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Arps K, Li B, Allen JC, Alenezi F, Frazier-Mills C, Al-Khatib SM, Jackson KP, Jackson LR, Thomas KL, Piccini JP. Association of leadless pacing with ventricular and valvular function. J Cardiovasc Electrophysiol 2023; 34:2233-2242. [PMID: 37702140 DOI: 10.1111/jce.16046] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/05/2023] [Revised: 08/10/2023] [Accepted: 08/19/2023] [Indexed: 09/14/2023]
Abstract
BACKGROUND Traditional transvenous pacemakers are associated with worsening tricuspid valve function due to lead-related leaflet impingement, as well as ventricular dysfunction related to electromechanical dyssynchrony from chronic right ventricular (RV) pacing. The association of leadless pacing with ventricular and valvular function has not been well established. We aimed to assess the association of leadless pacemaker placement with changes in valvular regurgitation and ventricular function. METHODS AND RESULTS Echocardiographic features before and after leadless pacemaker implant were analyzed in consecutive patients who received a leadless pacemaker with pre- and postprocedure echocardiography at Duke University Hospital between November 2014 and November 2019. Valvular regurgitation was graded ordinally from 0 (none) to 3 (severe). Among 54 patients, the mean age was mean age was 70.1 ± 14.3 years, 24 (44%) were women, and the most frequent primary pacing indication was complete heart block in 24 (44%). The median RV pacing burden was 45.4 (interquartile range [IQR] 3.5-97.0). On echocardiogram performed 8.9 months (IQR 4.5-14.5) after implant, there was no change in the average severity of tricuspid regurgitation (mean change 0.07 ± 1.15, p = .64) from pre-procedure echocardiogram. We observed a decrease in the average left ventricular ejection fraction (LVEF) (52.3 ± 9.3 to 47.9 ± 12.1, p = .0019) and tricuspid annular plane systolic excursion (TAPSE) (1.8 ± 0.6 to 1.6 ± 0.4, p = .0437). Thirteen patients (24%) had absolute drop in LVEF of ≥10%. CONCLUSION We did not observe short term worsening valvular function in patients with leadless pacemakers. However, consistent with the pathophysiologic impact of RV pacing, leadless pacing was associated with a reduction in biventricular function.
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Affiliation(s)
- Kelly Arps
- Division of Cardiovascular Disease, Section of Cardiac Electrophysiology, Duke University Medical Center, Durham, North Carolina, USA
| | - Bicong Li
- Division of Cardiovascular Disease, Section of Cardiac Electrophysiology, Duke University Medical Center, Durham, North Carolina, USA
| | - John Carson Allen
- Division of Cardiovascular Disease, Section of Cardiac Electrophysiology, Duke University Medical Center, Durham, North Carolina, USA
| | - Fawaz Alenezi
- Division of Cardiovascular Disease, Section of Cardiac Electrophysiology, Duke University Medical Center, Durham, North Carolina, USA
| | - Camille Frazier-Mills
- Division of Cardiovascular Disease, Section of Cardiac Electrophysiology, Duke University Medical Center, Durham, North Carolina, USA
| | - Sana M Al-Khatib
- Division of Cardiovascular Disease, Section of Cardiac Electrophysiology, Duke University Medical Center, Durham, North Carolina, USA
| | - Kevin P Jackson
- Division of Cardiovascular Disease, Section of Cardiac Electrophysiology, Duke University Medical Center, Durham, North Carolina, USA
| | - Larry R Jackson
- Division of Cardiovascular Disease, Section of Cardiac Electrophysiology, Duke University Medical Center, Durham, North Carolina, USA
| | - Kevin L Thomas
- Division of Cardiovascular Disease, Section of Cardiac Electrophysiology, Duke University Medical Center, Durham, North Carolina, USA
| | - Jonathan P Piccini
- Division of Cardiovascular Disease, Section of Cardiac Electrophysiology, Duke University Medical Center, Durham, North Carolina, USA
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Arps K, Doss J, Geiger K, Flores-Rosario K, DeVore AD, Karra R, Kim HW, Piccini JP, Pokorney SD, Sun AY. Incidence and Predictors of Relapse After Weaning Immune Suppressive Therapy in Cardiac Sarcoidosis. Am J Cardiol 2023; 204:249-256. [PMID: 37556894 DOI: 10.1016/j.amjcard.2023.07.088] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/29/2023] [Accepted: 07/13/2023] [Indexed: 08/11/2023]
Abstract
Cardiac sarcoidosis (CS) is a relapsing-remitting disease, and immune suppression (IS) is the mainstay of therapy. Predictors of relapse for patients with CS in remission are not well characterized. We assessed incidence of relapse in consecutive patients with CS treated with high-dose steroids and/or steroid-sparing agents (SSA) in our center from 2000 to 2020. Remission was defined as reaching maintenance therapy (no IS, SSA, and/or prednisone ≤5 mg/d) for ≥1 month. Relapse was defined as recurrence of CS syndrome requiring IS intensification: heart failure, ventricular arrhythmia, decrease in left ventricular ejection fraction, or increased disease burden on imaging. Among 68 patients, the mean age was 50.7±9.0 years; 25 (37%) were women, and 32 (47%) were Black. In total, 59 patients (87%) reached remission. Over a median follow-up of 39.5 months (interquartile range 17.6, 92.5), 28 (48%) relapsed. Greater percentage of late gadolinium enhancement (LGE) on pretreatment magnetic resonance imaging corresponded with increased likelihood of relapse (odds ratio 1.396 per 5% increase [95% confidence interval (CI) 1.04 to 1.88]; p = 0.028). LGE ≥11% predicted elevated risk of relapse (adjusted odds ratio 4.998 [1.34 to 18.64]; p = 0.017). Shorter time to relapse was observed with isolated CS (adjusted hazard ratio 4.084 [1.44,11.56]; p = 0.008) and LGE ≥11% (adjusted hazard ratio 3.007 [1.01, 8.98]; p = 0.049). Approximately 1 in 2 patients with CS in remission experienced relapse. Greater burden of LGE on cardiac magnetic resonance imaging and isolated CS are associated with greater risk of relapse. Future work is needed to refine risk stratification for relapse and to optimize surveillance strategies on the basis of the burden of disease.
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Affiliation(s)
- Kelly Arps
- Duke University Medical Center, Durham, North Carolina; Duke Clinical Research Institute, Durham, North Carolina.
| | - Jayanth Doss
- Duke University Medical Center, Durham, North Carolina
| | - Kelly Geiger
- Duke University Medical Center, Durham, North Carolina
| | | | - Adam D DeVore
- Duke University Medical Center, Durham, North Carolina; Duke Clinical Research Institute, Durham, North Carolina
| | - Ravi Karra
- Duke University Medical Center, Durham, North Carolina
| | - Han W Kim
- Duke University Medical Center, Durham, North Carolina
| | - Jonathan P Piccini
- Duke University Medical Center, Durham, North Carolina; Duke Clinical Research Institute, Durham, North Carolina
| | - Sean D Pokorney
- Duke University Medical Center, Durham, North Carolina; Duke Clinical Research Institute, Durham, North Carolina
| | - Albert Y Sun
- Duke University Medical Center, Durham, North Carolina; Durham Veterans Affairs Medical Center, Durham, North Carolina
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Arps K, Barnett AS, Koontz JI, Pokorney SD, Jackson KP, Bahnson TD, Piccini JP, Sun AY. Reply to: Two ripples in a pond: The subtleties of mapping observations in localizing PVC sites. J Cardiovasc Electrophysiol 2023; 34:1789-1790. [PMID: 37493497 DOI: 10.1111/jce.16004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/02/2023] [Accepted: 07/06/2023] [Indexed: 07/27/2023]
Affiliation(s)
- Kelly Arps
- Division of Cardiovascular Disease, Section of Cardiac Electrophysiology, Duke University Medical Center, Durham, North Carolina, USA
- Duke Clinical Research Institute, Durham, North Carolina, USA
| | - Adam S Barnett
- Division of Cardiovascular Disease, Section of Cardiac Electrophysiology, Duke University Medical Center, Durham, North Carolina, USA
- Division of Cardiology, Prisma Health, Greenville, South Carolina, USA
| | - Jason I Koontz
- Division of Cardiovascular Disease, Section of Cardiac Electrophysiology, Duke University Medical Center, Durham, North Carolina, USA
- Division of Cardiovascular Disease, Section of Cardiac Electrophysiology, Durham VA Medical Center, Durham, North Carolina, USA
| | - Sean D Pokorney
- Division of Cardiovascular Disease, Section of Cardiac Electrophysiology, Duke University Medical Center, Durham, North Carolina, USA
- Duke Clinical Research Institute, Durham, North Carolina, USA
| | - Kevin P Jackson
- Division of Cardiovascular Disease, Section of Cardiac Electrophysiology, Duke University Medical Center, Durham, North Carolina, USA
| | - Tristram D Bahnson
- Division of Cardiovascular Disease, Section of Cardiac Electrophysiology, Duke University Medical Center, Durham, North Carolina, USA
| | - Jonathan P Piccini
- Division of Cardiovascular Disease, Section of Cardiac Electrophysiology, Duke University Medical Center, Durham, North Carolina, USA
- Duke Clinical Research Institute, Durham, North Carolina, USA
| | - Albert Y Sun
- Division of Cardiovascular Disease, Section of Cardiac Electrophysiology, Duke University Medical Center, Durham, North Carolina, USA
- Division of Cardiovascular Disease, Section of Cardiac Electrophysiology, Durham VA Medical Center, Durham, North Carolina, USA
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Arps K, Barnett AS, Koontz JI, Pokorney SD, Jackson KP, Bahnson TD, Piccini JP, Sun AY. Use of Ripple mapping to enhance localization and ablation of outflow tract premature ventricular contractions. J Cardiovasc Electrophysiol 2023; 34:1552-1560. [PMID: 37293826 DOI: 10.1111/jce.15963] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/30/2023] [Revised: 05/16/2023] [Accepted: 05/24/2023] [Indexed: 06/10/2023]
Abstract
INTRODUCTION Accurate localization of septal outflow tract premature ventricular contractions (PVCs) is often difficult due to frequent mid-myocardial or protected origin. Compared with traditional activation mapping, CARTO Ripple mapping provides visualization of all captured electrogram data without assignment of a specific local activation time and thus may enhance PVC localization. METHODS Electroanatomic maps for consecutive catheter ablation procedures for septal outflow tract PVCs (July 2018-December 2020) were analyzed. For each PVC, we identified the earliest local activation point (EA), defined by the point of maximal -dV/dt in a simultaneously recorded unipolar electrogram, and the earliest Ripple signal (ERS), defined as the earliest point at which three grouped simultaneous Ripple bars appeared in late diastole. Immediate success was defined as full suppression of the clinical PVC. RESULTS Fifty-seven unique PVCs in 55 procedures were included. When ERS and EA were in the same chamber (RV, LV, or CS), the odds ratio for the successful procedure was 13.1 (95% confidence interval [CI] 2.2-79.9, p = .005). Discordance between sites was associated with a higher likelihood of needing multi-site ablation (odds ratio [OR] 7.9 [1.4-4.6; p = .020]). Median EA-ERS distance in successful versus unsuccessful cases was 4.6 mm (interquartile range 2.9-8.5) versus 12.5 mm (7.8-18.5); (p = .020). CONCLUSION Greater EA-ERS concordance was associated with higher odds of single-site PVC suppression and successful septal outflow tract PVC ablation. Visualization of complex signals via automated Ripple mapping may offer rapid localization information complementary to local activation mapping for PVCs of mid-myocardial origin.
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Affiliation(s)
- Kelly Arps
- Division of Cardiovascular Disease, Section of Cardiac Electrophysiology, Duke University Medical Center, Durham, North Carolina, USA
- Duke Clinical Research Institute, Durham, North Carolina, USA
| | - Adam S Barnett
- Division of Cardiovascular Disease, Section of Cardiac Electrophysiology, Duke University Medical Center, Durham, North Carolina, USA
- Prisma Health, Greenville, South Carolina, USA
| | - Jason I Koontz
- Division of Cardiovascular Disease, Section of Cardiac Electrophysiology, Duke University Medical Center, Durham, North Carolina, USA
- Durham VA Medical Center, Durham, North Carolina, USA
| | - Sean D Pokorney
- Division of Cardiovascular Disease, Section of Cardiac Electrophysiology, Duke University Medical Center, Durham, North Carolina, USA
- Duke Clinical Research Institute, Durham, North Carolina, USA
| | - Kevin P Jackson
- Division of Cardiovascular Disease, Section of Cardiac Electrophysiology, Duke University Medical Center, Durham, North Carolina, USA
| | - Tristram D Bahnson
- Division of Cardiovascular Disease, Section of Cardiac Electrophysiology, Duke University Medical Center, Durham, North Carolina, USA
| | - Jonathan P Piccini
- Division of Cardiovascular Disease, Section of Cardiac Electrophysiology, Duke University Medical Center, Durham, North Carolina, USA
- Duke Clinical Research Institute, Durham, North Carolina, USA
| | - Albert Y Sun
- Division of Cardiovascular Disease, Section of Cardiac Electrophysiology, Duke University Medical Center, Durham, North Carolina, USA
- Durham VA Medical Center, Durham, North Carolina, USA
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Jentzer JC, Noseworthy PA, Kashou AH, May AM, Chrispin J, Kabra R, Arps K, Blumer V, Tisdale JE, Solomon MA. Multidisciplinary Critical Care Management of Electrical Storm: JACC State-of-the-Art Review. J Am Coll Cardiol 2023; 81:2189-2206. [PMID: 37257955 PMCID: PMC10683004 DOI: 10.1016/j.jacc.2023.03.424] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [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: 02/16/2023] [Accepted: 03/14/2023] [Indexed: 06/02/2023]
Abstract
Electrical storm (ES) reflects life-threatening cardiac electrical instability with 3 or more ventricular arrhythmia episodes within 24 hours. Identification of underlying arrhythmogenic cardiac substrate and reversible triggers is essential, as is interrogation and programming of an implantable cardioverter-defibrillator, if present. Medical management includes antiarrhythmic drugs, beta-adrenergic blockade, sedation, and hemodynamic support. The initial intensity of these interventions should be matched to the severity of ES using a stepped-care algorithm involving escalating treatments for higher-risk presentations or recurrent ventricular arrhythmias. Many patients with ES are considered for catheter ablation, which may require the use of temporary mechanical circulatory support. Outcomes after ES are poor, including frequent ES recurrences and deaths caused by progressive heart failure and other cardiac causes. A multidisciplinary collaborative approach to the management of ES is crucial, and evaluation for heart transplantation or palliative care is often appropriate, even for patients who survive the initial episode.
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Affiliation(s)
- Jacob C Jentzer
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, Minnesota, USA.
| | - Peter A Noseworthy
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, Minnesota, USA
| | - Anthony H Kashou
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, Minnesota, USA
| | - Adam M May
- Cardiovascular Division, Washington University School of Medicine, St Louis, Missouri, USA
| | - Jonathan Chrispin
- Clinical Cardiac Electrophysiology, Division of Cardiology, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Rajesh Kabra
- Kansas City Heart Rhythm Institute, Overland Park, Kansas, USA
| | - Kelly Arps
- Cardiac Electrophysiology Section, Division of Cardiology, Duke University Medical Center, Durham, North Carolina, USA
| | - Vanessa Blumer
- Department of Cardiology, Cleveland Clinic, Cleveland, Ohio, USA
| | - James E Tisdale
- College of Pharmacy, Purdue University, West Lafayette, Indiana, USA; School of Medicine, Indiana University, Indianapolis, Indiana, USA
| | - Michael A Solomon
- Critical Care Medicine Department, National Institutes of Health Clinical Center, National Institutes of Health, Bethesda, Maryland, USA; Cardiovascular Branch, National Heart, Lung, and Blood Institute, National Institutes of Health, Bethesda, Maryland, USA
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Arps K, Piccini JP. Women, men and the safety gap after catheter ablation of atrial fibrillation. Heart 2023; 109:576-577. [PMID: 36549681 DOI: 10.1136/heartjnl-2022-321632] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/24/2022] Open
Affiliation(s)
- Kelly Arps
- Department of Medicine, Duke Heart Center, Duke University Hospital, Durham, North Carolina, USA
| | - Jonathan P Piccini
- Department of Medicine, Duke Heart Center, Duke University Hospital, Durham, North Carolina, USA
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Carnicelli AP, Keane R, Brown KM, Loriaux DB, Kendsersky P, Alviar CL, Arps K, Berg DD, Bohula EA, Burke JA, Dixson JA, Gerber DA, Goldfarb M, Granger CB, Guo J, Harrison RW, Kontos M, Lawler PR, Miller PE, Nativi-Nicolau J, Newby LK, Racharla L, Roswell RO, Shah KS, Sinha SS, Solomon MA, Teuteberg J, Wong G, van Diepen S, Katz JN, Morrow DA. Characteristics, therapies, and outcomes of In-Hospital vs Out-of-Hospital cardiac arrest in patients presenting to cardiac intensive care units: From the critical care Cardiology trials network (CCCTN). Resuscitation 2023; 183:109664. [PMID: 36521683 PMCID: PMC9899313 DOI: 10.1016/j.resuscitation.2022.12.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/10/2022] [Revised: 11/19/2022] [Accepted: 12/05/2022] [Indexed: 12/15/2022]
Abstract
BACKGROUND Cardiac arrest (CA) is a common reason for admission to the cardiac intensive care unit (CICU), though the relative burden of morbidity, mortality, and resource use between admissions with in-hospital (IH) and out-of-hospital (OH) CA is unknown. We compared characteristics, care patterns, and outcomes of admissions to contemporary CICUs after IHCA or OHCA. METHODS The Critical Care Cardiology Trials Network is a multicenter network of tertiary CICUs in the US and Canada. Participating centers contributed data from consecutive admissions during 2-month annual snapshots from 2017 to 2021. We analyzed characteristics and outcomes of admissions by IHCA vs OHCA. RESULTS We analyzed 2,075 admissions across 29 centers (50.3% IHCA, 49.7% OHCA). Admissions with IHCA were older (median 66 vs 62 years), more commonly had coronary disease (38.3% vs 29.7%), atrial fibrillation (26.7% vs 15.6%), and heart failure (36.3% vs 22.1%), and were less commonly comatose on CICU arrival (34.2% vs 71.7%), p < 0.001 for all. IHCA admissions had lower lactate (median 4.3 vs 5.9) but greater utilization of invasive hemodynamics (34.3% vs 23.6%), mechanical circulatory support (28.4% vs 16.8%), and renal replacement therapy (15.5% vs 9.4%); p < 0.001 for all. Comatose IHCA patients underwent targeted temperature management less frequently than OHCA patients (63.3% vs 84.9%, p < 0.001). IHCA admissions had lower unadjusted CICU (30.8% vs 39.0%, p < 0.001) and in-hospital mortality (36.1% vs 44.1%, p < 0.001). CONCLUSION Despite a greater burden of comorbidities, CICU admissions after IHCA have lower lactate, greater invasive therapy utilization, and lower crude mortality than admissions after OHCA.
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Affiliation(s)
- Anthony P Carnicelli
- Division of Cardiology, Department of Medicine, Medical University of South Carolina, Charleston, SC, USA.
| | - Ryan Keane
- Division of Cardiology, Department of Medicine, Cleveland Clinic Foundation, Cleveland, OH, USA
| | - Kelly M Brown
- Duke University Hospital, Division of Cardiology, Durham, NC, USA
| | - Daniel B Loriaux
- Duke University Hospital, Division of Cardiology, Durham, NC, USA
| | - Payton Kendsersky
- Division of Cardiology, Department of Medicine, Medical University of South Carolina, Charleston, SC, USA
| | - Carlos L Alviar
- Leon H Charney Division of Cardiology, Bellevue Hospital Center, New York University School of Medicine, New York, NY, USA
| | - Kelly Arps
- Duke University Hospital, Division of Cardiology, Durham, NC, USA
| | - David D Berg
- TIMI Study Group, Cardiovascular Division, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Erin A Bohula
- TIMI Study Group, Cardiovascular Division, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | | | - Jeffrey A Dixson
- Duke University Hospital, Division of Cardiology, Durham, NC, USA
| | - Daniel A Gerber
- Division of Cardiovascular Medicine, Stanford University School of Medicine, Stanford, CA, USA
| | - Michael Goldfarb
- Division of Cardiology, Jewish General Hospital, McGill University, Montreal, Quebec, Canada
| | | | - Jianping Guo
- TIMI Study Group, Cardiovascular Division, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | | | - Michael Kontos
- Division of Cardiology, Department of Medicine, Virginia Commonwealth University School of Medicine, Richmond, VA, USA
| | - Patrick R Lawler
- Peter Munk Cardiac Centre, Toronto General Hospital, Toronto, Ontario, Canada
| | - P Elliott Miller
- Section of Cardiovascular Medicine, Yale School of Medicine, New Haven, CT, USA
| | - Jose Nativi-Nicolau
- Division of Cardiology, Department of Medicine, Mayo Clinic, Rochester, MN, USA
| | - L Kristin Newby
- Duke University Hospital, Division of Cardiology, Durham, NC, USA
| | | | - Robert O Roswell
- Lennox Hill Hospital, Zucker School of Medicine at Hofstra/Northwell, Hempstead, NY, USA
| | - Kevin S Shah
- Division of Cardiology, Department of Medicine, University of Utah, Salt Lake City, UT, USA
| | - Shashank S Sinha
- Inova Heart and Vascular Institute, Inova Fairfax Medical Campus, Falls Church, VA, USA
| | - Michael A Solomon
- Critical Care Medicine Department, National Institutes of Health Clinical Center and Cardiovascular Branch, National Heart, Lung, and Blood Institute of the National Institutes of Health, Bethesda, MD, USA
| | - Jeffrey Teuteberg
- Division of Cardiovascular Medicine, Stanford University School of Medicine, Stanford, CA, USA
| | - Graham Wong
- Division of Cardiology, Department of Medicine, University of British Columbia, Vancouver, British Columbia, Canada
| | - Sean van Diepen
- Department of Critical Care Medicine and Division of Cardiology, Department of Medicine, University of Alberta, Alberta, Canada
| | - Jason N Katz
- Duke University Hospital, Division of Cardiology, Durham, NC, USA
| | - David A Morrow
- TIMI Study Group, Cardiovascular Division, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
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Rosario KF, Brezitski K, Arps K, Milne M, Doss J, Karra R. Cardiac Sarcoidosis: Current Approaches to Diagnosis and Management. Curr Allergy Asthma Rep 2022; 22:171-182. [PMID: 36308680 DOI: 10.1007/s11882-022-01046-x] [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] [Accepted: 10/04/2022] [Indexed: 12/13/2022]
Abstract
PURPOSE OF REVIEW Cardiac sarcoidosis (CS) is an important cause of non-ischemic cardiomyopathy and has specific diagnostic and therapeutic considerations. With advances in imaging techniques and treatment approaches, the approach to monitoring disease progression and management of CS continues to evolve. The purpose of this review is to highlight advances in CS diagnosis and treatment and present a center's multidisciplinary approach to CS care. RECENT FINDINGS In this review, we highlight advances in granuloma biology along with contemporary diagnostic approaches. Moreover, we expand on current targets of immunosuppression focused on granuloma biology and concurrent advances in the cardiovascular care of CS in light of recent guideline recommendations. Here, we review advances in the understanding of the sarcoidosis granuloma along with contemporary diagnostic and therapeutic considerations for CS. Additionally, we highlight knowledge gaps and areas for future research in CS treatment.
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Affiliation(s)
- Karen Flores Rosario
- Division of Cardiology, Department of Medicine, Duke University Medical Center, Durham, NC, 27710, USA
| | - Kyla Brezitski
- Division of Cardiology, Department of Medicine, Duke University Medical Center, Durham, NC, 27710, USA
| | - Kelly Arps
- Division of Cardiology, Department of Medicine, Duke University Medical Center, Durham, NC, 27710, USA
| | - Megan Milne
- Division of Rheumatology, Department of Medicine, Duke University Medical Center, Durham, NC, 27710, USA
| | - Jayanth Doss
- Division of Rheumatology, Department of Medicine, Duke University Medical Center, Durham, NC, 27710, USA
| | - Ravi Karra
- Division of Cardiology, Department of Medicine, Duke University Medical Center, Durham, NC, 27710, USA. .,Department of Pathology, Duke University Medical Center, Box 102152 DUMC, Durham, NC, 27710, USA.
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Arps K, Harrington J, Carnicelli AP, Wu A, Chiswell K, Chamberlain AM, Chrischilles E, Jones WS, Raj V, Steinberg BA, Mundl H, Viethen T, Granger CB, Piccini JP, Patel MR. Incidence and risk factors for major bleeding events in atrial fibrillation patients on direct oral anticoagulant therapy: data from the National Patient-Centered Clinical Research Network. Eur Heart J 2022. [DOI: 10.1093/eurheartj/ehac544.624] [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: 11/15/2022] Open
Abstract
Abstract
Background
Direct oral anticoagulation (DOACs) prevent stroke in patients with atrial fibrillation (AF) and have a superior safety profile compared with vitamin K antagonists (VKA). Yet, better definition of incidence and risk factors for major bleeding associated with DOACs in clinical practice may be important given emerging stroke prevention technologies, both pharmacologic and nonpharmacologic.
Purpose
To describe the incidence of and risk factors for major bleeding in individuals with AF on DOAC therapy.
Methods
We reviewed electronic health record data for two patient cohorts with AF prescribed DOACs: (1) Duke University Health System (DUHS) (2010–2018) and (2) Sites within the Patient-Centered Clinical Research Network (PCORnet) (2015–2019) which had ≥6 years assimilated data from both inpatient and outpatient encounters (7 sites). In each cohort, we assessed the 5-year incidence of major bleeding events defined as hospitalization for intracranial hemorrhage, or hospitalization for gastro-intestinal bleeding or procedure to control bleeding accompanied by transfusion within ±7 days or death within 30 days. Multivariable Fine-Gray proportional hazards modeling in each cohort was performed to evaluate independent risk factors for major bleeding on DOAC therapy.
Results
The cohorts included 10,625 patients (DUHS) and 58,321 patients (PCORnet) with AF. Major bleeding events occurred within 5 years of diagnosis in 639 (7.9%) of DUHS patients and 2568 (6.6%) of PCORnet patients (Table 1). The DUHS model predicted time to first major bleeding event with a C-index of 0.756 (95% CI 0.737, 0.775) and the PCORNet model had a c-index of 0.745 (0.736, 0.755) (Table 2). Independent factors associated with major bleeding consistent across both models (p<0.001 in PCORnet for all unless noted) were higher CHA2DS2-VASc scores, lower eGFR, anemia (HR per 1-point increase in hemoglobin up to 12 g/dL 0.79 [0.76, 0.82]), prior major bleeding (HR 2.70 [2.22, 3.30]), cancer (HR 1.23 [1.12, 1.36]), recent cardiac surgery (HR 0.70 [0.51, 0.97]; p=0.030), alcohol use (HR 1.56 [1.29, 1.88]), aspirin use (HR 1.44 [1.32, 1.57]), and selective serotonin reuptake inhibitor use (HR 1.30 [1.19, 1.42]).
Conclusions
Across a large and geographically diverse contemporary population, risk of bleeding on DOAC for stroke prevention in AF remains a frequent and important clinical problem. There is an unmet need for stroke prevention therapies with improved safety profiles. We identified risk factors for major bleeding events on DOAC therapy, some of which are not represented in traditional risk scores, which may inform shared decision making for stroke prevention.
Funding Acknowledgement
Type of funding sources: Private company. Main funding source(s): Bayer Pharmaceuticals
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Affiliation(s)
- K Arps
- Duke Clinical Research Institute , Durham , United States of America
| | - J Harrington
- Duke Clinical Research Institute , Durham , United States of America
| | - A P Carnicelli
- Duke Clinical Research Institute , Durham , United States of America
| | - A Wu
- Duke Clinical Research Institute , Durham , United States of America
| | - K Chiswell
- Duke Clinical Research Institute , Durham , United States of America
| | | | - E Chrischilles
- University of Iowa , Iowa City , United States of America
| | - W S Jones
- Duke Clinical Research Institute , Durham , United States of America
| | - V Raj
- Allina Health , Minneapolis , United States of America
| | - B A Steinberg
- University of Utah , Salt Lake City , United States of America
| | - H Mundl
- Bayer AG , Wuppertal , Germany
| | | | - C B Granger
- Duke Clinical Research Institute , Durham , United States of America
| | - J P Piccini
- Duke Clinical Research Institute , Durham , United States of America
| | - M R Patel
- Duke Clinical Research Institute , Durham , United States of America
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Harrington J, Arps K, Wu A, Carnicelli AP, Chiswell K, Chrischilles E, Shantha G, Vanwormer J, Mundl H, Viethan T, Alexander JH, Lopes RD, Washam J, Patel MR. Reduced dose, but not reduced risk: rates of inappropriate apixaban dose reduction and stroke and bleeding incidence. Eur Heart J 2022. [DOI: 10.1093/eurheartj/ehac544.2709] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
Abstract
Introduction
Patients with atrial fibrillation (AF) should be prescribed standard-dose (5mg twice daily) apixaban for stroke prevention unless they meet 2 or more criteria: age ≥80, weight ≤60kg, and/or creatinine ≤1.5mg/dL, in which case a reduced-dose (2.5mg twice daily) is indicated. Despite this, some clinicians may also prescribe reduced-dose apixaban to patients who do not meet criteria for dose reduction, in an effort to reduce bleeding risk.
Purpose
To assess apixaban prescribing patterns in patients with AF based on dose reduction criteria and to characterize baseline demographics and incidence of ischemic stroke, major bleeding, and intracranial hemorrhage (ICH) for patients stratified by standard-dose, appropriately reduced-dose, and inappropriately reduced-dose apixaban.
Methods
Using pooled data from 8 large hospitals in PCORnet, a multicenter national healthcare research network, we assessed the standard and reduced-dose apixaban prescribing patterns for patients with AF, with additional stratification of patients prescribed 2.5mg based on presence or absence of 2+ criteria for dose reduction. We then assessed baseline characteristics and 5-year event rate of ischemic stroke, major bleeding, ICH and death.
Results
Of 45,947 patients with AF on apixaban and available dosing information, 38,861 (85%) were prescribed apixaban 5mg and 7086 (15%) were prescribed 2.5mg. Of patients prescribed apixaban 2.5mg, 4321 (61%) did not meet criteria for dose reduction. Patients on reduced dose apixaban were more likely to be female and have comorbidities such as heart failure, hypertension, and prior ischemic stroke. These trends were more pronounced for patients meeting dose adjustment criteria than those not meeting criteria (Table 1).
Unadjusted analyses found patients on 2.5mg of apixaban were significantly more likely to experience ischemic stroke, major bleeding, and all-cause death. Patients with 2+ dose reduction criteria on 2.5mg of apixaban had the highest rates of each event, but patients who were prescribed reduced dose without meeting criteria were also at elevated risk (Table 2).
Conclusion
Many patients prescribed reduced-dose apixaban do not meet criteria for dose reduction. Because patients prescribed reduced dose apixaban are older and have more cardiovascular risk factors, their incidence of stroke, major bleeding, and death exceeds that of full dose treated patients. These risks exist both for patients who do and do not meet criteria for dose reduction, suggesting potential under-treatment for the majority of dose-reduced patients.
Funding Acknowledgement
Type of funding sources: Private company. Main funding source(s): Bayer
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Affiliation(s)
- J Harrington
- Duke Clinical Research Institute , Durham , United States of America
| | - K Arps
- Duke Clinical Research Institute , Durham , United States of America
| | - A Wu
- Duke Clinical Research Institute , Durham , United States of America
| | - A P Carnicelli
- Duke Clinical Research Institute , Durham , United States of America
| | - K Chiswell
- Duke Clinical Research Institute , Durham , United States of America
| | - E Chrischilles
- University of Iowa College of Public Health , Iowa , United States of America
| | - G Shantha
- Wake Forest Baptist Health , Winston-Salem , United States of America
| | - J Vanwormer
- Marshfield Clinic Research Institute , Marshfield , United States of America
| | - H Mundl
- Bayer AG , Wuppertal , Germany
| | | | - J H Alexander
- Duke Clinical Research Institute , Durham , United States of America
| | - R D Lopes
- Duke Clinical Research Institute , Durham , United States of America
| | - J Washam
- Duke Clinical Research Institute , Durham , United States of America
| | - M R Patel
- Duke Clinical Research Institute , Durham , United States of America
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11
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Blumer V, Arps K, Turco JV, Taqueti VR, Walsh MN, Douglas PS. Increase in Gender Diversity Among JACC Editorialists and Editors From 2008 to 2019. J Am Coll Cardiol 2022; 80:562-563. [PMID: 35902179 DOI: 10.1016/j.jacc.2022.05.022] [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] [Received: 02/24/2022] [Revised: 04/21/2022] [Accepted: 05/23/2022] [Indexed: 11/15/2022]
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12
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Arps K, Geiger K, Devore AD, Doss J, Karra R, Kim HW, Piccini JP, Pokorney SD, Sun AY. PO-638-06 TEMPORAL RELATIONSHIP OF ATRIAL ARRHYTHMIAS WITH THE DIAGNOSIS OF CARDIAC SARCOIDOSIS. Heart Rhythm 2022. [DOI: 10.1016/j.hrthm.2022.03.962] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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13
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Piccini JP, Arps K. Sacubitril/Valsartan Therapy for AF and HFpEF: Is the Glass Half Empty or Half Full? JACC Heart Fail 2022; 10:347-349. [PMID: 35483797 DOI: 10.1016/j.jchf.2022.02.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/24/2022] [Accepted: 02/28/2022] [Indexed: 06/14/2023]
Affiliation(s)
- Jonathan P Piccini
- Duke University Medical Center and Duke Clinical Research Institute, Durham, North Carolina, USA.
| | - Kelly Arps
- Duke University Medical Center and Duke Clinical Research Institute, Durham, North Carolina, USA
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14
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Arps K, Barnett AS, Koontz JI, Pokorney SD, Jackson KP, Bahnson TD, Piccini JP, Sun AY. CE-520-03 USE OF RIPPLE MAPPING TO ENHANCE LOCALIZATION AND ABLATION OF OUTFLOW TRACT PREMATURE VENTRICULAR CONTRACTIONS. Heart Rhythm 2022. [DOI: 10.1016/j.hrthm.2022.03.105] [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: 11/15/2022]
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15
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Bicong L, Allen JC, Arps K, Al-Khatib SM, Bahnson TD, Daubert JP, Frazier-Mills C, Hegland DD, Jackson KP, Jackson LR, Lewis RK, Pokorney SD, Sun AY, Thomas KL, Piccini JP. Leadless Pacemaker Implantation after Lead Extraction for Cardiac Implanted Electronic Device Infection. J Cardiovasc Electrophysiol 2022; 33:464-470. [PMID: 35029307 DOI: 10.1111/jce.15363] [Citation(s) in RCA: 14] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/24/2021] [Revised: 10/19/2021] [Accepted: 10/29/2021] [Indexed: 11/27/2022]
Abstract
BACKGROUND Cardiac implanted electronic device (CIED) pocket and systemic infection remain common complications with traditional CIEDs and are associated with high morbidity and mortality. Leadless pacemakers may be an attractive pacing alternative for many patients following complete hardware removal for a CIED infection by eliminating surgical pocket-related complications as well as lower risk of recurrent complications. OBJECTIVE To describe use and outcomes associated with leadless pacemaker implantation following extraction of a prior CIED system due to infection. METHODS Patient characteristics and post-procedural outcomes were described in patients who underwent leadless pacemaker implantation at Duke University Hospital between November 11, 2014 and November 18, 2019, following CIED infection and device extraction. Outcomes of interest included procedural complications, pacemaker syndrome, need for system revision, and recurrent infection. RESULTS Among 39 patients, the mean age was 71 ±17 years, 31% were women, and the most frequent primary pacing indication was complete heart block (64.1%) with 9 (23.1%) patients being pacemaker dependent at the time of Micra implantation. The primary organism implicated in the CIED infection was Staphylococcus aureus (43.6%). Nine of the 39 patients had a leadless pacemaker implanted before or on the same day as their extraction procedure, and the remaining 30 patients had a leadless pacemaker implanted after their extraction procedure. During the mean follow-up time (mean 24.8 ± 14.7 months) following the leadless pacemaker implantation, there were a total of 3 major complications: 1 groin hematoma, 1 femoral arteriovenous fistula, and 1 case of pacemaker syndrome. No patients had evidence of recurrent CIED infection after leadless pacemaker implantation. CONCLUSIONS Despite a prior CIED infection and an elevated risk of recurrent infection, there was no evidence of CIED infection with a mean follow up of over 2 years following leadless pacemaker implantation at or after CIED system removal. Larger studies with longer follow-up are required to determine if there is a long-term advantage to implanting a leadless pacemaker versus a traditional pacemaker following temporary pacing when needed during the peri-extraction period in patients with a prior CIED infection. This article is protected by copyright. All rights reserved.
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Affiliation(s)
- Li Bicong
- Duke University Medical Center Division of Cardiovascular Disease, Section of Cardiac Electrophysiology, Durham, NC, USA
| | - John Carson Allen
- Duke University School of Medicine, Medicine, Durham, North Carolina
| | - Kelly Arps
- Duke University Medical Center Division of Cardiovascular Disease, Section of Cardiac Electrophysiology, Durham, NC, USA
| | - Sana M Al-Khatib
- Duke University Medical Center Division of Cardiovascular Disease, Section of Cardiac Electrophysiology, Durham, NC, USA.,Duke Clinical Research Institute, Durham, North Carolina, USA
| | - Tristram D Bahnson
- Duke University Medical Center Division of Cardiovascular Disease, Section of Cardiac Electrophysiology, Durham, NC, USA
| | - James P Daubert
- Duke University Medical Center Division of Cardiovascular Disease, Section of Cardiac Electrophysiology, Durham, NC, USA
| | - Camille Frazier-Mills
- Duke University Medical Center Division of Cardiovascular Disease, Section of Cardiac Electrophysiology, Durham, NC, USA
| | - Donald D Hegland
- Duke University Medical Center Division of Cardiovascular Disease, Section of Cardiac Electrophysiology, Durham, NC, USA
| | - Kevin P Jackson
- Duke University Medical Center Division of Cardiovascular Disease, Section of Cardiac Electrophysiology, Durham, NC, USA
| | - Larry R Jackson
- Duke University Medical Center Division of Cardiovascular Disease, Section of Cardiac Electrophysiology, Durham, NC, USA.,Durham VA Medical Center, Durham, NC, USA
| | - Robert K Lewis
- Duke University Medical Center Division of Cardiovascular Disease, Section of Cardiac Electrophysiology, Durham, NC, USA.,Durham VA Medical Center, Durham, NC, USA
| | - Sean D Pokorney
- Duke University Medical Center Division of Cardiovascular Disease, Section of Cardiac Electrophysiology, Durham, NC, USA.,Duke Clinical Research Institute, Durham, North Carolina, USA
| | - Albert Y Sun
- Duke University Medical Center Division of Cardiovascular Disease, Section of Cardiac Electrophysiology, Durham, NC, USA.,Durham VA Medical Center, Durham, NC, USA
| | - Kevin L Thomas
- Duke University Medical Center Division of Cardiovascular Disease, Section of Cardiac Electrophysiology, Durham, NC, USA.,Duke Clinical Research Institute, Durham, North Carolina, USA
| | - Jonathan P Piccini
- Duke University Medical Center Division of Cardiovascular Disease, Section of Cardiac Electrophysiology, Durham, NC, USA.,Duke Clinical Research Institute, Durham, North Carolina, USA
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16
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Arps K, Piccini JP, Yapejian R, Leguire R, Smith B, Al-Khatib SM, Bahnson TD, Daubert JP, Hegland DD, Jackson KP, Jackson LR, Lewis RK, Pokorney SD, Sun AY, Thomas KL, Frazier-Mills C. Optimizing mechanically sensed atrial tracking in patients with atrioventricular-synchronous leadless pacemakers: A single-center experience. Heart Rhythm O2 2021; 2:455-462. [PMID: 34667960 PMCID: PMC8505205 DOI: 10.1016/j.hroo.2021.08.003] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
Background Atrioventricular (AV)-synchronous single-chamber leadless pacing using a mechanical atrial sensing algorithm produced high AV synchrony in clinical trials, but clinical practice experience with these devices has not yet been described. Objective To describe pacing outcomes and programming changes with AV-synchronous leadless pacemakers in clinical practice. Methods Consecutive patients without persistent atrial fibrillation who received an AV-synchronous leadless pacemaker and completed follow-up between February 2020 and April 2021 were included. We evaluated tracking index (atrial mechanical sense followed by ventricular pace [AM-VP] divided by total VP), total AV synchrony (sum of AM-ventricular sense [AM-VS], AM-VP, and AV conduction mode switch), use of programming optimization, and improvement in AV synchrony after optimization. Results Fifty patients met the inclusion criteria. Mean age was 69 ± 16.8 years, 24 (48%) were women, 24 (48%) had complete heart block, and 17 (34%) required ≥50% pacing. Mean tracking index was 41% ± 34%. Thirty-five patients (70%) received ≥1 programming change. In 36 patients with 2 follow-up visits, tracking improved by +9% ± 28% (P value for improvement = .09) and +18% ± 19% (P = .02) among 15 patients with complete heart block. Average total AV synchrony increased from 89% [67%, 99%] to 93% [78%, 100%] in all patients (P = .22), from 86% [52%, 98%] to 97% [82%, 99%] in those with complete heart block (P = .04), and from 73% [52%, 80%] to 78% [70%, 85%] in those with ≥50% pacing (P = .09). Conclusion In patients with AV-synchronous leadless pacemakers, programming changes are frequent and are associated with increased atrial tracking and increased AV synchrony in patients with complete heart block.
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Affiliation(s)
- Kelly Arps
- Section of Cardiac Electrophysiology, Duke University Medical Center Division of Cardiovascular Disease, Durham, North Carolina
| | - Jonathan P Piccini
- Section of Cardiac Electrophysiology, Duke University Medical Center Division of Cardiovascular Disease, Durham, North Carolina.,Duke Clinical Research Institute, Durham, North Carolina
| | - Rebecca Yapejian
- Section of Cardiac Electrophysiology, Duke University Medical Center Division of Cardiovascular Disease, Durham, North Carolina
| | - Rhonda Leguire
- Section of Cardiac Electrophysiology, Duke University Medical Center Division of Cardiovascular Disease, Durham, North Carolina
| | - Brenda Smith
- Section of Cardiac Electrophysiology, Duke University Medical Center Division of Cardiovascular Disease, Durham, North Carolina
| | - Sana M Al-Khatib
- Section of Cardiac Electrophysiology, Duke University Medical Center Division of Cardiovascular Disease, Durham, North Carolina.,Duke Clinical Research Institute, Durham, North Carolina
| | - Tristram D Bahnson
- Section of Cardiac Electrophysiology, Duke University Medical Center Division of Cardiovascular Disease, Durham, North Carolina
| | - James P Daubert
- Section of Cardiac Electrophysiology, Duke University Medical Center Division of Cardiovascular Disease, Durham, North Carolina
| | - Donald D Hegland
- Section of Cardiac Electrophysiology, Duke University Medical Center Division of Cardiovascular Disease, Durham, North Carolina
| | - Kevin P Jackson
- Section of Cardiac Electrophysiology, Duke University Medical Center Division of Cardiovascular Disease, Durham, North Carolina
| | - Larry R Jackson
- Section of Cardiac Electrophysiology, Duke University Medical Center Division of Cardiovascular Disease, Durham, North Carolina.,Durham VA Medical Center, Durham, North Carolina
| | - Robert K Lewis
- Section of Cardiac Electrophysiology, Duke University Medical Center Division of Cardiovascular Disease, Durham, North Carolina.,Durham VA Medical Center, Durham, North Carolina
| | - Sean D Pokorney
- Section of Cardiac Electrophysiology, Duke University Medical Center Division of Cardiovascular Disease, Durham, North Carolina.,Duke Clinical Research Institute, Durham, North Carolina
| | - Albert Y Sun
- Section of Cardiac Electrophysiology, Duke University Medical Center Division of Cardiovascular Disease, Durham, North Carolina.,Durham VA Medical Center, Durham, North Carolina
| | - Kevin L Thomas
- Section of Cardiac Electrophysiology, Duke University Medical Center Division of Cardiovascular Disease, Durham, North Carolina.,Duke Clinical Research Institute, Durham, North Carolina
| | - Camille Frazier-Mills
- Section of Cardiac Electrophysiology, Duke University Medical Center Division of Cardiovascular Disease, Durham, North Carolina
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17
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Gamble F, Arps K, Barnett AS, Koontz J, Sun AY. B-PO02-172 INCIDENCE OF VENTRICULAR ARRHYTHMIAS IN COVID-19. Heart Rhythm 2021. [PMCID: PMC8315753 DOI: 10.1016/j.hrthm.2021.06.425] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/03/2022]
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18
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Jacobsen AP, Al Rifai M, Arps K, Whelton SP, Budoff MJ, Nasir K, Blaha MJ, Psaty BM, Blumenthal RS, Post WS, McEvoy JW. A cohort study and meta-analysis of isolated diastolic hypertension: searching for a threshold to guide treatment. Eur Heart J 2021; 42:2119-2129. [PMID: 33677498 PMCID: PMC8169158 DOI: 10.1093/eurheartj/ehab111] [Citation(s) in RCA: 20] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/04/2020] [Revised: 12/16/2020] [Accepted: 02/10/2021] [Indexed: 01/01/2023] Open
Abstract
AIMS Whether isolated diastolic hypertension (IDH), as defined by the 2017 American College of Cardiology (ACC)/American Heart Association (AHA) guideline, is associated with cardiovascular disease (CVD) has been disputed. We aimed to further study the associations of IDH with (i) subclinical CVD in the form of coronary artery calcium (CAC), (ii) incident systolic hypertension, and (iii) CVD events. METHODS AND RESULTS We used multivariable-adjusted logistic and Cox regression to test whether IDH by 2017 ACC/AHA criteria (i.e. systolic blood pressure <130 mmHg and diastolic blood pressure ≥80 mmHg) was associated with the above outcomes in the Multi-Ethnic Study of Atherosclerosis (MESA). In a random-effects meta-analysis of the association between IDH and CVD events, we combined the MESA results with those from seven other previously published cohort studies. Among the 5104 MESA participants studied, 7.5% had IDH by the 2017 ACC/AHA criteria. There was no association between IDH and CAC [e.g. adjusted prevalence odds ratio for CAC >0 of 0.88 (95% CI 0.66, 1.17)]. Similarly, while IDH was associated with incident systolic hypertension, there was no statistically significant associations with incident CVD [hazard ratio 1.19 (95% CI 0.77, 1.84)] or death [hazard ratio 0.94 (95% CI 0.65, 1.36)] over 13 years in MESA. In a stratified meta-analysis of eight cohort studies (10 037 843 participants), the 2017 IDH definition was also not consistently associated with CVD and the relative magnitude of any potential association was noted to be numerically small [e.g. depending on inclusion criteria applied in the stratification, the adjusted hazard ratios ranged from 1.04 (95% CI 0.98, 1.10) to 1.09 (95% 1.03, 1.15)]. CONCLUSION The lack of consistent excess in CAC or CVD suggests that emphasis on healthy lifestyle rather than drug therapy is sufficient among the millions of middle-aged or older adults who now meet the 2017 ACC/AHA criteria for IDH, though they require follow-up for incident systolic hypertension. These findings may not extrapolate to adults younger than 40 years, motivating further study in this age group.
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Affiliation(s)
- Alan P Jacobsen
- Ciccarone Center for the Prevention of Cardiovascular Disease, Division of Cardiology, Department of Medicine, Johns Hopkins Medical Institutions, Baltimore, MD, USA
| | - Mahmoud Al Rifai
- Department of Medicine, Section of Cardiology, Baylor College of Medicine, Houston, TX, USA
| | - Kelly Arps
- Department of Medicine, Duke University School of Medicine, Durham, NC, USA
| | - Seamus P Whelton
- Ciccarone Center for the Prevention of Cardiovascular Disease, Division of Cardiology, Department of Medicine, Johns Hopkins Medical Institutions, Baltimore, MD, USA
| | - Matthew J Budoff
- Division of Cardiology, Harbor-UCLA Medical Center, Torrance, CA, USA
| | - Khurram Nasir
- Division of Cardiovascular Prevention and Wellness, Department of Cardiology, Houston Methodist DeBakey Heart & Vascular Center, Houston, TX, USA
| | - Michael J Blaha
- Ciccarone Center for the Prevention of Cardiovascular Disease, Division of Cardiology, Department of Medicine, Johns Hopkins Medical Institutions, Baltimore, MD, USA
| | - Bruce M Psaty
- Cardiovascular Health Research Unit, Departments of Medicine, Epidemiology, and Health Services, University of Washington and Kaiser Permanente Health Research Institute, Seattle, WA, USA
| | - Roger S Blumenthal
- Ciccarone Center for the Prevention of Cardiovascular Disease, Division of Cardiology, Department of Medicine, Johns Hopkins Medical Institutions, Baltimore, MD, USA
| | - Wendy S Post
- Ciccarone Center for the Prevention of Cardiovascular Disease, Division of Cardiology, Department of Medicine, Johns Hopkins Medical Institutions, Baltimore, MD, USA
| | - John W McEvoy
- Ciccarone Center for the Prevention of Cardiovascular Disease, Division of Cardiology, Department of Medicine, Johns Hopkins Medical Institutions, Baltimore, MD, USA
- National Institute for Prevention and Cardiovascular Health, National University of Ireland Galway School of Medicine, Moyola Lane, Newcastle, Galway, H91 FF68, Ireland
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19
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Arps K, Chakravartti J, Hess CN, Rao SV. Ventricular Fibrillation Due to Aortocoronary Vein Graft Spasm During Angiography: Case Report and Literature Review. JACC Case Rep 2021; 3:388-391. [PMID: 34317543 PMCID: PMC8311046 DOI: 10.1016/j.jaccas.2020.12.044] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2020] [Revised: 12/17/2020] [Accepted: 12/22/2020] [Indexed: 11/03/2022]
Abstract
A 69-year-old man underwent coronary angiography 7 years after coronary artery bypass. Saphenous vein graft spasm was observed during contrast injection, resulting in ventricular fibrillation. Angiography 6 years later showed graft patency. Vein graft spasm after coronary artery bypass grafting is rarely described. Further investigation is needed regarding incidence, mechanism, and clinical outcomes. (Level of Difficulty: Beginner.).
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Affiliation(s)
- Kelly Arps
- Duke University Medical Center, Division of Cardiology, Durham, North Carolina, USA
| | - Jaidip Chakravartti
- Duke University Medical Center, Division of Cardiology, Durham, North Carolina, USA
| | - Connie N Hess
- Division of Cardiology, Department of Medicine, University of Colorado School of Medicine and CPC Clinical Research, Aurora, Colorado, USA
| | - Sunil V Rao
- Duke University Medical Center, Division of Cardiology, Durham, North Carolina, USA.,Duke Clinical Research Institute, Durham, North Carolina.,Durham VA Health System, Durham, North Carolina, USA
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20
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Arps K, Rajagopal S. EXTRA VOLUME: PULMONARY HYPERTENSION CAUSED BY EXTRA-CARDIAC AND INTRA-CARDIAC SHUNTING. J Am Coll Cardiol 2020. [DOI: 10.1016/s0735-1097(20)33431-8] [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: 10/24/2022]
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21
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Arps K, Rifai MA, Blaha MJ, Michos ED, Nasir K, Yeboah J, Budoff MJ, Blumenthal RS, Bittencourt MS, McEvoy JW. Usefulness of Coronary Artery Calcium to Identify Adults of Sufficiently High Risk for Atherothrombotic Cardiovascular Events to Consider Low-Dose Rivaroxaban Thromboprophylaxis (from MESA). Am J Cardiol 2019; 124:1198-1206. [PMID: 31416591 DOI: 10.1016/j.amjcard.2019.07.016] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/19/2019] [Revised: 07/08/2019] [Accepted: 07/11/2019] [Indexed: 11/17/2022]
Abstract
Low-dose rivaroxaban was effective in secondary prevention of atherosclerotic cardiovascular disease (ASCVD) in the COMPASS trial. There is no established role, however, for oral anticoagulants in primary prevention. We evaluated whether coronary artery calcium (CAC) scoring identifies a high-risk primary prevention adult population who may benefit from low-dose rivaroxaban to prevent ASCVD events. We modeled expected outcomes of low-dose rivaroxaban in 5,196 Multiethnic Study of Atherosclerosis (MESA) cohort participants not already on antiplatelet or anticoagulant therapy. We applied relative risk ratios from COMPASS to absolute MESA event rates in order to estimate number needed to treat (NNT) to avoid a composite of cardiovascular death, nonfatal myocardial infarction, or nonfatal stroke, as well as number needed to harm (NNH) to cause 1 hospitalized bleed; with both NNT and NNH stratified by calculated ASCVD risk and by baseline CAC. MESA participants with CAC ≥300 had crude ASCVD event rate of 20 per 1000 patient-years, which is comparable to that observed in the COMPASS control-arm. CAC was independently associated with the composite ASCVD outcome (p <0.001 for trend). However, CAC was not independently associated with adjusted hazard ratio for hospitalized major bleeding. Predicted 5-year NNT (modeled from COMPASS) was 75 in persons with CAC 100-299 and 45 with CAC ≥300 despite NNH values of 252 and 98, respectively. In conclusion, CAC helps to distinguish estimated ASCVD benefit from estimated bleeding harm, thereby identifying very high-risk primary prevention adults without established cardiovascular disease who may derive net-benefit from low-dose rivaroxaban.
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Affiliation(s)
- Kelly Arps
- Johns Hopkins Ciccarone Center for the Prevention of Cardiovascular Disease, Baltimore, Maryland
| | - Mahmoud Al Rifai
- Johns Hopkins Ciccarone Center for the Prevention of Cardiovascular Disease, Baltimore, Maryland
| | - Michael J Blaha
- Johns Hopkins Ciccarone Center for the Prevention of Cardiovascular Disease, Baltimore, Maryland
| | - Erin D Michos
- Johns Hopkins Ciccarone Center for the Prevention of Cardiovascular Disease, Baltimore, Maryland
| | - Khurram Nasir
- Center for Outcomes Research and Evaluation, Yale-New Haven Hospital, New Haven, Connecticut
| | - Joseph Yeboah
- Department of Heart and Vascular Center of Excellence, Wake Forest Baptist Health, Winston Salem, North Carolina
| | - Matthew J Budoff
- Department of Medicine, Harbor UCLA Medical Center, Los Angeles, California
| | - Roger S Blumenthal
- Johns Hopkins Ciccarone Center for the Prevention of Cardiovascular Disease, Baltimore, Maryland
| | - Marcio S Bittencourt
- Centro de Pesquisa Clínica e Epidemiológica da Universidade de São Paulo (USP), São Paulo, Brazil
| | - John W McEvoy
- Johns Hopkins Ciccarone Center for the Prevention of Cardiovascular Disease, Baltimore, Maryland; National Institute for Preventive Cardiology and National University of Ireland, Galway, Ireland.
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22
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Arps K, Pallazola VA, Cardoso R, Meyer J, Jones R, Latina J, Gluckman TJ, Stone NJ, Blumenthal RS, McEvoy JW. Clinician's Guide to the Updated ABCs of Cardiovascular Disease Prevention: A Review Part 2. Am J Med 2019; 132:e599-e609. [PMID: 30716297 DOI: 10.1016/j.amjmed.2019.01.031] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/12/2019] [Revised: 01/23/2019] [Accepted: 01/23/2019] [Indexed: 12/11/2022]
Abstract
Efforts to better control risk factors for cardiovascular disease and prevent the development of subsequent cardiovascular events are crucial to maintaining healthy populations. In today's busy practice environment and with the overwhelming pace of new research findings, ensuring appropriate emphasis and implementation of evidence-based preventive cardiovascular care can be challenging. The ABCDEF approach to cardiovascular disease prevention is intended to improve dissemination of contemporary best practices and ease the implementation of comprehensive preventive strategies for clinicians. This review serves as a succinct yet authoritative overview for interested internists as well as for cardiologists not otherwise focused on cardiovascular disease prevention. The goal of this 2-part series is to compile a state-of-the-art list of elements central to primary and secondary prevention of cardiovascular disease, using an ABCDEF checklist. In Part 2, we review new recommendations about lipid-modifying strategies, contemporary best practice for tobacco cessation, new evidence related to cardiovascular risk reduction in diabetes using novel therapies, ways to implement a heart-healthy diet, modern interventions to improve physical exercise, and how best to prevent the onset of heart failure.
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Affiliation(s)
- Kelly Arps
- Johns Hopkins Ciccarone Center for the Prevention of Cardiovascular Disease, Baltimore, Md.
| | - Vincent A Pallazola
- Johns Hopkins Ciccarone Center for the Prevention of Cardiovascular Disease, Baltimore, Md
| | - Rhanderson Cardoso
- Johns Hopkins Ciccarone Center for the Prevention of Cardiovascular Disease, Baltimore, Md
| | - Joseph Meyer
- Johns Hopkins Ciccarone Center for the Prevention of Cardiovascular Disease, Baltimore, Md
| | - Richard Jones
- Johns Hopkins Ciccarone Center for the Prevention of Cardiovascular Disease, Baltimore, Md
| | - Jacqueline Latina
- Johns Hopkins Ciccarone Center for the Prevention of Cardiovascular Disease, Baltimore, Md
| | - Ty J Gluckman
- Center for Cardiovascular Analytics, Research and Data Science (CARDS), Providence Heart Institute, Portland, Ore
| | - Neil J Stone
- Division of Cardiology, Feinberg School of Medicine. Northwestern University, Chicago, Ill
| | - Roger S Blumenthal
- Johns Hopkins Ciccarone Center for the Prevention of Cardiovascular Disease, Baltimore, Md
| | - John W McEvoy
- Johns Hopkins Ciccarone Center for the Prevention of Cardiovascular Disease, Baltimore, Md; National Institute for Preventive Cardiology and National University of Ireland, Galway, Ireland
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Arps K, Pallazola VA, Cardoso R, Meyer J, Jones R, Latina J, Gluckman TJ, Stone NJ, Blumenthal RS, McEvoy JW. Clinician's Guide to the Updated ABCs of Cardiovascular Disease Prevention: A Review Part 1. Am J Med 2019; 132:e569-e580. [PMID: 30710541 DOI: 10.1016/j.amjmed.2019.01.016] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/12/2019] [Revised: 01/23/2019] [Accepted: 01/23/2019] [Indexed: 01/17/2023]
Abstract
Efforts to better control risk factors for cardiovascular disease and prevent the development of subsequent events are crucial to maintaining healthy populations. In today's busy practice environment and with the overwhelming pace of new research findings, ensuring appropriate emphasis and implementation of evidence-based preventive cardiovascular care can be challenging. The ABCDEF approach to cardiovascular disease prevention is intended to improve dissemination of contemporary best practices and facilitate the implementation of comprehensive preventive strategies for clinicians. This review serves as a succinct yet authoritative overview for internists and subspecialty cardiologists not otherwise focused on cardiovascular prevention. The goal of this 2-part series is to compile a state-of-the-art list of elements central to both primary and secondary prevention of cardiovascular disease, using an ABCDEF checklist, with particular focus on recent society guideline updates. In Part 1 we highlight developments in cardiovascular risk assessment tools, summarize important recent aspirin trials, discuss prevention considerations in atrial fibrillation, and review guidelines for blood pressure categorization, goals, and therapy.
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Affiliation(s)
- Kelly Arps
- Johns Hopkins Ciccarone Center for the Prevention of Cardiovascular Disease, Baltimore, Md.
| | - Vincent A Pallazola
- Johns Hopkins Ciccarone Center for the Prevention of Cardiovascular Disease, Baltimore, Md
| | - Rhanderson Cardoso
- Johns Hopkins Ciccarone Center for the Prevention of Cardiovascular Disease, Baltimore, Md
| | - Joseph Meyer
- Johns Hopkins Ciccarone Center for the Prevention of Cardiovascular Disease, Baltimore, Md
| | - Richard Jones
- Johns Hopkins Ciccarone Center for the Prevention of Cardiovascular Disease, Baltimore, Md
| | - Jacqueline Latina
- Johns Hopkins Ciccarone Center for the Prevention of Cardiovascular Disease, Baltimore, Md
| | - Ty J Gluckman
- Center for Cardiovascular Analytics, Research and Data Science (CARDS), Providence Heart Institute, Portland, Ore
| | - Neil J Stone
- Division of Cardiology, Feinberg School of Medicine, Northwestern University, Chicago, Ill
| | - Roger S Blumenthal
- Johns Hopkins Ciccarone Center for the Prevention of Cardiovascular Disease, Baltimore, Md
| | - John W McEvoy
- Johns Hopkins Ciccarone Center for the Prevention of Cardiovascular Disease, Baltimore, Md; National Institute for Preventive Cardiology and National University of Ireland, Galway
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Al Rifai M, Cainzos-Achirica M, Blaha MJ, Arps K, Wood DA, Blumenthal RS, McEvoy JW. Health Factors Associated with Cardiovascular Wellness. Curr Atheroscler Rep 2019; 21:10. [PMID: 30747344 DOI: 10.1007/s11883-019-0771-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
Abstract
PURPOSE OF REVIEW In this review, we discuss a new paradigm for atherosclerotic cardiovascular disease (ASCVD) prevention that is focused on cultivating cardiovascular wellness through the promotion of "health factors." RECENT FINDINGS Cardiovascular prevention efforts have contributed to falling rates of ASCVD over the past five decades. However, contemporary increases in obesity and diabetes have led to a recent slowing in the annual decline of ASCVD death rates. This slowing represents an opportunity for new thinking to change the current ASCVD prevention paradigm, i.e., the identification and treatment or control of risk factors for disease. Indeed, a new paradigm focusing on cultivating cardiovascular wellness in addition to preventing disease is gaining increased traction. With this approach, the goal of ASCVD prevention is shifting to include consideration of both treating "risk factors" and cultivating health factors. Importantly, cardiovascular wellness is more than just the absence of disease and, therefore, risk factors and health factors are not always mere opposites. We review healthy lifestyle tools such as the American Heart Association Life's simple 7 and Fuster-BEWAT score. We summarize landmark studies of interventions aimed at improving adherence to health factors. We highlight the inherent limitations of current studies to adequately examine cardiovascular wellness. We propose new study designs that are required to identify novel health factors and measures of wellness. We conclude with recommendations regarding the utility of health factors and cardiovascular wellness in current practice.
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Affiliation(s)
- Mahmoud Al Rifai
- Department of Internal Medicine, University of Kansas School of Medicine, Wichita, KS, USA.,Johns Hopkins Ciccarone Center for the Prevention of Cardiovascular Disease, Department of Cardiology, Johns Hopkins Medical Institutions, Baltimore, MD, USA
| | - Miguel Cainzos-Achirica
- Johns Hopkins Ciccarone Center for the Prevention of Cardiovascular Disease, Department of Cardiology, Johns Hopkins Medical Institutions, Baltimore, MD, USA.,Bellvitge University Hospital and Bellvitge Biomedical Research Institute (IDIBELL), L'Hospitalet de Llobregat, Barcelona, Spain
| | - Michael J Blaha
- Johns Hopkins Ciccarone Center for the Prevention of Cardiovascular Disease, Department of Cardiology, Johns Hopkins Medical Institutions, Baltimore, MD, USA
| | - Kelly Arps
- Johns Hopkins Ciccarone Center for the Prevention of Cardiovascular Disease, Department of Cardiology, Johns Hopkins Medical Institutions, Baltimore, MD, USA
| | - David A Wood
- Department of Cardiovascular Medicine, National Heart and Lung Institute, Imperial College London, London, UK.,National University of Ireland, Galway Campus, Galway, Ireland.,National Institute for Preventive Cardiology; and Saolta University Healthcare Group, University College Hospital Galway, Newcastle Rd, Galway, Ireland
| | - Roger S Blumenthal
- Johns Hopkins Ciccarone Center for the Prevention of Cardiovascular Disease, Department of Cardiology, Johns Hopkins Medical Institutions, Baltimore, MD, USA
| | - John W McEvoy
- Johns Hopkins Ciccarone Center for the Prevention of Cardiovascular Disease, Department of Cardiology, Johns Hopkins Medical Institutions, Baltimore, MD, USA. .,National University of Ireland, Galway Campus, Galway, Ireland. .,National Institute for Preventive Cardiology; and Saolta University Healthcare Group, University College Hospital Galway, Newcastle Rd, Galway, Ireland.
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25
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Schlager A, Arps K, Siddharthan R, Glenn I, Hill SJ, Wulkan ML, Keene SD, Clifton MS. Thoracoscopic Repair of Congenital Diaphragmatic Hernia After Extracorporeal Membrane Oxygenation: Feasibility and Outcomes. J Laparoendosc Adv Surg Tech A 2018; 28:774-779. [PMID: 29641364 DOI: 10.1089/lap.2016.0583] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
INTRODUCTION Thoracoscopic repair of congenital diaphragmatic hernia (CDH) has been associated with faster recovery, earlier extubation, and decreased morbidity. Nevertheless, thoracoscopic repair is rarely attempted in the post-extracorporeal membrane oxygenation (ECMO) patient. Commonly cited reasons for not attempting thoracoscopy include concerns that the patients' respiratory status is too tenuous to tolerate insufflation pressures or that presumed defect size is so large that it precludes thoracoscopic repair. Our purpose is to review our experience with post-ECMO thoracoscopic CDH repair and evaluate the success of this approach. METHODS We performed retrospective analysis of attempted thoracoscopic CDH repairs after ECMO decannulation at our institution from 2001 to 2015. Primary outcome was rate of conversion. Secondary outcomes were intraoperative end-tidal CO2, time to extubation, and rate of recurrence. RESULTS We identified 21 post-ECMO patients in whom thoracoscopic CDH repair was attempted. Thoracoscopic repair was successfully completed in 28%. No patients had reported intolerance to insufflation at 3-7 mmHg. Average end-tidal CO2 at 15 operative minutes was 36.9 mmHg in the thoracoscopic group versus 50.7 mmHg in the open group and at 60 minutes was 34.25 mmHg versus 45.6 mmHg, respectively. One patient in the thoracoscopic group died and 1 experienced a large pneumothorax. In the converted group there was one clinically significant pneumothorax and three pleural effusions. Survivors after thoracoscopy were extubated an average of 5.6 ± 2.6 days after surgery versus 19.4 ± 10 days in the converted group (P < .05). Recurrence rates at last follow-up were equal between the two groups at 20%. CONCLUSIONS Thoracoscopic CDH repair is both safe and feasible after ECMO with no increase in operative morbidity or mortality. Insufflation pressures of 3-7 mmHg are well tolerated without undue increase in end-tidal CO2. When compared to conversion cases, thoracoscopic repair is associated with significantly decreased time to extubation with no difference in recurrence.
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Affiliation(s)
| | - Kelly Arps
- 2 Department of Surgery, Emory University/Children's Healthcare of Atlanta , Atlanta, Georgia
| | - Ragavan Siddharthan
- 3 Department of Surgery, Oregon Health and Sciences University , Portland, Oregon
| | - Ian Glenn
- 1 Akron Children's Hospital , Akron, Ohio
| | - Sarah J Hill
- 2 Department of Surgery, Emory University/Children's Healthcare of Atlanta , Atlanta, Georgia
| | - Mark L Wulkan
- 2 Department of Surgery, Emory University/Children's Healthcare of Atlanta , Atlanta, Georgia
| | - Sarah D Keene
- 2 Department of Surgery, Emory University/Children's Healthcare of Atlanta , Atlanta, Georgia
| | - Matthew S Clifton
- 2 Department of Surgery, Emory University/Children's Healthcare of Atlanta , Atlanta, Georgia
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26
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Short HL, Clifton MS, Arps K, Travers C, Loewen J, Schlager A. The “Flat Diaphragm”: Does the Degree of Curvature of the Diaphragm on Postoperative X-Ray Predict Congenital Diaphragmatic Hernia Recurrence? J Laparoendosc Adv Surg Tech A 2018; 28:476-480. [DOI: 10.1089/lap.2017.0228] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Affiliation(s)
- Heather L. Short
- Division of Pediatric Surgery, Department of Surgery, Emory University School of Medicine, Children's Healthcare of Atlanta, Atlanta, Georgia
| | - Matthew S. Clifton
- Division of Pediatric Surgery, Department of Surgery, Emory University School of Medicine, Children's Healthcare of Atlanta, Atlanta, Georgia
| | - Kelly Arps
- Division of Pediatric Surgery, Department of Surgery, Emory University School of Medicine, Children's Healthcare of Atlanta, Atlanta, Georgia
| | - Curtis Travers
- Department of Pediatrics, Emory University School of Medicine, Atlanta, Georgia
| | - Jonathan Loewen
- Division of Pediatric Radiology, Department of Radiology, Emory University School of Medicine, Atlanta, Georgia
| | - Avraham Schlager
- Division of Pediatric Surgery, Akron Children's Hospital, Akron, Ohio
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Bhatt D, Travers C, Patel RM, Shinnick J, Arps K, Keene S, Raval MV. Predicting Mortality or Intestinal Failure in Infants with Surgical Necrotizing Enterocolitis. J Pediatr 2017; 191:22-27.e3. [PMID: 29173311 PMCID: PMC5871227 DOI: 10.1016/j.jpeds.2017.08.046] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/28/2017] [Revised: 07/18/2017] [Accepted: 08/17/2017] [Indexed: 01/20/2023]
Abstract
OBJECTIVE To compare existing outcome prediction models and create a novel model to predict death or intestinal failure (IF) in infants with surgical necrotizing enterocolitis (NEC). STUDY DESIGN A retrospective, observational cohort study conducted in a 2-campus health system in Atlanta, Georgia, from September 2009 to May 2015. Participants included all infants ≤37 weeks of gestation with surgical NEC. Logistic regression was used to model the probability of death or IF, as a composite outcome, using preoperative variables defined by specifications from 3 existing prediction models: American College of Surgeons National Surgical Quality Improvement Program Pediatric, Score for Neonatal Acute Physiology Perinatal Extension, and Vermont Oxford Risk Adjustment Tool. A novel preoperative hybrid prediction model was also derived and validated against a patient cohort from a separate campus. RESULTS Among 147 patients with surgical NEC, discrimination in predicting death or IF was greatest with American College of Surgeons National Surgical Quality Improvement Program Pediatric (area under the receiver operating characteristic curve [AUC], 0.84; 95% CI, 0.77-0.91) when compared with the Score for Neonatal Acute Physiology Perinatal Extension II (AUC, 0.60; 95% CI, 0.48-0.72) and Vermont Oxford Risk Adjustment Tool (AUC, 0.74; 95% CI, 0.65-0.83). A hybrid model was developed using 4 preoperative variables: the 1-minute Apgar score, inotrope use, mean blood pressure, and sepsis. The hybrid model AUC was 0.85 (95% CI, 0.78-0.92) in the derivation cohort and 0.77 (95% CI, 0.66-0.86) in the validation cohort. CONCLUSIONS Preoperative prediction of death or IF among infants with surgical NEC is possible using existing prediction tools and, to a greater extent, using a newly proposed 4-variable hybrid model.
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Affiliation(s)
- Darshna Bhatt
- Division of Neonatology, Department of Pediatrics, Emory University School of Medicine, Children's Healthcare of Atlanta, Atlanta, GA.
| | - Curtis Travers
- Biostatisitcal Core, Department of Pediatrics, Emory University School of Medicine, Atlanta, GA, USA
| | - Ravi M. Patel
- Division of Neonatology, Department of Pediatrics, Emory University School of Medicine, Children’s Healthcare of Atlanta, Atlanta, GA, USA
| | - Julia Shinnick
- Division of Pediatric Surgery, Department of Surgery, Emory University School of Medicine, Children’s Healthcare of Atlanta, Atlanta, GA, USA
| | - Kelly Arps
- Division of Pediatric Surgery, Department of Surgery, Emory University School of Medicine, Children’s Healthcare of Atlanta, Atlanta, GA, USA
| | - Sarah Keene
- Division of Neonatology, Department of Pediatrics, Emory University School of Medicine, Children’s Healthcare of Atlanta, Atlanta, GA, USA
| | - Mehul V. Raval
- Division of Pediatric Surgery, Department of Surgery, Emory University School of Medicine, Children’s Healthcare of Atlanta, Atlanta, GA, USA
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Schlager A, Arps K, Siddharthan R, Clifton MS. Tube Thoracostomy at the Time of Congenital Diaphragmatic Hernia Repair: Reassessing the Risks and Benefits. J Laparoendosc Adv Surg Tech A 2017; 27:311-317. [DOI: 10.1089/lap.2016.0233] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Affiliation(s)
| | - Kelly Arps
- Emory University/Children's Healthcare of Atlanta, Department of Surgery, Atlanta, Georgia
| | - Ragavan Siddharthan
- Oregon Health and Science University, Department of Surgery, Portland, Oregon
| | - Matthew S. Clifton
- Emory University/Children's Healthcare of Atlanta, Department of Surgery, Atlanta, Georgia
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Bruns NE, Glenn IC, McNinch NL, Arps K, Ponsky TA, Schlager A. Approach to Recurrent Congenital Diaphragmatic Hernia: Results of an International Survey. J Laparoendosc Adv Surg Tech A 2016; 26:925-929. [PMID: 27705081 DOI: 10.1089/lap.2016.0247] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
PURPOSE Although recurrence remains one of the most feared complications following congenital diaphragmatic hernia (CDH) repair, there are minimal data on the optimal surgical approach to these complex situations. The purpose of this study was to survey the international pediatric surgery community to ascertain practice patterns for both minimally invasive (MIS) and open approaches for recurrent CDH. MATERIALS AND METHODS A survey was e-mailed to members of an online community of pediatric surgeons. The questionnaire elicited surgeons' clinical experience, the continent in which they practice, and their surgical approach (laparotomy, thoracotomy, laparoscopy, or thoracoscopy) to five clinical cases, including initial and recurrent Bochdalek hernias. Fisher's exact test and chi-square test were used for statistical analysis. RESULTS Two-hundred eighty pediatric surgeons responded to the survey. In total, 52.1% of surgeons chose an MIS approach for an initial repair of left CDH with the younger surgeons more likely to use an MIS approach. For the recurrence scenarios, 42.5%-55.5% of these surgeons would attempt an MIS repair after a recurrence. Specifically, thoracoscopy was favored over laparoscopy following both prior laparotomy (30.0% versus 7.5%) and prior right thoracoscopy (26.4% versus 10.0%), less favored following thoracotomy (9.3% versus 18.9%), and relatively similar proportions following prior left thoracoscopy (17.5% versus 16.4%). Laparotomy was the preferred open approach both for initial presentation and all recurrence scenarios. Among surgeons who would treat initial CDH with an open procedure, between 10.4% and 17.9% would switch to an MIS approach, most commonly after prior failed laparotomy. CONCLUSIONS Approximately half surgeons who approach initial left CDH in an MIS manner would attempt an MIS approach for recurrence. The tendency to approach CDH recurrence from the opposite body cavity as the initial repair clearly impacted the surgical approach. This was particularly pronounced for MIS repairs, whereas for open approach, laparotomy remained, by far, the most popular in all scenarios.
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Affiliation(s)
- Nicholas E Bruns
- 1 Division of Pediatric Surgery, Akron Children's Hospital , Akron, Ohio
| | - Ian C Glenn
- 1 Division of Pediatric Surgery, Akron Children's Hospital , Akron, Ohio
| | - Neil L McNinch
- 2 Rebecca D. Considine Research Institute , Akron Children's Hospital, Akron, Ohio
| | - Kelly Arps
- 3 Emory University School of Medicine , Atlanta, Georgia
| | - Todd A Ponsky
- 1 Division of Pediatric Surgery, Akron Children's Hospital , Akron, Ohio
| | - Avraham Schlager
- 1 Division of Pediatric Surgery, Akron Children's Hospital , Akron, Ohio
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Schlager A, Arps K, Siddharthan R, Rajdev P, Heiss KF. The "omega" jejunostomy tube: A preferred alternative for postpyloric feeding access. J Pediatr Surg 2016; 51:260-3. [PMID: 26681348 DOI: 10.1016/j.jpedsurg.2015.10.073] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/23/2015] [Accepted: 10/30/2015] [Indexed: 10/22/2022]
Abstract
AIM We present our technique for construction of the "Omega Jejunostomy" (OJ), a novel method of postpyloric feeding using a pouched-jejunal loop capable of accommodating a balloon gastrostomy button. We describe potential indications for the procedure and outcomes in a complex patient population. MATERIALS AND METHODS We retrospectively reviewed records of patients who underwent an OJ at our institution between 2005 and 2014. Primary outcomes include operating time, length of hospital stay, time to feeding goals, and postoperative complications. RESULTS We identified 12 children (6 males) with multiple comorbidities who underwent OJ procedures. The median age at surgery was 11years (range 3months-23years). Eleven patients had failed previous alternative feeding access or antireflux procedures. All patients eventually reached their feeding goals. Eight were at goal feeds in <10days. Two achieved goal feeds <1month, one <4months, and one within 7months. There was one OJ failure because of fistula formation requiring surgical revision, and one child was treated successfully but died of unrelated causes. Four children eventually transitioned to PO or G-tube feeds, and six were tolerating feeds via OJ at last follow-up (8-74months). CONCLUSIONS OJ provides a durable alternative to gastrojejunostomy tube for patients who are poor candidates for or have failed Nissen fundoplication. It is technically easier to perform than a gastroesophageal disconnect procedure, has minimal surgical comorbidities, and can provide durable feeding access and achievement of goal feeds in a complex and refractory patient subset.
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Affiliation(s)
| | - Kelly Arps
- Emory University Department of Surgery, USA
| | | | | | - Kurt F Heiss
- Emory University/Children's Healthcare of Atlanta, USA
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Cialdini RB, Schaller M, Houlihan D, Arps K, Fultz J, Beaman AL. Empathy-based helping: is it selflessly or selfishly motivated? J Pers Soc Psychol 1987. [PMID: 3572736 DOI: 10.1037//0022-3514.52.4.749] [Citation(s) in RCA: 45] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/06/2023]
Abstract
A substantial body of evidence collected by Batson and his associates has advanced the idea that pure (i.e., selfless) altruism occurs under conditions of empathy for a needy other. An egoistic alternative account of this evidence was proposed and tested in our work. We hypothesized that an observer's heightened empathy for a sufferer brings with it increased personal sadness in the observer and that it is the egoistic desire to relieve the sadness, rather than the selfless desire to relieve the sufferer, that motivates helping. Two experiments contrasted predictions from the selfless and egoistic alternatives in the paradigm typically used by Batson and his associates. In the first, an emphatic orientation to a victim increased personal sadness, as expected. Furthermore, when sadness and empathic emotion were separated experimentally, helping was predicted by the levels of sadness subjects were experiencing but not by their empathy scores. In the second experiment, enhanced sadness was again associated with empathy for a victim. However, subjects who were led to perceive that their moods could not be altered through helping (because of the temporary action of a "mood-fixing" placebo drug) were not helpful, despite high levels of empathic emotion. The results were interpreted as providing support for an egoistically based interpretation of helping under conditions of high empathy.
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Abstract
A substantial body of evidence collected by Batson and his associates has advanced the idea that pure (i.e., selfless) altruism occurs under conditions of empathy for a needy other. An egoistic alternative account of this evidence was proposed and tested in our work. We hypothesized that an observer's heightened empathy for a sufferer brings with it increased personal sadness in the observer and that it is the egoistic desire to relieve the sadness, rather than the selfless desire to relieve the sufferer, that motivates helping. Two experiments contrasted predictions from the selfless and egoistic alternatives in the paradigm typically used by Batson and his associates. In the first, an emphatic orientation to a victim increased personal sadness, as expected. Furthermore, when sadness and empathic emotion were separated experimentally, helping was predicted by the levels of sadness subjects were experiencing but not by their empathy scores. In the second experiment, enhanced sadness was again associated with empathy for a victim. However, subjects who were led to perceive that their moods could not be altered through helping (because of the temporary action of a "mood-fixing" placebo drug) were not helpful, despite high levels of empathic emotion. The results were interpreted as providing support for an egoistically based interpretation of helping under conditions of high empathy.
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