773) in a held-out test set and an AUC of 0.709 (0.708-0.710) in the external cohort. Our 12-lead ECG-based model performance is consistent across the severity of CKD, with an AUC of 0.753 (0.735-0.770) for mild CKD, AUC of 0.759 (0.750-0.767) for moderate-severe CKD, and an AUC of 0.783 (0.773-0.793) for ESRD. In patients under 60 years old, our model achieves high performance in detecting any stage CKD with both 12-lead (AUC 0.843 [0.836-0.852]) and 1-lead ECG waveform (0.824 [0.815-0.832]). CONCLUSIONS Our deep learning algorithm is able to detect CKD using ECG waveforms, with stronger performance in younger patients and more severe CKD stages. This ECG algorithm has the potential to augment screening for CKD.
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Affiliation(s)
- Lauri Holmstrom
- Department of Cardiology, Smidt Heart Institute, Cedars-Sinai Medical Center, Los Angeles, CA, USA
- Center for Cardiac Arrest Prevention, Department of Cardiology, Smidt Heart Institute, Cedars-Sinai Medical Center, Los Angeles, CA, USA
- Research Unit of Internal Medicine, Medical Research Center Oulu, University of Oulu and Oulu University Hospital, Oulu, Finland
- Division of Artificial Intelligence in Medicine, Department of Medicine, Cedars-Sinai Medical Center, Los Angeles, CA, USA
| | - Matthew Christensen
- Department of Cardiology, Smidt Heart Institute, Cedars-Sinai Medical Center, Los Angeles, CA, USA
- Division of Artificial Intelligence in Medicine, Department of Medicine, Cedars-Sinai Medical Center, Los Angeles, CA, USA
| | - Neal Yuan
- Department of Medicine, Division of Cardiology, San Francisco VA, UCSF, San Francisco, CA, USA
| | - J Weston Hughes
- Department of Computer Science, Stanford University, Palo Alto, CA, USA
| | - John Theurer
- Department of Cardiology, Smidt Heart Institute, Cedars-Sinai Medical Center, Los Angeles, CA, USA
- Division of Artificial Intelligence in Medicine, Department of Medicine, Cedars-Sinai Medical Center, Los Angeles, CA, USA
| | - Melvin Jujjavarapu
- Enterprise Information Service, Cedars-Sinai Medical Center, Los Angeles, CA, USA
| | - Pedram Fatehi
- Division of Nephrology, Department of Medicine, Stanford University, Palo Alto, CA, USA
| | - Alan Kwan
- Department of Cardiology, Smidt Heart Institute, Cedars-Sinai Medical Center, Los Angeles, CA, USA
| | - Roopinder K Sandhu
- Department of Cardiology, Smidt Heart Institute, Cedars-Sinai Medical Center, Los Angeles, CA, USA
| | - Joseph Ebinger
- Department of Cardiology, Smidt Heart Institute, Cedars-Sinai Medical Center, Los Angeles, CA, USA
| | - Susan Cheng
- Department of Cardiology, Smidt Heart Institute, Cedars-Sinai Medical Center, Los Angeles, CA, USA
| | - James Zou
- Department of Computer Science, Stanford University, Palo Alto, CA, USA
- Department of Biomedical Data Science, Stanford University, Palo Alto, CA, USA
| | - Sumeet S Chugh
- Department of Cardiology, Smidt Heart Institute, Cedars-Sinai Medical Center, Los Angeles, CA, USA
- Center for Cardiac Arrest Prevention, Department of Cardiology, Smidt Heart Institute, Cedars-Sinai Medical Center, Los Angeles, CA, USA
- Division of Artificial Intelligence in Medicine, Department of Medicine, Cedars-Sinai Medical Center, Los Angeles, CA, USA
| | - David Ouyang
- Department of Cardiology, Smidt Heart Institute, Cedars-Sinai Medical Center, Los Angeles, CA, USA.
- Division of Artificial Intelligence in Medicine, Department of Medicine, Cedars-Sinai Medical Center, Los Angeles, CA, USA.
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Gao H, Kransdorf E, Ebinger J, Kittleson MM. Hypertrophic Cardiomyopathy After Heart Transplantation: A Single-Center Case Series. JACC Case Rep 2023; 14:101825. [PMID: 37077874 PMCID: PMC10107007 DOI: 10.1016/j.jaccas.2023.101825] [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: 12/21/2022] [Revised: 03/01/2023] [Accepted: 03/20/2023] [Indexed: 04/21/2023]
Abstract
We present 3 heart transplant recipients who developed hypertrophic cardiomyopathy years after transplantation. In all 3 cases, the diagnosis was initially made based on echocardiography and confirmed using cardiac magnetic resonance imaging. (Level of Difficulty: Advanced.).
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Affiliation(s)
| | | | | | - Michelle M. Kittleson
- Address for correspondence: Dr Michelle M. Kittleson, 8670 Wilshire Boulevard, 2nd Floor, Beverly Hills, California 90211, USA. @MKittlesonMD
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Nurok M, Friedman O, Driver M, Sun N, Kumaresan A, Chen P, Cheng S, Talmor DS, Ebinger J. Mechanically Ventilated Patients With Coronavirus Disease 2019 Had a Higher Chance of In-Hospital Death If Treated With High-Flow Nasal Cannula Oxygen Before Intubation. Anesth Analg 2023; 136:692-698. [PMID: 36730796 PMCID: PMC9990488 DOI: 10.1213/ane.0000000000006211] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
BACKGROUND The impact of high-flow nasal cannula (HFNC) on outcomes of patients with respiratory failure from coronavirus disease 2019 (COVID-19) is unknown. We sought to assess whether exposure to HFNC before intubation was associated with successful extubation and in-hospital mortality compared to patients receiving intubation only. METHODS This single-center retrospective study examined patients with COVID-19-related respiratory failure from March 2020 to March 2021 who required HFNC, intubation, or both. Data were abstracted from the electronic health record. Use and duration of HFNC and intubation were examined' as well as demographics and clinical characteristics. We assessed the association between HFNC before intubation (versus without) and chance of successful extubation and in-hospital death using Cox proportional hazards models adjusting for age, sex, race/ethnicity, obesity, hypertension, diabetes, prior chronic obstructive pulmonary disease or asthma, HCO 3 , CO 2 , oxygen-saturation-to-inspired-oxygen (S:F) ratio, pulse, respiratory rate, temperature, and length of stay before intervention. RESULTS A total of n = 440 patients were identified, of whom 311 (70.7%) received HFNC before intubation, and 129 (29.3%) were intubated without prior use of HFNC. Patients who received HFNC before intubation had a higher chance of in-hospital death (hazard ratio [HR], 2.08; 95% confidence interval [CI], 1.06-4.05). No difference was found in the chance of successful extubation between the 2 groups (0.70, 0.41-1.20). CONCLUSIONS Among patients with respiratory failure from COVID-19 requiring mechanical ventilation, patients receiving HFNC before intubation had a higher chance of in-hospital death. Decisions on initial respiratory support modality should weigh the risks of intubation with potential increased mortality associated with HFNC.
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Affiliation(s)
- Michael Nurok
- From the Departments of Anesthesiology and Cardiac Surgery, Smidt Heart Institute, Cedars-Sinai Medical Center, Los Angeles, California
| | - Oren Friedman
- Department of Medicine, Intensive Care Unit, Marina del Rey Hospital, Division of Pulmonary & Critical Care Medicine, Cedars-Sinai Health System and Medical Center, Los Angeles, California
| | - Matthew Driver
- Department of Cardiology, Smidt Heart Institute, Cedars-Sinai Medical Center, Los Angeles, California
| | - Nancy Sun
- Department of Cardiology, Smidt Heart Institute, Cedars-Sinai Medical Center, Los Angeles, California
| | - Abirami Kumaresan
- From the Departments of Anesthesiology and Cardiac Surgery, Smidt Heart Institute, Cedars-Sinai Medical Center, Los Angeles, California
| | - Peter Chen
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, Women's Guild Lung Institute, Cedars-Sinai Medical Center, Cedars-Sinai Medical Center, Los Angeles, California
| | - Susan Cheng
- Department of Cardiology, Smidt Heart Institute, Cedars-Sinai Medical Center, Los Angeles, California
| | - Daniel S Talmor
- Department of Anesthesia, Harvard Medical School, Beth Israel Deaconess Medical Center, Boston, Massachusetts
| | - Joseph Ebinger
- Department of Cardiology, Smidt Heart Institute, Cedars-Sinai Medical Center, Los Angeles, California
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He B, Kwan AC, Cho JH, Yuan N, Pollick C, Shiota T, Ebinger J, Bello NA, Wei J, Josan K, Duffy G, Jujjavarapu M, Siegel R, Cheng S, Zou JY, Ouyang D. Blinded, randomized trial of sonographer versus AI cardiac function assessment. Nature 2023; 616:520-524. [PMID: 37020027 PMCID: PMC10115627 DOI: 10.1038/s41586-023-05947-3] [Citation(s) in RCA: 43] [Impact Index Per Article: 43.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/12/2022] [Accepted: 03/13/2023] [Indexed: 04/07/2023]
Abstract
Artificial intelligence (AI) has been developed for echocardiography1-3, although it has not yet been tested with blinding and randomization. Here we designed a blinded, randomized non-inferiority clinical trial (ClinicalTrials.gov ID: NCT05140642; no outside funding) of AI versus sonographer initial assessment of left ventricular ejection fraction (LVEF) to evaluate the impact of AI in the interpretation workflow. The primary end point was the change in the LVEF between initial AI or sonographer assessment and final cardiologist assessment, evaluated by the proportion of studies with substantial change (more than 5% change). From 3,769 echocardiographic studies screened, 274 studies were excluded owing to poor image quality. The proportion of studies substantially changed was 16.8% in the AI group and 27.2% in the sonographer group (difference of -10.4%, 95% confidence interval: -13.2% to -7.7%, P < 0.001 for non-inferiority, P < 0.001 for superiority). The mean absolute difference between final cardiologist assessment and independent previous cardiologist assessment was 6.29% in the AI group and 7.23% in the sonographer group (difference of -0.96%, 95% confidence interval: -1.34% to -0.54%, P < 0.001 for superiority). The AI-guided workflow saved time for both sonographers and cardiologists, and cardiologists were not able to distinguish between the initial assessments by AI versus the sonographer (blinding index of 0.088). For patients undergoing echocardiographic quantification of cardiac function, initial assessment of LVEF by AI was non-inferior to assessment by sonographers.
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Affiliation(s)
- Bryan He
- Department of Computer Science, Stanford University, Palo Alto, CA, USA
| | - Alan C Kwan
- Department of Cardiology, Smidt Heart Institute, Cedars-Sinai Medical Center, Los Angeles, CA, USA
| | - Jae Hyung Cho
- Department of Cardiology, Smidt Heart Institute, Cedars-Sinai Medical Center, Los Angeles, CA, USA
| | - Neal Yuan
- Department of Medicine, Division of Cardiology, San Francisco VA, UCSF, San Francisco, CA, USA
| | - Charles Pollick
- Department of Cardiology, Smidt Heart Institute, Cedars-Sinai Medical Center, Los Angeles, CA, USA
| | - Takahiro Shiota
- Department of Cardiology, Smidt Heart Institute, Cedars-Sinai Medical Center, Los Angeles, CA, USA
| | - Joseph Ebinger
- Department of Cardiology, Smidt Heart Institute, Cedars-Sinai Medical Center, Los Angeles, CA, USA
| | - Natalie A Bello
- Department of Cardiology, Smidt Heart Institute, Cedars-Sinai Medical Center, Los Angeles, CA, USA
| | - Janet Wei
- Department of Cardiology, Smidt Heart Institute, Cedars-Sinai Medical Center, Los Angeles, CA, USA
| | - Kiranbir Josan
- Department of Cardiology, Smidt Heart Institute, Cedars-Sinai Medical Center, Los Angeles, CA, USA
| | - Grant Duffy
- Department of Cardiology, Smidt Heart Institute, Cedars-Sinai Medical Center, Los Angeles, CA, USA
| | - Melvin Jujjavarapu
- Enterprise Information Services, Cedars-Sinai Medical Center, Los Angeles, CA, USA
| | - Robert Siegel
- Department of Cardiology, Smidt Heart Institute, Cedars-Sinai Medical Center, Los Angeles, CA, USA
| | - Susan Cheng
- Department of Cardiology, Smidt Heart Institute, Cedars-Sinai Medical Center, Los Angeles, CA, USA.
| | - James Y Zou
- Department of Computer Science, Stanford University, Palo Alto, CA, USA.
- Department of Biomedical Data Science, Stanford University, Palo Alto, CA, USA.
| | - David Ouyang
- Department of Cardiology, Smidt Heart Institute, Cedars-Sinai Medical Center, Los Angeles, CA, USA.
- Division of Artificial Intelligence in Medicine, Cedars-Sinai Medical Center, Los Angeles, CA, USA.
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9
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Visrodia P, CAO L, Shah M, Naami R, Ebinger J, Rader F, Shiota T, Siegel RJ, Skaf S. 2D-ECHOCARDIOGRAPHIC CHARACTERIZATION OF DYSPNEA IN TRICUSPID REGURGITATION. J Am Coll Cardiol 2023. [DOI: 10.1016/s0735-1097(23)02443-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 03/06/2023]
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10
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Trivedi R, Tacon P, Aiken AV, Chyu KY, Ebinger J. GRAVE CONSEQUENCES OF IMMUNE CHECKPOINT INHIBITOR TOXICITY BEYOND MYOCARDITIS. J Am Coll Cardiol 2023. [DOI: 10.1016/s0735-1097(23)03914-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 03/06/2023]
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11
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Yuan N, Oesterle A, Botting P, Chugh S, Albert C, Ebinger J, Ouyang D. High-Throughput Assessment of Real-World Medication Effects on QT Interval Prolongation: Observational Study. JMIR Cardio 2023; 7:e41055. [PMID: 36662566 PMCID: PMC9898836 DOI: 10.2196/41055] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/13/2022] [Revised: 12/28/2022] [Accepted: 12/29/2022] [Indexed: 01/21/2023] Open
Abstract
BACKGROUND Drug-induced prolongation of the corrected QT interval (QTc) increases the risk for Torsades de Pointes (TdP) and sudden cardiac death. Medication effects on the QTc have been studied in controlled settings but may not be well evaluated in real-world settings where medication effects may be modulated by patient demographics and comorbidities as well as the usage of other concomitant medications. OBJECTIVE We demonstrate a new, high-throughput method leveraging electronic health records (EHRs) and the Surescripts pharmacy database to monitor real-world QTc-prolonging medication and potential interacting effects from demographics and comorbidities. METHODS We included all outpatient electrocardiograms (ECGs) from September 2008 to December 2019 at a large academic medical system, which were in sinus rhythm with a heart rate of 40-100 beats per minute, QRS duration of <120 milliseconds, and QTc of 300-700 milliseconds, determined using the Bazett formula. We used prescription information from the Surescripts pharmacy database and EHR medication lists to classify whether a patient was on a medication during an ECG. Negative control ECGs were obtained from patients not currently on the medication but who had been or would be on that medication within 1 year. We calculated the difference in mean QTc between ECGs of patients who are on and those who are off a medication and made comparisons to known medication TdP risks per the CredibleMeds.org database. Using linear regression analysis, we studied the interaction of patient-level demographics or comorbidities on medication-related QTc prolongation. RESULTS We analyzed the effects of 272 medications on 310,335 ECGs from 159,397 individuals. Medications associated with the greatest QTc prolongation were dofetilide (mean QTc difference 21.52, 95% CI 10.58-32.70 milliseconds), mexiletine (mean QTc difference 18.56, 95% CI 7.70-29.27 milliseconds), amiodarone (mean QTc difference 14.96, 95% CI 13.52-16.33 milliseconds), rifaximin (mean QTc difference 14.50, 95% CI 12.12-17.13 milliseconds), and sotalol (mean QTc difference 10.73, 95% CI 7.09-14.37 milliseconds). Several top QT prolonging medications such as rifaximin, lactulose, cinacalcet, and lenalidomide were not previously known but have plausible mechanistic explanations. Significant interactions were observed between demographics or comorbidities and QTc prolongation with many medications, such as coronary disease and amiodarone. CONCLUSIONS We demonstrate a new, high-throughput technique for monitoring real-world effects of QTc-prolonging medications from readily accessible clinical data. Using this approach, we confirmed known medications for QTc prolongation and identified potential new associations and demographic or comorbidity interactions that could supplement findings in curated databases. Our single-center results would benefit from additional verification in future multisite studies that incorporate larger numbers of patients and ECGs along with more precise medication adherence and comorbidity data.
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Affiliation(s)
- Neal Yuan
- Division of Cardiology, Department of Medicine, San Francisco Veteran Affairs Medical Center, San Francisco, CA, United States
| | - Adam Oesterle
- Division of Cardiology, Department of Medicine, San Francisco Veteran Affairs Medical Center, San Francisco, CA, United States
| | - Patrick Botting
- Smidt Heart Institute, Department of Cardiology, Cedars-Sinai Medical Center, Los Angeles, CA, United States
| | - Sumeet Chugh
- Smidt Heart Institute, Department of Cardiology, Cedars-Sinai Medical Center, Los Angeles, CA, United States
| | - Christine Albert
- Smidt Heart Institute, Department of Cardiology, Cedars-Sinai Medical Center, Los Angeles, CA, United States
| | - Joseph Ebinger
- Smidt Heart Institute, Department of Cardiology, Cedars-Sinai Medical Center, Los Angeles, CA, United States
| | - David Ouyang
- Smidt Heart Institute, Department of Cardiology, Cedars-Sinai Medical Center, Los Angeles, CA, United States
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12
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Abrahamowicz AA, Ebinger J, Whelton SP, Commodore-Mensah Y, Yang E. Racial and Ethnic Disparities in Hypertension: Barriers and Opportunities to Improve Blood Pressure Control. Curr Cardiol Rep 2023; 25:17-27. [PMID: 36622491 PMCID: PMC9838393 DOI: 10.1007/s11886-022-01826-x] [Citation(s) in RCA: 10] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 10/26/2022] [Indexed: 01/10/2023]
Abstract
PURPOSE OF REVIEW To characterize the barriers and opportunities associated with racial and ethnic disparities in blood pressure (BP) control. RECENT FINDINGS Blood pressure (BP) control rates in the USA have worsened over the last decade, with significantly lower rates of control among people from racial and ethnic minority groups, with non-Hispanic (NH) Black persons having 10% lower control rates compared to NH White counterparts. Many factors contribute to BP control including key social determinants of health (SDoH) such as health literacy, socioeconomic status, and access to healthcare as well as low awareness rates and dietary habits. Numerous pharmacologic and non-pharmacologic interventions have been developed to reduce racial and ethnic disparities in BP control. Among these, dietary programs designed to help reduce salt intake, faith-based interventions, and community-based programs have found success in achieving better BP control among people from racial and ethnic minority groups. Disparities in the prevalence and management of hypertension persist and remain high, particularly among racial and ethnic minority populations. Ongoing efforts are needed to address SDoH along with the unique genetic, social, economic, and cultural diversity within these groups that contribute to ongoing BP management inequalities.
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Affiliation(s)
| | - Joseph Ebinger
- Smidt Heart Institute, Department of Cardiology, Cedars-Sinai Medical Center, Los Angeles, CA, USA
| | - Seamus P Whelton
- Ciccarone Center for the Prevention of Cardiovascular Disease, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | | | - Eugene Yang
- Division of Cardiology, University of Washington School of Medicine, 1959 NE Pacific Street, Box 356005, Seattle, WA, 98195, USA.
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13
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Yuan N, Zhang J, Khaki R, Leong D, Bhoopalam C, Tabak S, Elad Y, Pevnick JM, Cheng S, Ebinger J. Implementation of an Electronic Health Records-Based Safe Contrast Limit for Preventing Contrast-Associated Acute Kidney Injury After Percutaneous Coronary Intervention. Circ Cardiovasc Qual Outcomes 2023; 16:e009235. [PMID: 36475471 PMCID: PMC9858238 DOI: 10.1161/circoutcomes.122.009235] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/25/2022] [Accepted: 09/13/2022] [Indexed: 12/12/2022]
Abstract
BACKGROUND Contrast-associated acute kidney injury (CA-AKI) after percutaneous coronary intervention is associated with increased mortality. We assessed the effectiveness of an electronic health records safe contrast limit tool in predicting CA-AKI risk and reducing contrast use and CA-AKI. METHODS We created an alert displaying the safe contrast limit to cardiac catheterization laboratory staff prior to percutaneous coronary intervention. The alert used risk factors automatically extracted from the electronic health records. We included procedures from June 1, 2020 to October 1, 2021; the intervention went live February 10, 2021. Using difference-in-differences analysis, we evaluated changes in contrast volume and CA-AKI rates after contrast limit tool implementation compared to control hospitals. Cardiologists were surveyed prior to and 9 months after alert implementation on beliefs, practice patterns, and safe contrast estimates for example patients. RESULTS At the one intervention site, there were 508 percutaneous coronary interventions before and 531 after tool deployment. At 15 control sites, there were 3550 and 3979 percutaneous coronary interventions, respectively. The contrast limit predicted CA-AKI with an accuracy of 64.1%, negative predictive value of 93.3%, and positive predictive value of 18.7%. After implementation, in high/modifiable risk patients (defined as having a calculated contrast limit <500ml) there was a small but significant -4.60 mL/month (95% CI, -8.24 to -1.00) change in average contrast use but no change in CA-AKI rates (odds ratio, 0.96 [95% CI, 0.84-1.10]). Low-risk patients had no change in contrast use (-0.50 mL/month [95% CI, -7.49 to 6.49]) or CA-AKI (odds ratio, 1.24 [95% CI, 0.79-1.93]). In assessing CA-AKI risk, clinicians heavily weighted age and diabetes but often did not consider anemia, cardiogenic shock, and heart failure. CONCLUSIONS Clinicians often used a simplified assessment of CA-AKI risk that did not include important risk factors, leading to risk estimations inconsistent with established models. Despite clinician skepticism, an electronic health records-based contrast limit tool more accurately predicted CA-AKI risk and was associated with a small decrease in contrast use during percutaneous coronary intervention but no change in CA-AKI rates.
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Affiliation(s)
- Neal Yuan
- School of Medicine, University of California, San Francisco, CA; Section of Cardiology, San Francisco Veterans Affairs Medical Center, San Francisco, CA
| | - Justin Zhang
- School of Medicine, University of California, Los Angeles, CA
| | | | - Derek Leong
- Smidt Heart Institute, Cedars-Sinai Medical Center, Los Angeles, CA
| | - Chandrashekhar Bhoopalam
- Smidt Heart Institute, Cedars-Sinai Medical Center, Los Angeles, CA
- Division of Informatics, Department of Biomedical Sciences, Cedars-Sinai Medical Center, Los Angeles, California
| | - Steven Tabak
- Smidt Heart Institute, Cedars-Sinai Medical Center, Los Angeles, CA
| | - Yaron Elad
- Smidt Heart Institute, Cedars-Sinai Medical Center, Los Angeles, CA
- Division of Informatics, Department of Biomedical Sciences, Cedars-Sinai Medical Center, Los Angeles, California
| | - Joshua M Pevnick
- Division of Informatics, Department of Biomedical Sciences, Cedars-Sinai Medical Center, Los Angeles, California
- Department of Medicine, Cedars-Sinai Medical Center, Los Angeles, California
| | - Susan Cheng
- Smidt Heart Institute, Cedars-Sinai Medical Center, Los Angeles, CA
| | - Joseph Ebinger
- Smidt Heart Institute, Cedars-Sinai Medical Center, Los Angeles, CA
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Driver M, Ebinger J, Cheng S, Tan ZS. Variability Independent of Mean Blood Pressure as an Electronic health record‐based Measure of Dementia Risk. Alzheimers Dement 2022. [DOI: 10.1002/alz.062450] [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] [Indexed: 12/24/2022]
Affiliation(s)
| | | | | | - Zaldy S Tan
- Cedars‐Sinai Medical Center Los Angeles CA USA
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15
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Zhang J, Khaki R, Leong D, Bhoopalam C, Tabak S, Elad Y, Ebinger J, Yuan N. Abstract 58: Implementation Of An Electronic Health Records-based Safe Contrast Limit For Preventing Contrast-associated Acute Kidney Injury After Percutaneous Coronary Intervention. Circ Cardiovasc Qual Outcomes 2022. [DOI: 10.1161/circoutcomes.15.suppl_1.58] [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: 11/16/2022]
Abstract
Background:
Contrast-associated acute kidney injury (CA-AKI) after percutaneous coronary intervention (PCI) is associated with cardiovascular complications and mortality. We previously published a multivariable model for calculating safe contrast volume limits derived from National Cardiovascular Data Registry (NCDR) data. We assessed the performance of this safe contrast limit when implemented in an electronic health records (EHR) system.
Methods:
We created an advisory alert in our Epic EHR system, which displayed the safe contrast limit to catheterization lab staff and operators prior to PCI along with CA-AKI risk reduction strategies. The alert required no clinician data entry and used risk factors automatically pulled from the EHR: age, sex, body mass index, creatinine clearance, hemoglobin, and use of intra-aortic balloon pump pre-procedure. We included procedures from 11/1/2020 to 10/1/2021 that had pre- and post-procedure creatinine data; the intervention went live 2/10/2021. We used NCDR-defined CA-AKI events to assess the performance of the safe contrast limit in predicting CA-AKI. We used interrupted time series analysis to determine if the intervention reduced contrast use and CA-AKI.
Results:
There were 201 PCIs; 10.4% (21 out of 201) had CA-AKI. The contrast limit predicted CA-AKI well using real-time EHR data (sensitivity 76.2%, specificity 50.0%, negative predictive value 94.7%). Among 178 patients with modifiable CA-AKI risk (defined as safe contrast limit ≤ 500mL), the intervention was associated with an immediate significant decrease in contrast use (-44.34mL (95% CI -81.71, -6.97)) and a decrease with time (-0.77mL/day (-1.31, -0.22)). For 23 patients at low CA-AKI risk (contrast limit > 500mL), there was a non-significant increase in contrast use (28.55 (-92.79, 149.88) and with time (1.15 (-0.73, 3.03)). There was no significant decrease in CA-AKI (OR 0.21 (0.03, 1.37)).
Conclusion:
An EHR-based safe contrast limit using automatically derived patient data performed well in predicting CA-AKI. The intervention significantly decreased contrast use for patients with modifiable CA-AKI risk and non-significantly increased contrast in patients with low risk. Longer follow-up will help clarify effects on CA-AKI rates.
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Affiliation(s)
- Justin Zhang
- David Geffen Sch of Medicine at UCLA, Los Angeles, CA
| | | | | | | | | | | | | | - Neal Yuan
- Univ of California, San Francisco, San Francisco, CA
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16
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Zhang JC, Khaki R, Leong D, Bhoopalam C, Tabak S, Elad Y, Ebinger J, YUAN NEAL. Abstract 33: Interventional Cardiologist Beliefs And Practices Before And After Implementation Of An Electronic Health Records-based Safe Contrast Limit Tool For Percutaneous Coronary Interventions. Circ Cardiovasc Qual Outcomes 2022. [DOI: 10.1161/circoutcomes.15.suppl_1.33] [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: 11/16/2022]
Abstract
Background:
Best Practice Advisories (BPAs) within electronic health record (EHR) systems can inform clinician decision-making and improve patient care. Their success depends on BPA content, clinical context, and staff buy-in. We recently implemented a safe contrast limit tool to reduce contrast-associated AKI (CA-AKI) after percutaneous coronary intervention (PCI). We evaluated the impact of this Contrast Limit BPA on interventional cardiologist attitudes and practices, and examined possible factors that influenced the BPA’s success.
Methods:
Using a published model, we implemented a BPA in our Epic EHR that displayed calculated individualized safe contrast limits prior to PCI. Cardiologists were surveyed prior to and 9 months after BPA implementation. Pre-implementation questions covered beliefs about CA-AKI, practice patterns, knowledge of CA-AKI risk factors, and asked for safe contrast estimates for example patients. Post-implementation questions assessed practice patterns and the BPA’s perceived accuracy, efficacy, and utility. Survey data was compared to clinician PCI contrast use using logistic regression.
Results:
We surveyed 8 clinicians pre-implementation and 10 post-implementation. Pre-implementation, 25% (2/8) reported using a contrast limit to make decisions about PCI and 12.5% (1/8) believed that they could improve their CA-AKI rates. In both their assessment of CA-AKI risk factors and contrast limit estimations, respondents often overestimated the contribution of age and diabetes while underestimating the influence of anemia and cardiogenic shock. Post-implementation, 30% (3/10) stated they were often surprised by the contrast limit and 80% (8/10) reported using the Contrast Limit when making PCI decisions. Clinicians who found the BPA to be clear and understandable or had catheterization lab staff discuss the limit prior to PCI had significantly lower odds of exceeding the safe contrast limit (OR=4.63, 95% CI [1.17, 18.35]; OR=6.76, 95% CI [1.81, 25.27]).
Conclusion:
Clinicians often misestimated safe contrast limits and believed that there was little room for improvement in their CA-AKI rates. Despite initial skepticism, an EHR-based safe contrast limit BPA was frequently used and influenced contrast use.
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Affiliation(s)
| | | | | | | | | | | | | | - NEAL YUAN
- Univ of California, San Francisco, San Francisco, CA
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18
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Duffy G, Cheng PP, Yuan N, He B, Kwan AC, Shun-Shin MJ, Alexander KM, Ebinger J, Lungren MP, Rader F, Liang DH, Schnittger I, Ashley EA, Zou JY, Patel J, Witteles R, Cheng S, Ouyang D. High-Throughput Precision Phenotyping of Left Ventricular Hypertrophy With Cardiovascular Deep Learning. JAMA Cardiol 2022; 7:386-395. [PMID: 35195663 PMCID: PMC9008505 DOI: 10.1001/jamacardio.2021.6059] [Citation(s) in RCA: 48] [Impact Index Per Article: 24.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
IMPORTANCE Early detection and characterization of increased left ventricular (LV) wall thickness can markedly impact patient care but is limited by under-recognition of hypertrophy, measurement error and variability, and difficulty differentiating causes of increased wall thickness, such as hypertrophy, cardiomyopathy, and cardiac amyloidosis. OBJECTIVE To assess the accuracy of a deep learning workflow in quantifying ventricular hypertrophy and predicting the cause of increased LV wall thickness. DESIGN, SETTINGS, AND PARTICIPANTS This cohort study included physician-curated cohorts from the Stanford Amyloid Center and Cedars-Sinai Medical Center (CSMC) Advanced Heart Disease Clinic for cardiac amyloidosis and the Stanford Center for Inherited Cardiovascular Disease and the CSMC Hypertrophic Cardiomyopathy Clinic for hypertrophic cardiomyopathy from January 1, 2008, to December 31, 2020. The deep learning algorithm was trained and tested on retrospectively obtained independent echocardiogram videos from Stanford Healthcare, CSMC, and the Unity Imaging Collaborative. MAIN OUTCOMES AND MEASURES The main outcome was the accuracy of the deep learning algorithm in measuring left ventricular dimensions and identifying patients with increased LV wall thickness diagnosed with hypertrophic cardiomyopathy and cardiac amyloidosis. RESULTS The study included 23 745 patients: 12 001 from Stanford Health Care (6509 [54.2%] female; mean [SD] age, 61.6 [17.4] years) and 1309 from CSMC (808 [61.7%] female; mean [SD] age, 62.8 [17.2] years) with parasternal long-axis videos and 8084 from Stanford Health Care (4201 [54.0%] female; mean [SD] age, 69.1 [16.8] years) and 2351 from CSMS (6509 [54.2%] female; mean [SD] age, 69.6 [14.7] years) with apical 4-chamber videos. The deep learning algorithm accurately measured intraventricular wall thickness (mean absolute error [MAE], 1.2 mm; 95% CI, 1.1-1.3 mm), LV diameter (MAE, 2.4 mm; 95% CI, 2.2-2.6 mm), and posterior wall thickness (MAE, 1.4 mm; 95% CI, 1.2-1.5 mm) and classified cardiac amyloidosis (area under the curve [AUC], 0.83) and hypertrophic cardiomyopathy (AUC, 0.98) separately from other causes of LV hypertrophy. In external data sets from independent domestic and international health care systems, the deep learning algorithm accurately quantified ventricular parameters (domestic: R2, 0.96; international: R2, 0.90). For the domestic data set, the MAE was 1.7 mm (95% CI, 1.6-1.8 mm) for intraventricular septum thickness, 3.8 mm (95% CI, 3.5-4.0 mm) for LV internal dimension, and 1.8 mm (95% CI, 1.7-2.0 mm) for LV posterior wall thickness. For the international data set, the MAE was 1.7 mm (95% CI, 1.5-2.0 mm) for intraventricular septum thickness, 2.9 mm (95% CI, 2.4-3.3 mm) for LV internal dimension, and 2.3 mm (95% CI, 1.9-2.7 mm) for LV posterior wall thickness. The deep learning algorithm accurately detected cardiac amyloidosis (AUC, 0.79) and hypertrophic cardiomyopathy (AUC, 0.89) in the domestic external validation site. CONCLUSIONS AND RELEVANCE In this cohort study, the deep learning model accurately identified subtle changes in LV wall geometric measurements and the causes of hypertrophy. Unlike with human experts, the deep learning workflow is fully automated, allowing for reproducible, precise measurements, and may provide a foundation for precision diagnosis of cardiac hypertrophy.
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Affiliation(s)
- Grant Duffy
- Department of Cardiology, Smidt Heart Institute, Cedars-Sinai Medical Center, Los Angeles, California
| | - Paul P. Cheng
- Department of Medicine, Division of Cardiology, Stanford University, Stanford, California
| | - Neal Yuan
- Department of Cardiology, Smidt Heart Institute, Cedars-Sinai Medical Center, Los Angeles, California
| | - Bryan He
- Department of Computer Science, Stanford University, Stanford, California
| | - Alan C. Kwan
- Department of Cardiology, Smidt Heart Institute, Cedars-Sinai Medical Center, Los Angeles, California
| | - Matthew J. Shun-Shin
- National Heart and Lung Institute, Imperial College London, London, United Kingdom
| | - Kevin M. Alexander
- Department of Medicine, Division of Cardiology, Stanford University, Stanford, California
| | - Joseph Ebinger
- Department of Cardiology, Smidt Heart Institute, Cedars-Sinai Medical Center, Los Angeles, California
| | | | - Florian Rader
- Department of Cardiology, Smidt Heart Institute, Cedars-Sinai Medical Center, Los Angeles, California
| | - David H. Liang
- Department of Medicine, Division of Cardiology, Stanford University, Stanford, California
| | - Ingela Schnittger
- Department of Medicine, Division of Cardiology, Stanford University, Stanford, California
| | - Euan A. Ashley
- Department of Medicine, Division of Cardiology, Stanford University, Stanford, California
| | - James Y. Zou
- Department of Computer Science, Stanford University, Stanford, California,Department of Biomedical Data Science, Stanford University, Stanford, California
| | - Jignesh Patel
- Department of Cardiology, Smidt Heart Institute, Cedars-Sinai Medical Center, Los Angeles, California
| | - Ronald Witteles
- Department of Medicine, Division of Cardiology, Stanford University, Stanford, California
| | - Susan Cheng
- Department of Cardiology, Smidt Heart Institute, Cedars-Sinai Medical Center, Los Angeles, California
| | - David Ouyang
- Department of Cardiology, Smidt Heart Institute, Cedars-Sinai Medical Center, Los Angeles, California,Division of Artificial Intelligence in Medicine, Cedars-Sinai Medical Center, Los Angeles, California
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Kohrman N, Blyler C, Barragan N, Kuo T, Inkelas M, Chen S, Rader F, Ebinger J. QUALITATIVE ANALYSIS OF THE LOS ANGELES BARBERSHOP BLOOD PRESSURE STUDY INTERVENTION: INSIGHTS FOR IMPLEMENTATION AT SCALE. J Am Coll Cardiol 2022. [DOI: 10.1016/s0735-1097(22)02444-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
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20
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Pozdnyakova VALERIYA, Botwin GREGORYJ, Sobhani K, Prostko J, Braun J, Mcgovern DPB, Melmed GY, Appel K, Banty A, Feldman E, Ha C, Kumar R, Lee S, Rabizadeh S, Stein T, Syal G, Targan S, Vasiliauskas E, Ziring D, Debbas P, Hampton M, Mengesha E, Stewart JL, Frias EC, Cheng S, Ebinger J, Figueiredo JC, Boland B, Charabaty A, Chiorean M, Cohen E, Flynn A, Valentine J, Fudman D, Horizon A, Hou J, Hwang C, Lazarev M, Lum D, Fausel R, Reddy S, Mattar M, Metwally M, Ostrov A, Parekh N, Raffals L, Sheibani S, Siegel C, Wolf D, Younes Z, Younes Z. Decreased Antibody Responses to Ad26.COV2.S Relative to SARS-CoV-2 mRNA Vaccines in Patients With Inflammatory Bowel Disease. Gastroenterology 2021; 161:2041-2043.e1. [PMID: 34391771 PMCID: PMC8359492 DOI: 10.1053/j.gastro.2021.08.014] [Citation(s) in RCA: 25] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/29/2021] [Revised: 07/22/2021] [Accepted: 08/09/2021] [Indexed: 02/08/2023]
Affiliation(s)
| | | | - Kimia Sobhani
- Department of Pathology and Laboratory Medicine, Cedars-Sinai Medical Center, Los Angeles, California
| | - John Prostko
- Applied Research and Technology, Abbott Diagnostics, Abbott Park, Illinois
| | - Jonathan Braun
- Inflammatory Bowel and Immunobiology Research Institute, Karsh Division of Digestive and Liver Diseases, Department of Medicine, Cedars-Sinai Medical Center, Los Angeles, California
| | - Dermot P B Mcgovern
- Inflammatory Bowel and Immunobiology Research Institute, Karsh Division of Digestive and Liver Diseases, Department of Medicine, Cedars-Sinai Medical Center, Los Angeles, California
| | - Gil Y Melmed
- Inflammatory Bowel and Immunobiology Research Institute, Karsh Division of Digestive and Liver Diseases, Department of Medicine, Cedars-Sinai Medical Center, Los Angeles, California.
| | - Keren Appel
- Inflammatory Bowel and Immunobiology Research Institute, Karsh Division of Digestive and Liver Diseases, Department of Medicine, Cedars-Sinai Medical Center, Los Angeles, California
| | - Andrea Banty
- Inflammatory Bowel and Immunobiology Research Institute, Karsh Division of Digestive and Liver Diseases, Department of Medicine, Cedars-Sinai Medical Center, Los Angeles, California
| | - Edward Feldman
- Inflammatory Bowel and Immunobiology Research Institute, Karsh Division of Digestive and Liver Diseases, Department of Medicine, Cedars-Sinai Medical Center, Los Angeles, California
| | - Christina Ha
- Inflammatory Bowel and Immunobiology Research Institute, Karsh Division of Digestive and Liver Diseases, Department of Medicine, Cedars-Sinai Medical Center, Los Angeles, California
| | - Rashmi Kumar
- Inflammatory Bowel and Immunobiology Research Institute, Karsh Division of Digestive and Liver Diseases, Department of Medicine, Cedars-Sinai Medical Center, Los Angeles, California
| | - Susie Lee
- Inflammatory Bowel and Immunobiology Research Institute, Karsh Division of Digestive and Liver Diseases, Department of Medicine, Cedars-Sinai Medical Center, Los Angeles, California
| | - Shervin Rabizadeh
- Inflammatory Bowel and Immunobiology Research Institute, Karsh Division of Digestive and Liver Diseases, Department of Medicine, Cedars-Sinai Medical Center, Los Angeles, California
| | - Theodore Stein
- Inflammatory Bowel and Immunobiology Research Institute, Karsh Division of Digestive and Liver Diseases, Department of Medicine, Cedars-Sinai Medical Center, Los Angeles, California
| | - Gaurav Syal
- Inflammatory Bowel and Immunobiology Research Institute, Karsh Division of Digestive and Liver Diseases, Department of Medicine, Cedars-Sinai Medical Center, Los Angeles, California
| | - Stephan Targan
- Inflammatory Bowel and Immunobiology Research Institute, Karsh Division of Digestive and Liver Diseases, Department of Medicine, Cedars-Sinai Medical Center, Los Angeles, California
| | - Eric Vasiliauskas
- Inflammatory Bowel and Immunobiology Research Institute, Karsh Division of Digestive and Liver Diseases, Department of Medicine, Cedars-Sinai Medical Center, Los Angeles, California
| | - David Ziring
- Inflammatory Bowel and Immunobiology Research Institute, Karsh Division of Digestive and Liver Diseases, Department of Medicine, Cedars-Sinai Medical Center, Los Angeles, California
| | - Philip Debbas
- Inflammatory Bowel and Immunobiology Research Institute, Karsh Division of Digestive and Liver Diseases, Department of Medicine, Cedars-Sinai Medical Center, Los Angeles, California
| | - Melissa Hampton
- Inflammatory Bowel and Immunobiology Research Institute, Karsh Division of Digestive and Liver Diseases, Department of Medicine, Cedars-Sinai Medical Center, Los Angeles, California
| | - Emebet Mengesha
- Inflammatory Bowel and Immunobiology Research Institute, Karsh Division of Digestive and Liver Diseases, Department of Medicine, Cedars-Sinai Medical Center, Los Angeles, California
| | - James L Stewart
- Applied Research and Technology, Abbott Diagnostics, Abbott Park, Illinois
| | - Edwin C Frias
- Applied Research and Technology, Abbott Diagnostics, Abbott Park, Illinois
| | - Susan Cheng
- Smidt Heart Institute, Department of Medicine, Cedars-Sinai, Los Angeles, California
| | - Joseph Ebinger
- Smidt Heart Institute, Department of Medicine, Cedars-Sinai, Los Angeles, California
| | - Jane C Figueiredo
- Samual Oschin Comprehensive Cancer Center, Cedars-Sinai, Los Angeles, California
| | | | - Aline Charabaty
- Sibley Memorial Hospital, Johns Hopkins, Washington, District of Columbia
| | | | - Erica Cohen
- Capital Digestive Care, Chevy Chase, Maryland
| | - Ann Flynn
- University of Utah, Salt Lake City, Utah
| | | | | | | | - Jason Hou
- Baylor College of Medicine, Houston, Texas
| | | | | | | | | | | | - Mark Mattar
- Medstar-Georgetown, Washington, District of Columbia
| | - Mark Metwally
- Saratoga-Schenectady Gastroenterology, Saratoga Springs, New York
| | - Arthur Ostrov
- Saratoga-Schenectady Gastroenterology, Saratoga Springs, New York
| | | | | | - Sarah Sheibani
- Keck Medicine of University of Southern California, Los Angeles, California
| | - Corey Siegel
- Dartmouth-Hitchcock Medical Center, Lebanon, New Hampshire
| | - Douglas Wolf
- Atlanta Gastroenterology Associates, Atlanta, Georgia
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21
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Hughes JW, Yuan N, He B, Ouyang J, Ebinger J, Botting P, Lee J, Theurer J, Tooley JE, Nieman K, Lungren MP, Liang DH, Schnittger I, Chen JH, Ashley EA, Cheng S, Ouyang D, Zou JY. Deep learning evaluation of biomarkers from echocardiogram videos. EBioMedicine 2021; 73:103613. [PMID: 34656880 PMCID: PMC8524103 DOI: 10.1016/j.ebiom.2021.103613] [Citation(s) in RCA: 17] [Impact Index Per Article: 5.7] [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: 07/11/2021] [Revised: 09/16/2021] [Accepted: 09/20/2021] [Indexed: 01/19/2023] Open
Abstract
BACKGROUND Laboratory testing is routinely used to assay blood biomarkers to provide information on physiologic state beyond what clinicians can evaluate from interpreting medical imaging. We hypothesized that deep learning interpretation of echocardiogram videos can provide additional value in understanding disease states and can evaluate common biomarkers results. METHODS We developed EchoNet-Labs, a video-based deep learning algorithm to detect evidence of anemia, elevated B-type natriuretic peptide (BNP), troponin I, and blood urea nitrogen (BUN), as well as values of ten additional lab tests directly from echocardiograms. We included patients (n = 39,460) aged 18 years or older with one or more apical-4-chamber echocardiogram videos (n = 70,066) from Stanford Healthcare for training and internal testing of EchoNet-Lab's performance in estimating the most proximal biomarker result. Without fine-tuning, the performance of EchoNet-Labs was further evaluated on an additional external test dataset (n = 1,301) from Cedars-Sinai Medical Center. We calculated the area under the curve (AUC) of the receiver operating characteristic curve for the internal and external test datasets. FINDINGS On the held-out test set of Stanford patients not previously seen during model training, EchoNet-Labs achieved an AUC of 0.80 (0.79-0.81) in detecting anemia (low hemoglobin), 0.86 (0.85-0.88) in detecting elevated BNP, 0.75 (0.73-0.78) in detecting elevated troponin I, and 0.74 (0.72-0.76) in detecting elevated BUN. On the external test dataset from Cedars-Sinai, EchoNet-Labs achieved an AUC of 0.80 (0.77-0.82) in detecting anemia, of 0.82 (0.79-0.84) in detecting elevated BNP, of 0.75 (0.72-0.78) in detecting elevated troponin I, and of 0.69 (0.66-0.71) in detecting elevated BUN. We further demonstrate the utility of the model in detecting abnormalities in 10 additional lab tests. We investigate the features necessary for EchoNet-Labs to make successful detection and identify potential mechanisms for each biomarker using well-known and novel explainability techniques. INTERPRETATION These results show that deep learning applied to diagnostic imaging can provide additional clinical value and identify phenotypic information beyond current imaging interpretation methods. FUNDING J.W.H. and B.H. are supported by the NSF Graduate Research Fellowship. D.O. is supported by NIH K99 HL157421-01. J.Y.Z. is supported by NSF CAREER 1942926, NIH R21 MD012867-01, NIH P30AG059307 and by a Chan-Zuckerberg Biohub Fellowship.
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Affiliation(s)
- J Weston Hughes
- Department of Computer Science, Stanford University, Palo Alto, CA 94025
| | - Neal Yuan
- Department of Cardiology, Smidt Heart Institute, Cedars-Sinai Medical Center, Los Angeles, CA, 90048
| | - Bryan He
- Department of Computer Science, Stanford University, Palo Alto, CA 94025
| | - Jiahong Ouyang
- Department of Electrical Engineering, Stanford University, Palo Alto, CA, 94025
| | - Joseph Ebinger
- Department of Cardiology, Smidt Heart Institute, Cedars-Sinai Medical Center, Los Angeles, CA, 90048
| | - Patrick Botting
- Department of Cardiology, Smidt Heart Institute, Cedars-Sinai Medical Center, Los Angeles, CA, 90048
| | - Jasper Lee
- Department of Cardiology, Smidt Heart Institute, Cedars-Sinai Medical Center, Los Angeles, CA, 90048
| | - John Theurer
- Department of Cardiology, Smidt Heart Institute, Cedars-Sinai Medical Center, Los Angeles, CA, 90048
| | - James E Tooley
- Department of Medicine, Stanford University, Palo Alto, CA, 94025
| | - Koen Nieman
- Department of Medicine, Stanford University, Palo Alto, CA, 94025; Department of Radiology, Stanford University, Palo Alto, CA, 94025
| | | | - David H Liang
- Department of Medicine, Stanford University, Palo Alto, CA, 94025
| | | | - Jonathan H Chen
- Department of Medicine, Stanford University, Palo Alto, CA, 94025
| | - Euan A Ashley
- Department of Medicine, Stanford University, Palo Alto, CA, 94025
| | - Susan Cheng
- Department of Cardiology, Smidt Heart Institute, Cedars-Sinai Medical Center, Los Angeles, CA, 90048
| | - David Ouyang
- Department of Cardiology, Smidt Heart Institute, Cedars-Sinai Medical Center, Los Angeles, CA, 90048.
| | - James Y Zou
- Department of Computer Science, Stanford University, Palo Alto, CA 94025; Department of Electrical Engineering, Stanford University, Palo Alto, CA, 94025; Department of Biomedical Data Science, Stanford University, Palo Alto, CA, 94025.
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22
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Blyler CA, Ebinger J, Rashid M, Moy NP, Cheng S, Albert CM, Rader F. Improving Efficiency of the Barbershop Model of Hypertension Care for Black Men With Virtual Visits. J Am Heart Assoc 2021; 10:e020796. [PMID: 34155907 PMCID: PMC8403295 DOI: 10.1161/jaha.120.020796] [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] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
Background The LABBPS (Los Angeles Barbershop Blood Pressure Study) developed a new model of hypertension care for non‐Hispanic Black men that links health promotion by barbers to medication management by pharmacists. Barriers to scaling the model include inefficiencies that contribute to the cost of the intervention, most notably, pharmacist travel time. To address this, we tested whether virtual visits could be substituted for in‐person visits after blood pressure (BP) control was achieved. Methods and Results We enrolled 10 Black male patrons with systolic BP ≥140 mm Hg into a proof‐of‐concept study in which barbers promoted follow‐up with pharmacists who initially met each patron in the barbershop, where they prescribed BP medication under a collaborative practice agreement with the patrons' physician. Medications were titrated during bimonthly in‐person visits to achieve a BP goal of ≤130/80 mm Hg. Once BP goal was reached, visits were done by videoconference. Final BP and safety outcomes were assessed at 12 months. Nine patients completed the intervention. Baseline BP of 155±14/83.9±11 mm Hg decreased by −28.7±13/−8.9±15 mm Hg (P<0.0001). These data are statistically indistinguishable from prior LABBPS data (P=0.8 for change in systolic BP and diastolic BP). Hypertension control (≤130/80 mm Hg) was 67% (6 of 9), numerically greater than the 63% observed in LABBPS (P=not significant). As intended, the mean number of in‐person visits decreased from 11 in LABBPS to 6.6 visits over 12 months. No treatment‐related serious adverse events occurred. Conclusions Virtual visits represent a viable substitute for in‐person visits, both improving pharmacist efficiency and reducing cost while preserving intervention potency. Registration URL: https://www.clinicaltrials.gov; Unique identifier: NCT 03726710.
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Affiliation(s)
- Ciantel A Blyler
- Department of Cardiology Smidt Heart InstituteCedars-Sinai Medical Center Los Angeles CA
| | - Joseph Ebinger
- Department of Cardiology Smidt Heart InstituteCedars-Sinai Medical Center Los Angeles CA
| | - Mohamad Rashid
- Department of Cardiology Smidt Heart InstituteCedars-Sinai Medical Center Los Angeles CA
| | - Norma P Moy
- Department of Cardiology Smidt Heart InstituteCedars-Sinai Medical Center Los Angeles CA
| | - Susan Cheng
- Department of Cardiology Smidt Heart InstituteCedars-Sinai Medical Center Los Angeles CA
| | - Christine M Albert
- Department of Cardiology Smidt Heart InstituteCedars-Sinai Medical Center Los Angeles CA
| | - Florian Rader
- Department of Cardiology Smidt Heart InstituteCedars-Sinai Medical Center Los Angeles CA
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23
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Kazi DS, Wei PC, Penko J, Bellows BK, Coxson P, Bryant KB, Fontil V, Blyler CA, Lyles C, Lynch K, Ebinger J, Zhang Y, Tajeu GS, Boylan R, Pletcher MJ, Rader F, Moran AE, Bibbins-Domingo K. Scaling Up Pharmacist-Led Blood Pressure Control Programs in Black Barbershops: Projected Population Health Impact and Value. Circulation 2021; 143:2406-2408. [PMID: 34125566 DOI: 10.1161/circulationaha.120.051782] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Affiliation(s)
- Dhruv S Kazi
- Richard A. and Susan F. Smith Center for Outcomes Research in Cardiology, Beth Israel Deaconess Medical Center, Boston, MA (D.S.K.).,Harvard Medical School, Boston, MA (D.S.K.)
| | - Pengxiao C Wei
- University of California, San Francisco (P.C.W., J.P., P.C., V.F., C.L., R.B., M.J.P., K.B.-D.)
| | - Joanne Penko
- University of California, San Francisco (P.C.W., J.P., P.C., V.F., C.L., R.B., M.J.P., K.B.-D.)
| | - Brandon K Bellows
- Vagelos College of Physicians and Surgeons, Columbia University, NY (B.K.B., K.B.B., Y.Z., A.E.M.)
| | - Pamela Coxson
- University of California, San Francisco (P.C.W., J.P., P.C., V.F., C.L., R.B., M.J.P., K.B.-D.)
| | - Kelsey B Bryant
- Vagelos College of Physicians and Surgeons, Columbia University, NY (B.K.B., K.B.B., Y.Z., A.E.M.)
| | - Valy Fontil
- University of California, San Francisco (P.C.W., J.P., P.C., V.F., C.L., R.B., M.J.P., K.B.-D.)
| | - Ciantel A Blyler
- Smidt Heart Institute, Cedars-Sinai Medical Center, Los Angeles, CA (C.A.B., J.E., F.R.)
| | - Courtney Lyles
- University of California, San Francisco (P.C.W., J.P., P.C., V.F., C.L., R.B., M.J.P., K.B.-D.)
| | - Kathleen Lynch
- Harvard Medical School, Boston, MA (D.S.K.).,Providence Saint John's Health Center, John Wayne Cancer Institute, Santa Monica, CA (K.L.)
| | - Joseph Ebinger
- Smidt Heart Institute, Cedars-Sinai Medical Center, Los Angeles, CA (C.A.B., J.E., F.R.)
| | - Yiyi Zhang
- Vagelos College of Physicians and Surgeons, Columbia University, NY (B.K.B., K.B.B., Y.Z., A.E.M.)
| | - Gabriel S Tajeu
- College of Public Health, Temple University, Philadelphia, PA (G.S.T.)
| | - Ross Boylan
- University of California, San Francisco (P.C.W., J.P., P.C., V.F., C.L., R.B., M.J.P., K.B.-D.)
| | - Mark J Pletcher
- University of California, San Francisco (P.C.W., J.P., P.C., V.F., C.L., R.B., M.J.P., K.B.-D.)
| | - Florian Rader
- Smidt Heart Institute, Cedars-Sinai Medical Center, Los Angeles, CA (C.A.B., J.E., F.R.)
| | - Andrew E Moran
- Vagelos College of Physicians and Surgeons, Columbia University, NY (B.K.B., K.B.B., Y.Z., A.E.M.)
| | - Kirsten Bibbins-Domingo
- University of California, San Francisco (P.C.W., J.P., P.C., V.F., C.L., R.B., M.J.P., K.B.-D.)
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24
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Ebinger J, Wells M, Ouyang D, Davis T, Kaufman N, Cheng S, Chugh S. A Machine Learning Algorithm Predicts Duration of hospitalization in COVID-19 patients. ACTA ACUST UNITED AC 2021; 5:100035. [PMID: 34075366 PMCID: PMC8156835 DOI: 10.1016/j.ibmed.2021.100035] [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: 12/15/2020] [Revised: 04/14/2021] [Accepted: 05/19/2021] [Indexed: 02/04/2023]
Abstract
The COVID-19 pandemic has placed unprecedented strain on the healthcare system, particularly hospital bed capacity in the setting of large variations in patient length of stay (LOS). Using electronic health record data from 966 COVID-19 patients at a large academic medical center, we developed three machine learning algorithms to predict the likelihood of prolonged LOS, defined as >8 days. The models included 353 variables and were trained on 80% of the cohort, with 20% used for model validation. The three models were created on hospital days 1, 2 and 3, each including information available at or before that point in time. The models’ predictive capabilities improved sequentially over time, reaching an accuracy of 0.765, with an AUC of 0.819 by day 3. These models, developed using readily available data, may help hospital systems prepare for bed capacity needs, and help clinicians counsel patients on their likelihood of prolonged hospitalization.
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Affiliation(s)
- Joseph Ebinger
- Smidt Heart Institute, Cedars-Sinai Medical Center, Los Angeles, CA, USA
| | - Matthew Wells
- Enterprise Data Intelligence, Cedars-Sinai Medical Center, Los Angeles, CA, USA
| | - David Ouyang
- Smidt Heart Institute, Cedars-Sinai Medical Center, Los Angeles, CA, USA.,Division of Artificial Intelligence in Medicine, Department of Medicine, Cedars-Sinai Medical Center, Los Angeles, CA, USA
| | - Tod Davis
- Enterprise Data Intelligence, Cedars-Sinai Medical Center, Los Angeles, CA, USA
| | - Noy Kaufman
- David Geffen School of Medicine, University of California, Los Angles, Los Angeles, CA, USA
| | - Susan Cheng
- Smidt Heart Institute, Cedars-Sinai Medical Center, Los Angeles, CA, USA
| | - Sumeet Chugh
- Smidt Heart Institute, Cedars-Sinai Medical Center, Los Angeles, CA, USA.,Division of Artificial Intelligence in Medicine, Department of Medicine, Cedars-Sinai Medical Center, Los Angeles, CA, USA
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25
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Brown CL, Ebinger J, Bradley SM, Kavian JA, Ajoku A, Leong D, Tyler JM, Lange DC, Henry TD. Reliability and Validity of Current Approaches to Identification of Patients with ST-Segment-Elevation Myocardial Infarction. Circ Cardiovasc Qual Outcomes 2021; 14:e007228. [PMID: 33596664 DOI: 10.1161/circoutcomes.120.007228] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Affiliation(s)
| | - Joseph Ebinger
- Cedars-Sinai Smidt Heart Institute, Los Angeles, CA (J.E., J.A.K., A.A., D.L., J.T., T.D.H.)
| | - Steven M Bradley
- Minneapolis Heart Institute Foundation at Abbott Northwestern Hospital, MN (S.M.B., T.D.H.)
| | - Joseph Abraham Kavian
- Cedars-Sinai Smidt Heart Institute, Los Angeles, CA (J.E., J.A.K., A.A., D.L., J.T., T.D.H.)
| | - Andrew Ajoku
- Cedars-Sinai Smidt Heart Institute, Los Angeles, CA (J.E., J.A.K., A.A., D.L., J.T., T.D.H.)
| | - Derek Leong
- Cedars-Sinai Smidt Heart Institute, Los Angeles, CA (J.E., J.A.K., A.A., D.L., J.T., T.D.H.).,Kaiser Permanente, Los Angeles, CA (D.L.)
| | - Jeffrey M Tyler
- Cedars-Sinai Smidt Heart Institute, Los Angeles, CA (J.E., J.A.K., A.A., D.L., J.T., T.D.H.)
| | | | - Timothy D Henry
- Cedars-Sinai Smidt Heart Institute, Los Angeles, CA (J.E., J.A.K., A.A., D.L., J.T., T.D.H.).,Minneapolis Heart Institute Foundation at Abbott Northwestern Hospital, MN (S.M.B., T.D.H.).,The Carl and Edyth Lindner Center for Research and Education, The Christ Hospital, Cincinnati, OH (T.D.H.)
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26
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Yuan N, Ji H, Sun N, Botting P, Nguyen T, Torbati S, Cheng S, Ebinger J. Pseudo-safety in a cohort of patients with COVID-19 discharged home from the emergency department. Emerg Med J 2021; 38:304-307. [PMID: 33602725 DOI: 10.1136/emermed-2020-210041] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2020] [Revised: 01/07/2021] [Accepted: 01/29/2021] [Indexed: 12/22/2022]
Abstract
INTRODUCTION EDs are often the first line of contact with individuals infected with COVID-19 and play a key role in triage. However, there is currently little specific guidance for deciding when patients with COVID-19 require hospitalisation and when they may be safely observed as an outpatient. METHODS In this retrospective study, we characterised all patients with COVID-19 discharged home from EDs in our US multisite healthcare system from March 2020 to August 2020, focusing on individuals who returned within 2 weeks and required hospital admission. We restricted analyses to first-encounter data that do not depend on laboratory or imaging diagnostics in order to inform point-of-care assessments in resource-limited environments. Vitals and comorbidities were extracted from the electronic health record. We performed ordinal logistic regression analyses to identify predictors of inpatient admission, intensive care and intubation. RESULTS Of n=923 patients who were COVID-19 positive discharged from the ED, n=107 (11.6%) returned within 2 weeks and were admitted. In a multivariable-adjusted model including n=788 patients with complete risk factor information, history of hypertension increased odds of hospitalisation and severe illness by 1.92-fold (95% CI 1.07 to 3.41), diabetes by 2.20-fold (1.18 to 4.02), chronic lung disease by 2.21-fold (1.22 to 3.92) and fever by 2.89-fold (1.71 to 4.82). Having at least two of these risk factors increased the odds of future hospitalisation by 6.68-fold (3.54 to 12.70). Patients with hypertension, diabetes, chronic lung disease or fever had significantly longer hospital stays (median 5.92 days, 3.08-10.95 vs 3.21, 1.10-5.75, p<0.01) with numerically higher but not significantly different rates of intensive care unit admission (27.02% vs 14.30%, p=0.27) and intubation (12.16% vs 7.14%, p=0.71). DISCUSSION Patients infected with COVID-19 may appear clinically safe for home convalescence. However, those with hypertension, diabetes, chronic lung disease and fever may in fact be only 'pseudo-safe' and are most at risk for subsequent hospitalisation with more severe illness and longer hospital stays.
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Affiliation(s)
- Neal Yuan
- Smidt Heart Institute, Cedars-Sinai Medical Center, Los Angeles, California, USA
| | - Hongwei Ji
- Division of Cardiology, Brigham and Women's Hospital, Boston, Massachusetts, USA.,Department of Cardiology, Shanghai Tenth People's Hospital, Tongji University, Shanghai, China
| | - Nancy Sun
- Smidt Heart Institute, Cedars-Sinai Medical Center, Los Angeles, California, USA
| | - Patrick Botting
- Smidt Heart Institute, Cedars-Sinai Medical Center, Los Angeles, California, USA
| | - Trevor Nguyen
- Smidt Heart Institute, Cedars-Sinai Medical Center, Los Angeles, California, USA
| | - Sam Torbati
- Department of Emergency Medicine, Cedars-Sinai Medical Center, Los Angeles, California, USA
| | - Susan Cheng
- Smidt Heart Institute, Cedars-Sinai Medical Center, Los Angeles, California, USA
| | - Joseph Ebinger
- Smidt Heart Institute, Cedars-Sinai Medical Center, Los Angeles, California, USA
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27
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Rader F, Rashid M, Nguyen TT, Luong E, Kim A, Kim E, Elashoff R, Davoren K, Moy N, Nafeh F, Merz NB, Ebinger J, Hamburg N, Lindner J, Cheng S. E-Cigarette Use and Subclinical Cardiac Effects. Circ Res 2020; 127:1566-1567. [PMID: 33043813 DOI: 10.1161/circresaha.120.316683] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Affiliation(s)
- Florian Rader
- Smidt Heart Institute, Cedars-Sinai Medical Center, Los Angeles, CA (F.R., M.R., T.T.N., E.L., A.K., E.K., N.M., F.N., N.B.M., J.E., S.C.)
| | - Mohamad Rashid
- Smidt Heart Institute, Cedars-Sinai Medical Center, Los Angeles, CA (F.R., M.R., T.T.N., E.L., A.K., E.K., N.M., F.N., N.B.M., J.E., S.C.)
| | - Trevor Trung Nguyen
- Smidt Heart Institute, Cedars-Sinai Medical Center, Los Angeles, CA (F.R., M.R., T.T.N., E.L., A.K., E.K., N.M., F.N., N.B.M., J.E., S.C.)
| | - Eric Luong
- Smidt Heart Institute, Cedars-Sinai Medical Center, Los Angeles, CA (F.R., M.R., T.T.N., E.L., A.K., E.K., N.M., F.N., N.B.M., J.E., S.C.)
| | - Andy Kim
- Smidt Heart Institute, Cedars-Sinai Medical Center, Los Angeles, CA (F.R., M.R., T.T.N., E.L., A.K., E.K., N.M., F.N., N.B.M., J.E., S.C.)
| | - Elizabeth Kim
- Smidt Heart Institute, Cedars-Sinai Medical Center, Los Angeles, CA (F.R., M.R., T.T.N., E.L., A.K., E.K., N.M., F.N., N.B.M., J.E., S.C.)
| | | | - Katherine Davoren
- Division of Nephrology, University of Massachusetts School of Medicine, Worcester (K.D.)
| | - Norma Moy
- Smidt Heart Institute, Cedars-Sinai Medical Center, Los Angeles, CA (F.R., M.R., T.T.N., E.L., A.K., E.K., N.M., F.N., N.B.M., J.E., S.C.)
| | - Fida Nafeh
- Smidt Heart Institute, Cedars-Sinai Medical Center, Los Angeles, CA (F.R., M.R., T.T.N., E.L., A.K., E.K., N.M., F.N., N.B.M., J.E., S.C.)
| | - Noel Bairey Merz
- Smidt Heart Institute, Cedars-Sinai Medical Center, Los Angeles, CA (F.R., M.R., T.T.N., E.L., A.K., E.K., N.M., F.N., N.B.M., J.E., S.C.)
| | - Joseph Ebinger
- Smidt Heart Institute, Cedars-Sinai Medical Center, Los Angeles, CA (F.R., M.R., T.T.N., E.L., A.K., E.K., N.M., F.N., N.B.M., J.E., S.C.)
| | - Naomi Hamburg
- Whitaker Cardiovascular Institute, Boston University School of Medicine, MA (N.H)
| | - Jonathan Lindner
- Knight Cardiovascular Institute, Oregon Health and Science University, Portland (J.L.)
| | - Susan Cheng
- Smidt Heart Institute, Cedars-Sinai Medical Center, Los Angeles, CA (F.R., M.R., T.T.N., E.L., A.K., E.K., N.M., F.N., N.B.M., J.E., S.C.)
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Tyler J, Narbutas R, Oakley L, Ebinger J, Nakamura M. Percutaneous mitral valve repair with MitraClip XTR for acute mitral regurgitation due to papillary muscle rupture. J Cardiol Cases 2020; 22:246-248. [PMID: 33133320 PMCID: PMC7588477 DOI: 10.1016/j.jccase.2020.07.001] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2020] [Revised: 06/05/2020] [Accepted: 07/01/2020] [Indexed: 11/19/2022] Open
Abstract
Papillary muscle rupture is an infrequent and highly morbid mechanical complication of acute myocardial infarction. Surgical repair or replacement is traditionally considered first-line therapy. However, many of these patients present in extremis with prohibitively high surgical risk. Repair of mitral regurgitation with the MitraClip device (Abbot Vascular, Menlo Park, CA, USA) is an established therapy to treat degenerative and functional mitral regurgitation. We present a case of successful repair of severe mitral regurgitation due to papillary muscle rupture in the setting of acute myocardial infarction. A two-clip strategy resulted in mild residual mitral regurgitation with resolution of cardiogenic shock and refractory hypoxemia requiring veno-venous extracorporeal membrane oxygenation. Six-month follow-up echocardiogram identified durable results with mild mitral regurgitation and left ventricular ejection fraction of 63 %. Our case demonstrates that percutaneous mitral valve repair with MitraClip is a well-tolerated procedure that can provide acute and long-term benefit for patients with acute mitral regurgitation due to papillary muscle rupture who are at prohibitively high surgical risk. .
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Affiliation(s)
- Jeffrey Tyler
- Department of Cardiology, Smidt Heart Institute, Cedars-Sinai, Los Angeles, CA, USA
| | - Ryan Narbutas
- College of Medicine, Drexel University, Philadelphia, PA, USA
| | - Luke Oakley
- Department of Cardiology, Smidt Heart Institute, Cedars-Sinai, Los Angeles, CA, USA
| | - Joseph Ebinger
- Department of Cardiology, Smidt Heart Institute, Cedars-Sinai, Los Angeles, CA, USA
| | - Mamoo Nakamura
- Department of Cardiology, Smidt Heart Institute, Cedars-Sinai, Los Angeles, CA, USA
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29
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Goodman-Meza D, Rudas A, Chiang JN, Adamson PC, Ebinger J, Sun N, Botting P, Fulcher JA, Saab FG, Brook R, Eskin E, An U, Kordi M, Jew B, Balliu B, Chen Z, Hill BL, Rahmani E, Halperin E, Manuel V. A machine learning algorithm to increase COVID-19 inpatient diagnostic capacity. PLoS One 2020; 15:e0239474. [PMID: 32960917 PMCID: PMC7508387 DOI: 10.1371/journal.pone.0239474] [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] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2020] [Accepted: 09/01/2020] [Indexed: 01/09/2023] Open
Abstract
Worldwide, testing capacity for SARS-CoV-2 is limited and bottlenecks in the scale up of polymerase chain reaction (PCR-based testing exist. Our aim was to develop and evaluate a machine learning algorithm to diagnose COVID-19 in the inpatient setting. The algorithm was based on basic demographic and laboratory features to serve as a screening tool at hospitals where testing is scarce or unavailable. We used retrospectively collected data from the UCLA Health System in Los Angeles, California. We included all emergency room or inpatient cases receiving SARS-CoV-2 PCR testing who also had a set of ancillary laboratory features (n = 1,455) between 1 March 2020 and 24 May 2020. We tested seven machine learning models and used a combination of those models for the final diagnostic classification. In the test set (n = 392), our combined model had an area under the receiver operator curve of 0.91 (95% confidence interval 0.87-0.96). The model achieved a sensitivity of 0.93 (95% CI 0.85-0.98), specificity of 0.64 (95% CI 0.58-0.69). We found that our machine learning algorithm had excellent diagnostic metrics compared to SARS-CoV-2 PCR. This ensemble machine learning algorithm to diagnose COVID-19 has the potential to be used as a screening tool in hospital settings where PCR testing is scarce or unavailable.
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Affiliation(s)
- David Goodman-Meza
- Division of Infectious Diseases, David Geffen School of Medicine at UCLA, Los Angeles, California, United States of America
| | - Akos Rudas
- Department of Computational Medicine, UCLA, Los Angeles, California, United States of America
- Faculty of Informatics, Eötvös Loránd University (ELTE), Budapest, Hungary
| | - Jeffrey N. Chiang
- Department of Computational Medicine, UCLA, Los Angeles, California, United States of America
| | - Paul C. Adamson
- Division of Infectious Diseases, David Geffen School of Medicine at UCLA, Los Angeles, California, United States of America
| | - Joseph Ebinger
- Department of Cardiology, Cedars-Sinai Medical Center, Los Angeles, California, United States of America
| | - Nancy Sun
- Department of Cardiology, Cedars-Sinai Medical Center, Los Angeles, California, United States of America
| | - Patrick Botting
- Department of Cardiology, Cedars-Sinai Medical Center, Los Angeles, California, United States of America
| | - Jennifer A. Fulcher
- Division of Infectious Diseases, David Geffen School of Medicine at UCLA, Los Angeles, California, United States of America
| | - Faysal G. Saab
- Department of Medicine, David Geffen School of Medicine at UCLA, Los Angeles, California, United States of America
| | - Rachel Brook
- Department of Medicine, David Geffen School of Medicine at UCLA, Los Angeles, California, United States of America
| | - Eleazar Eskin
- Department of Computational Medicine, UCLA, Los Angeles, California, United States of America
- Department of Computer Science, UCLA, Los Angeles, California, United States of America
- Department of Human Genetics, UCLA, Los Angeles, California, United States of America
| | - Ulzee An
- Department of Computer Science, UCLA, Los Angeles, California, United States of America
| | - Misagh Kordi
- Department of Computational Medicine, UCLA, Los Angeles, California, United States of America
| | - Brandon Jew
- Department of Computational Medicine, UCLA, Los Angeles, California, United States of America
| | - Brunilda Balliu
- Department of Computational Medicine, UCLA, Los Angeles, California, United States of America
| | - Zeyuan Chen
- Department of Computer Science, UCLA, Los Angeles, California, United States of America
| | - Brian L. Hill
- Department of Computer Science, UCLA, Los Angeles, California, United States of America
| | - Elior Rahmani
- Department of Computer Science, UCLA, Los Angeles, California, United States of America
| | - Eran Halperin
- Department of Computational Medicine, UCLA, Los Angeles, California, United States of America
- Department of Computer Science, UCLA, Los Angeles, California, United States of America
- Department of Human Genetics, UCLA, Los Angeles, California, United States of America
- Department of Anesthesiology, David Geffen School of Medicine at UCLA, Los Angeles, California, United States of America
| | - Vladimir Manuel
- Faculty Practice Group, David Geffen School of Medicine at UCLA, Los Angeles, California, United States of America
- UCLA Clinical and Translational Science Institute, Los Angeles, California, United States of America
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Ramireddy A, Chugh H, Reinier K, Ebinger J, Park E, Thompson M, Cingolani E, Cheng S, Marban E, Albert CM, Chugh SS. Experience With Hydroxychloroquine and Azithromycin in the Coronavirus Disease 2019 Pandemic: Implications for QT Interval Monitoring. J Am Heart Assoc 2020; 9:e017144. [PMID: 32463348 PMCID: PMC7429030 DOI: 10.1161/jaha.120.017144] [Citation(s) in RCA: 86] [Impact Index Per Article: 21.5] [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] [Indexed: 02/06/2023]
Abstract
Background Despite a lack of clinical evidence, hydroxychloroquine and azithromycin are being administered widely to patients with verified or suspected coronavirus disease 2019 (COVID-19). Both drugs may increase risk of lethal arrhythmias associated with QT interval prolongation. Methods and Results We analyzed a case series of COVID-19-positive/suspected patients admitted between February 1, 2020, and April 4, 2020, who were treated with azithromycin, hydroxychloroquine, or a combination of both drugs. We evaluated baseline and postmedication QT interval (corrected QT interval [QTc]; Bazett) using 12-lead ECGs. Critical QTc prolongation was defined as follows: (1) maximum QTc ≥500 ms (if QRS <120 ms) or QTc ≥550 ms (if QRS ≥120 ms) and (2) QTc increase of ≥60 ms. Tisdale score and Elixhauser comorbidity index were calculated. Of 490 COVID-19-positive/suspected patients, 314 (64%) received either/both drugs and 98 (73 COVID-19 positive and 25 suspected) met study criteria (age, 62±17 years; 61% men). Azithromycin was prescribed in 28%, hydroxychloroquine in 10%, and both in 62%. Baseline mean QTc was 448±29 ms and increased to 459±36 ms (P=0.005) with medications. Significant prolongation was observed only in men (18±43 ms versus -0.2±28 ms in women; P=0.02). A total of 12% of patients reached critical QTc prolongation. Changes in QTc were highest with the combination compared with either drug, with much greater prolongation with combination versus azithromycin (17±39 ms versus 0.5±40 ms; P=0.07). No patients manifested torsades de pointes. Conclusions Overall, 12% of patients manifested critical QTc prolongation, and the combination caused greater prolongation than either drug alone. The balance between uncertain benefit and potential risk when treating COVID-19 patients should be carefully assessed.
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Affiliation(s)
- Archana Ramireddy
- The Smidt Heart Institute, Cedars-Sinai Health System Los Angeles CA
| | - Harpriya Chugh
- The Smidt Heart Institute, Cedars-Sinai Health System Los Angeles CA
| | - Kyndaron Reinier
- The Smidt Heart Institute, Cedars-Sinai Health System Los Angeles CA
| | - Joseph Ebinger
- The Smidt Heart Institute, Cedars-Sinai Health System Los Angeles CA
| | - Eunice Park
- Enterprise Information Systems Data Intelligence Team Cedars-Sinai Health System Los Angeles CA
| | - Michael Thompson
- Enterprise Information Systems Data Intelligence Team Cedars-Sinai Health System Los Angeles CA
| | - Eugenio Cingolani
- The Smidt Heart Institute, Cedars-Sinai Health System Los Angeles CA
| | - Susan Cheng
- The Smidt Heart Institute, Cedars-Sinai Health System Los Angeles CA
| | - Eduardo Marban
- The Smidt Heart Institute, Cedars-Sinai Health System Los Angeles CA
| | | | - Sumeet S Chugh
- The Smidt Heart Institute, Cedars-Sinai Health System Los Angeles CA
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Ouyang D, He B, Ghorbani A, Yuan N, Ebinger J, Langlotz CP, Heidenreich PA, Harrington RA, Liang DH, Ashley EA, Zou JY. Video-based AI for beat-to-beat assessment of cardiac function. Nature 2020; 580:252-256. [DOI: 10.1038/s41586-020-2145-8] [Citation(s) in RCA: 183] [Impact Index Per Article: 45.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/11/2019] [Accepted: 02/20/2020] [Indexed: 12/18/2022]
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Cho JH, Leong D, Ebinger J, Yoon SH, Bresee C, Ehdaie A, Shehata M, Wang X, Chugh SS, Marban E, Cingolani E. RHYTHM DISTURBANCES IN PATIENTS WITH HEART FAILURE AND PRESERVED EJECTION FRACTION. J Am Coll Cardiol 2020. [DOI: 10.1016/s0735-1097(20)31062-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
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Ebinger J, Henry T, Kim S, Inkelas M, Cheng S, Nuckols T. Development and Evaluation of Novel Electronic Medical Record Tools For Avoiding Bleeding After Percutaneous Coronary Intervention. J Am Heart Assoc 2019; 8:e013954. [PMID: 31707946 PMCID: PMC6915282 DOI: 10.1161/jaha.119.013954] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [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] [Indexed: 12/04/2022]
Abstract
Background Bleeding remains the most common complication of percutaneous coronary intervention. Guidelines recommend assessing bleeding risk before percutaneous coronary intervention to target use of bleeding avoidance strategies and mitigate bleeding events. Cedars‐Sinai Medical Center undertook an initiative to integrate these recommendations into the electronic medical record. Methods and Results The intervention included a voluntary clinical decision alert to assess bleeding risk before percutaneous coronary intervention, a bleeding risk calculator tool based on the NCDR (National Cardiovascular Data Registry) risk prediction model and, when indicated, a second alert to consider 4 bleeding avoidance strategies. We tested for changes in the use of bleeding avoidance strategies and bleeding event rates by comparing procedures performed before versus after implementation of the electronic medical record–based intervention and with versus without use of the bleeding risk calculator tool. Use of radial access increased (47.6% versus 64.8%; P<0.001) and glycoprotein IIb/IIIa inhibitors decreased (12.8% versus 3.17%; P<0.001) from before to after implementation, though risk‐adjusted bleeding event rates were stable (odds ratio, 0.82; P=0.164), even for high‐risk procedures. Use versus nonuse of the bleeding risk calculator tool was associated with increased radial access and reductions in glycoprotein IIb/IIIa inhibitors, but no change in bleeding events. Conclusions Integrating guideline recommendations into the electronic medical record to promote assessments of bleeding risk and use of bleeding avoidance strategies was feasible and associated with changes in clinical practice. Future work is needed to ensure that bleeding avoidance strategies are not overused among lower‐risk patients, and that, for high‐risk patients, the potential benefits of elective percutaneous coronary intervention are carefully weighed against the risk of bleeding.
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Affiliation(s)
- Joseph Ebinger
- Cedars-Sinai Smidt Heart Institute Los Angeles CA.,Department of Medicine Cedars-Sinai Medical Center Los Angeles CA
| | - Timothy Henry
- Christ Hospital Heart and Vascular Center Cincinnati OH
| | - Sungjin Kim
- Biostatistics and Bioinformatics Research Center Cedars-Sinai Medical Center Los Angeles CA
| | - Moira Inkelas
- Fielding School of Public Health University of California Los Angeles CA
| | - Susan Cheng
- Cedars-Sinai Smidt Heart Institute Los Angeles CA.,Department of Medicine Cedars-Sinai Medical Center Los Angeles CA
| | - Teryl Nuckols
- Department of Medicine Cedars-Sinai Medical Center Los Angeles CA
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Bryant KB, Kazi DS, Fontil V, Penko J, Blyler CA, Lynch K, Ebinger J, Moy NB, Rader F, Bibbins-Domingo K, Moran AE, Bellows BK. Abstract P156: Long-Term Blood Pressure Outcomes and Costs Associated With a Barber-Pharmacist Hypertension Intervention: 10-Year Simulation of the Los Angeles Barber Trial. Hypertension 2019. [DOI: 10.1161/hyp.74.suppl_1.p156] [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] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background:
Barber-pharmacist blood pressure (BP) management reduced systolic BP >20 mm Hg compared to education alone over one year in Non-Hispanic (NH) black men with uncontrolled hypertension (HTN) in the Los Angeles BARBER (LA-BARBER) Trial. Long-term BP outcomes and costs of this intervention are unknown.
Objective:
Simulate 10-year BP outcomes and intervention and medication costs of a one-year barber-pharmacist HTN intervention followed by usual care compared to usual care alone.
Methods:
We simulated 1000 LA BARBER-eligible NH black men sampled from the National Health and Nutrition Examination Survey. We used a discrete event simulation version of the validated BP Control Model to predict BP outcomes over 10 years. Model inputs were derived from published literature, national sources, LA-BARBER individual participant data, and interviews with LA-BARBER intervention pharmacists. Medication and intervention (clinical care, travel, and administrative time) costs were calculated from a 2018 US payer perspective and discounted 3% annually. Primary outcomes were percent with BP <130/80 mm Hg, medication and intervention costs, and the cost per patient with BP controlled. We used 100 probabilistic model iterations to examine parameter uncertainty.
Results:
Our calibrated model accurately reproduced baseline characteristics and predicted 1-year BP outcomes of the LA-BARBER study (mean age 54 years, baseline BP 153/91 mm Hg, 69% predicted 1-year BP control with the barber-pharmacist HTN intervention). Over 10 years, 64% of patients (95% uncertainty interval [UI] 61%-67%) were predicted to achieve BP control with the barber-pharmacist HTN intervention compared to 38% (95% UI 26%-48%) with usual care. Projected intervention and medication costs were $8084 (95% UI $7664-$8598) with the barber-pharmacist intervention compared to $4183 ($3514-$4768) with usual care costing $15,000 per controlled patient gained.
Conclusions:
Medication and intervention costs for a barber-pharmacist HTN intervention were about double usual care, but it achieved substantially higher BP control rates. Ongoing research will examine if this strategy meets traditional cost-effectiveness thresholds (e.g.,<$100,000 per quality-adjusted life year).
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Affiliation(s)
| | | | - Valy Fontil
- Univ of California San Francisco, San Francisco, CA
| | - Joanne Penko
- Univ of California San Francisco, San Francisco, CA
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Abstract
Use of the CADILLIAC Risk Score can accurately identify patients for safe early discharge after PCI for STEMI. Early discharge has the potential to both improve the quality and decrease the cost of care for STEMI patients. Prospective validation of this risk score and formal cost analysis would facilitate widespread utilization.
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Ebinger J, Tabak S, Elad Y, Gurvitz K, Patel S, Simon C, Henry TD. INFLUENCE OF AN ELECTRONIC MEDICAL RECORD BASED BLEEDING RISK CALCULATOR ON BLEEDING EVENTS, READMISSIONS AND COST FOLLOWING PERCUTANEOUS CORONARY INTERVENTION. J Am Coll Cardiol 2018. [DOI: 10.1016/s0735-1097(18)30630-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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Brown C, Ebinger J, Kavian JA, Ajoku A, Lange D, Hildebrandt D, Henry TD. ST-ELEVATION MYOCARDIAL INFARCTION: HOW ACCURATE ARE THE DATABASES? J Am Coll Cardiol 2018. [DOI: 10.1016/s0735-1097(18)31710-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/17/2022]
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Ebinger J, Wiley B, Devendra G, Kazi D, Hsue P, Carroll C, Pitts R, Tseng Z, Barnett C. STIMULANT ASSOCIATED HEART FAILURE WITH METHAMPHETAMINE AND COCAINE USE: SURVIVAL AND RESOURCE UTILIZATION AT A SAFETY-NET HOSPITAL. J Am Coll Cardiol 2018. [DOI: 10.1016/s0735-1097(18)31331-7] [Citation(s) in RCA: 2] [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: 11/25/2022]
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Affiliation(s)
| | | | - Alexander Zhu
- University of Iowa Carver School of Medicine, Iowa City, IA
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Ebinger J, Tabak S, Rabin L, Bhoopalam C, Makkar R, Henry T. TCT-343 Implementation of an Electronic Medical Record Based Bleeding Risk Calculator to Reduce Bleeding Events after PCI. J Am Coll Cardiol 2016. [DOI: 10.1016/j.jacc.2016.09.474] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
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Ebinger J, Sedighi Manesh R, Dhaliwal G, Sharpe B, Monash B. A coat with a clue. J Hosp Med 2015; 10:462-6. [PMID: 25976609 DOI: 10.1002/jhm.2378] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/15/2015] [Revised: 04/06/2015] [Accepted: 04/10/2015] [Indexed: 11/10/2022]
Affiliation(s)
- Joseph Ebinger
- Division of Cardiology, Cedars Sinai Medical Center, Los Angeles, California
| | - Reza Sedighi Manesh
- Department of Medicine, University of California, San Francisco, San Francisco, California
| | - Gurpreet Dhaliwal
- Department of Medicine, University of California, San Francisco, San Francisco, California
- Medical Service, San Francisco VA Medical Center, San Francisco, California
| | - Bradley Sharpe
- Department of Medicine, University of California, San Francisco, San Francisco, California
| | - Bradley Monash
- Department of Medicine, University of California, San Francisco, San Francisco, California
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