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Brunton N, Best PJM, Skelding KA, Cendrowski EE. Spontaneous Coronary Artery Dissection (SCAD) from an Interventionalist Perspective. Curr Cardiol Rep 2024; 26:91-96. [PMID: 38236518 PMCID: PMC10991027 DOI: 10.1007/s11886-023-02019-w] [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] [Accepted: 12/30/2023] [Indexed: 01/19/2024]
Abstract
PURPOSE OF REVIEW Spontaneous coronary artery dissection (SCAD) is an increasingly recognized cause of acute coronary syndrome (ACS), particularly among women < 50 years of age. Here, we aim to review the pathogenesis of SCAD, discuss SCAD as an initial manifestation of systemic arterial disease, and highlight invasive strategies as well as unique challenges in the care of women with SCAD. RECENT FINDINGS A paradigm shift has occurred in the care of SCAD patients in the past decade as recommendations for conservative management have become widespread. Invasive interventions are reserved for patients with hemodynamic compromise or active ischemia due to increased periprocedural complications and failure rates. Certain patient populations have been identified for larger territory infarcts and proximal disease including patients with known connective tissue disease, premenopausal women, and patients with pregnancy-associated SCAD (P-SCAD). Current recommended management of SCAD is conservative. Despite a growing awareness of SCAD and its known association with systemic arteriopathies in women, evidence-based data remains scarce. Future studies focused on identifying genetic factors, optimal medical therapy after SCAD, and techniques to minimize interventional complications are needed.
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Affiliation(s)
- Nichole Brunton
- Department of Cardiovascular Diseases, Mayo Clinic College of Medicine, 200 1st St SW, Rochester, MN, 55905, USA
| | - Patricia J M Best
- Department of Cardiovascular Diseases, Mayo Clinic College of Medicine, 200 1st St SW, Rochester, MN, 55905, USA.
| | | | - Emily E Cendrowski
- Department of Cardiovascular Diseases, Mayo Clinic College of Medicine, 200 1st St SW, Rochester, MN, 55905, USA
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Bass TA, Abbott JD, Mahmud E, Parikh SA, Aboulhosn J, Ashwath ML, Baranowski B, Bergersen L, Chaudry HI, Coylewright M, Denktas AE, Gupta K, Gutierrez JA, Haft J, Hawkins BM, Herrmann HC, Kapur NK, Kilic S, Lesser J, Lin CH, Mendirichaga R, Nkomo VT, Park LG, Phoubandith DR, Quader N, Rich MW, Rosenfield K, Sabri SS, Shames ML, Shernan SK, Skelding KA, Tamis-Holland J, Thourani VH, Tremmel JA, Uretsky S, Wageman J, Welt F, Whisenant BK, White CJ, Yong CM, Mendes LA, Arrighi JA, Breinholt JP, Day J, Dec GW, Denktas AE, Drajpuch D, Faza N, Francis SA, Hahn RT, Housholder-Hughes SD, Khan SS, Kondapaneni MD, Lee KS, Lin CH, Hussain Mahar J, McConnaughey S, Niazi K, Pearson DD, Punnoose LR, Reejhsinghani RS, Ryan T, Silvestry FE, Solomon MA, Spicer RL, Weissman G, Werns SW. 2023 ACC/AHA/SCAI advanced training statement on interventional cardiology (coronary, peripheral vascular, and structural heart interventions): A report of the ACC Competency Management Committee. J Thorac Cardiovasc Surg 2023; 166:e73-e123. [PMID: 37269254 DOI: 10.1016/j.jtcvs.2023.04.024] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 06/05/2023]
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Bass TA, Abbott JD, Mahmud E, Parikh SA, Aboulhosn J, Ashwath ML, Baranowski B, Bergersen L, Chaudry HI, Coylewright M, Denktas AE, Gupta K, Gutierrez JA, Haft J, Hawkins BM, Herrmann HC, Kapur NK, Kilic S, Lesser J, Lin CH, Mendirichaga R, Nkomo VT, Park LG, Phoubandith DR, Quader N, Rich MW, Rosenfield K, Sabri SS, Shames ML, Shernan SK, Skelding KA, Tamis-Holland J, Thourani VH, Tremmel JA, Uretsky S, Wageman J, Welt F, Whisenant BK, White CJ, Yong CM. 2023 ACC/AHA/SCAI Advanced Training Statement on Interventional Cardiology (Coronary, Peripheral Vascular, and Structural Heart Interventions): A Report of the ACC Competency Management Committee. JACC Cardiovasc Interv 2023; 16:1239-1291. [PMID: 37115166 DOI: 10.1016/j.jcin.2023.04.011] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 04/29/2023]
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Bass TA, Abbott JD, Mahmud E, Parikh SA, Aboulhosn J, Ashwath ML, Baranowski B, Bergersen L, Chaudry HI, Coylewright M, Denktas AE, Gupta K, Gutierrez JA, Haft J, Hawkins BM, Herrmann HC, Kapur NK, Kilic S, Lesser J, Lin CH, Mendirichaga R, Nkomo VT, Park LG, Phoubandith DR, Quader N, Rich MW, Rosenfield K, Sabri SS, Shames ML, Shernan SK, Skelding KA, Tamis-Holland J, Thourani VH, Tremmel JA, Uretsky S, Wageman J, Welt F, Whisenant BK, White CJ, Yong CM. 2023 ACC/AHA/SCAI Advanced Training Statement on Interventional Cardiology (Coronary, Peripheral Vascular, and Structural Heart Interventions): A Report of the ACC Competency Management Committee. J Am Coll Cardiol 2023; 81:1386-1438. [PMID: 36801119 DOI: 10.1016/j.jacc.2022.11.002] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/18/2023]
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Skelding KA, Kraev AS. Invited Commentary: Impact of New eGFR Equations on Risk Assessment in Patients Undergoing Transcatheter Aortic Valve Replacement. Cardiovasc Revasc Med 2023; 49:47-48. [PMID: 36813697 DOI: 10.1016/j.carrev.2023.01.022] [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] [Subscribe] [Scholar Register] [Received: 01/20/2023] [Accepted: 01/25/2023] [Indexed: 02/04/2023]
Affiliation(s)
- Kimberly A Skelding
- Department of Cardiology, Confluence Health 1201 S Miller Street, Wenatchee, WA 98801, United States of America; Department of Cardiovascular Surgery, Confluence Health 1201 S Miller Street, Wenatchee, WA 98801, United States of America.
| | - Alexander S Kraev
- Department of Cardiology, Confluence Health 1201 S Miller Street, Wenatchee, WA 98801, United States of America; Department of Cardiovascular Surgery, Confluence Health 1201 S Miller Street, Wenatchee, WA 98801, United States of America
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Bass TA, Abbott JD, Mahmud E, Parikh SA, Aboulhosn J, Ashwath ML, Baranowski B, Bergersen L, Chaudry HI, Coylewright M, Denktas AE, Gupta K, Gutierrez JA, Haft J, Hawkins BM, Herrmann HC, Kapur NK, Kilic S, Lesser J, Huie LC, Mendirichaga R, Nkomo VT, Park LG, Phoubandith DR, Quader N, Rich MW, Rosenfield K, Sabri SS, Shames ML, Shernan SK, Skelding KA, Tamis-Holland J, Thourani VH, Tremmel JA, Uretsky S, Wageman J, Welt F, Whisenant BK, White CJ, Yong CM. 2023 ACC/AHA/SCAI Advanced Training Statement on Interventional Cardiology (Coronary, Peripheral Vascular, and Structural Heart Interventions): A Report of the ACC Competency Management Committee. Circ Cardiovasc Interv 2023; 16:e000088. [PMID: 36795800 DOI: 10.1161/hcv.0000000000000088] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/18/2023]
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Kern MJ, Applegate B, Bittl J, Block P, Butman S, Dehmer G, Garratt KN, Henry T, Hirshfeld J, Holmes DR, Kaplan A, King S, Klein LW, Krucoff MW, Kutcher MA, Naidu SS, Pichard A, Ruiz CE, Skelding KA, Tobis JM, Tommaso C, Weiner BH, White C. Conversations in cardiology: Late career transitions-Retool, retire, refocus. Catheter Cardiovasc Interv 2022; 99:2136-2144. [PMID: 35446473 DOI: 10.1002/ccd.30210] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/05/2022] [Accepted: 04/08/2022] [Indexed: 11/10/2022]
Affiliation(s)
- Morton J Kern
- Department of Cardiology, Veterans Administration Long Beach Health Care System, Long Beach, California, USA.,University of California Irvine, Orange, California, USA
| | - Bob Applegate
- Professor of Medicine, Wake Forest School of Medicine, Winston-Salem, North Carolina, USA
| | | | - Peter Block
- Emory University School of Medicine, Atlanta, Georgia, USA
| | | | - Gregory Dehmer
- Quality and Outcomes, Carilion Clinic and Cardiovascular Institute, Virginia Tech Carilion School of Medicine, Roanoke, Virginia, USA
| | | | - Tim Henry
- The Carl and Edyth Lindner Center for Research and Education, Cincinnati, Ohio, USA
| | - John Hirshfeld
- Professor Emeritus of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - David R Holmes
- Scripps Professor of Cardiovascular Medicine, Mayo Graduate School of Medicine, Rochester, Minnesota, USA
| | - Aaron Kaplan
- Dartmouth Device Development Symposium, Heart and Vascular Center, Dartmouth-Hitchcock Medical Center/Geisel School of Medicine, Lebanon, Dartmouth, New Hampshire, USA
| | - Spencer King
- Emory University School of Medicine, Atlanta, Georgia, USA
| | | | - Mitchell W Krucoff
- Medicine/Cardiology, Duke University Medical Center, Cardiovascular Devices Unit, eECG Core Laboratories Duke Clinical Research Institute, Raleigh, North Carolina, USA
| | - Michael A Kutcher
- Professor of Medicine, Wake Forest School of Medicine, Winston-Salem, North Carolina, USA
| | - Srihari S Naidu
- Cardiac Cath Labs, Westchester Medical Center, Winthrop, New York, USA
| | - Augusto Pichard
- Medstar Washington Hospital Center, Georgetown University, Washington, District of Columbia, USA
| | | | | | - Jonathan M Tobis
- David Geffen Shool of Medicine at UCLA, Santa Barbara, California, USA
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Yu J, Park K, Chandrasekhar J, Kalkman DN, Johnson JA, Wild RA, Dobies D, Thomas L, Skelding KA, Ahmed B, Barber KR, Mungee S, Mehran R. Feasibility and Utility of a Cardiovascular Risk Screening Tool in Women Undergoing Routine Gynecology Evaluation. J Womens Health (Larchmt) 2020; 29:1150-1159. [PMID: 32667846 DOI: 10.1089/jwh.2019.8074] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
Background The goals of this multicenter survey were to examine the prevalence and patient awareness of cardiovascular risk factors, and the association between history of adverse pregnancy outcomes (APO—including gestational hypertension, gestational diabetes, and preeclampsia) and prevalence of cardiovascular risks among women presenting to outpatient obstetrics/gynecology (OB/GYN) clinics. Materials and Methods We surveyed 2,946 female patients attending 16 outpatient OB/GYN clinics across the United States between January 2010 and January 2012. Main outcome measures were self-reported cardiovascular risk factors and symptoms such as angina and dyspnea. Results Mean age of the patients was 51 ± 13.6 years. Cardiovascular risks and symptoms were highly prevalent (86.0% and 40.1%, respectively). Many patients did not know if they had common risk factors such as hypertension, hypercholesterolemia, or diabetes (18.4%, 32.0%, and 17.9%, respectively). Women with a history of APO were slightly more likely to be aware of common risk factors, including abnormal blood pressure (17% vs. 18.6%), high cholesterol (31.7% vs. 32%), and obesity/elevated body mass index (43.9% vs. 49.7%). Compared with patients with no history of APO, patients with APO (n = 380, 12.9%) were more likely to have risk factors (89.5% vs. 83.9%, p = 0.002) and symptoms (45.5% vs. 39.3%, p = 0.02). Conclusions Awareness of cardiovascular risk factors and symptoms among all women surveyed in this study was poor, although awareness for some risk factors was relatively higher among patients with APO. This study demonstrates the feasibility of cardiovascular assessment in OB/GYN clinics using a simple questionnaire and its potential role for early recognition and timely intervention.
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Affiliation(s)
- Jennifer Yu
- Mount Sinai School of Medicine, New York, New York, USA.,Prince of Wales Clinical School, University of New South Wales, Randwick, Australia
| | - Ki Park
- University of Florida, Gainesville, Florida, USA
| | | | - Deborah N Kalkman
- Mount Sinai School of Medicine, New York, New York, USA.,Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
| | | | - Robert A Wild
- Oklahoma University Health Sciences Center, Oklahoma City, Oklahoma, USA
| | - David Dobies
- Genesys Regional Medical Center, Grand Blanc, Michigan, USA
| | - Lynn Thomas
- Sanford USD Medical Center, Sioux Falls, South Dakota, USA
| | | | - Bina Ahmed
- Dartmouth-Hitchcock Medical Center, Lebanon, New Hampshire, USA
| | | | | | - Roxana Mehran
- Mount Sinai School of Medicine, New York, New York, USA
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Harjai KJ, Bules T, Berger A, Young B, Singh D, Carter R, Agarwal S, Crockett S, Mascarenhas V, Nawaz Y, Stella J, Burnside J, Skelding KA, Desciak M, Casale AS. Efficiency, Safety, and Quality of Life After Transcatheter Aortic Valve Implantation Performed With Moderate Sedation Versus General Anesthesia. Am J Cardiol 2020; 125:1088-1095. [PMID: 32046822 DOI: 10.1016/j.amjcard.2020.01.002] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/03/2019] [Revised: 01/03/2020] [Accepted: 01/03/2020] [Indexed: 12/21/2022]
Abstract
There is growing interest in "minimalist" transcatheter aortic valve implantation (M-TAVI), performed with conscious sedation instead of general anesthesia (GA-TAVI). We assessed the impact of M-TAVI on procedural efficiency, long-term safety, and quality of life (QoL) in 477 patients with severe aortic stenosis (82 years, women 50%, STS 5.0), who underwent M-TAVI (n = 278) or GA-TAVI (n = 199). M-TAVI patients were less likely to have NYHA Class ≥3, valve-in-valve TAVI, and receive self-expanding valves. M-TAVI was completed without conversion to GA in 269 (97%) patients. M-TAVI was more efficient that GA-TAVI including shorter lengths of stay (2 vs 3 days, p <0.0001), higher likelihood of being discharged home (87% vs 72%, p <0.0001), less use of blood transfusions (10% vs 22%, p = 0.0008), inotropes (13% vs 32%, p <0.0001), contrast volume (50 vs 90 ml, p <0.0001), fluoroscopy time (20 vs 24 minute, p <0.0001), and need for >1 valves (0.4 vs 5.5%, p = 0.0004). At 1-month, death/stroke (M-TAVI vs GA-TAVI 4.0 vs 6.5%) and a "safety composite" end point (death, stroke, transient ischemic attack, myocardial infarction, new dialysis, major vascular complication, major or life-threatening bleeding, and new pacemaker: 17.6% vs 21.1%) were similar (p = NS for both). At a median follow-up of 365 days, survival curves showed similar incidence of death/stroke as well as the safety composite end point between the groups. QoL scores were similar at baseline and 1-month after TAVI. In multivariable analyses, M-TAVI showed significant improvements in all parameters of procedural efficiency. In conclusion, M-TAVI is more efficient than GA-TAVI, with similar safety at 1-month and long-term, and similar QoL scores at 1 month.
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Affiliation(s)
- Cindy L Grines
- Department of Cardiology, Detroit Medical Center Heart Hospital, Detroit, Michigan.
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Agarwal S, Thakkar B, Skelding KA, Blankenship JC. Trends and Outcomes After Same-Day Discharge After Percutaneous Coronary Interventions. Circ Cardiovasc Qual Outcomes 2018; 10:CIRCOUTCOMES.117.003936. [PMID: 28794119 DOI: 10.1161/circoutcomes.117.003936] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/04/2017] [Accepted: 07/06/2017] [Indexed: 11/16/2022]
Abstract
BACKGROUND Despite the demonstrated safety of the same-day discharge (SDD) after percutaneous coronary intervention (PCI), uptake of this program has been relatively poor in the United States. We evaluated the temporal trends and variations in the utilization of SDD after PCI during the contemporary era. In addition, we evaluated the predictors of SDD (compared with next-day discharge) and the causes of readmission in these 2 patient cohorts. METHODS AND RESULTS Data were extracted from State Ambulatory Surgical Database and State Inpatient Database from Florida and New York ranging from 2009 to 2013. All adults undergoing PCI in an outpatient setting were included. Data were merged with the directory available from the American Hospital Association to obtain detailed information on hospital-related characteristics. Unplanned readmissions within 7 and 30 days constituted the coprimary outcomes. There was modest increase in the proportion of SDD after PCI from 2.5% in 2009 to 7.4% in 2013 (P-trend <0.001). SDD was more frequently used among male and younger patients with fewer comorbidities. There were considerable differences in the discharge practices among the different hospital types. Larger hospitals, teaching hospitals, and high PCI volume hospitals had higher utilization of SDD compared with their respective counterparts. SDD and next-day discharge cohorts had similar rates of unplanned readmissions, in-hospital mortality, and acute myocardial infarction during follow-up. Furthermore, uninsured patients had significantly lower odds of SDD along with higher incidence of unplanned readmission within 30 days after PCI compared with insured patients. CONCLUSIONS During 2009 to 2013, there has been a modest increase in SDD after PCI. Several demographic and clinical characteristics play critical role in determination of SDD after PCI. There were significant disparities in discharge practices between different sex, racial, and insurance-based strata.
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Affiliation(s)
- Shikhar Agarwal
- From the Department of Cardiology, Section of Interventional Cardiology, Geisinger Medical Center, Danville, PA (S.A., K.A.S., J.C.B.); and Division of Internal Medicine, Rutgers New Jersey Medical School, Newark (B.T.).
| | - Badal Thakkar
- From the Department of Cardiology, Section of Interventional Cardiology, Geisinger Medical Center, Danville, PA (S.A., K.A.S., J.C.B.); and Division of Internal Medicine, Rutgers New Jersey Medical School, Newark (B.T.)
| | - Kimberly A Skelding
- From the Department of Cardiology, Section of Interventional Cardiology, Geisinger Medical Center, Danville, PA (S.A., K.A.S., J.C.B.); and Division of Internal Medicine, Rutgers New Jersey Medical School, Newark (B.T.)
| | - James C Blankenship
- From the Department of Cardiology, Section of Interventional Cardiology, Geisinger Medical Center, Danville, PA (S.A., K.A.S., J.C.B.); and Division of Internal Medicine, Rutgers New Jersey Medical School, Newark (B.T.)
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Madonis SM, Skelding KA, Roberts M. Management of acute coronary syndromes: special considerations in women. Heart 2018; 103:1638-1646. [PMID: 28970234 DOI: 10.1136/heartjnl-2016-309938] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [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] [Received: 11/23/2016] [Revised: 06/07/2017] [Accepted: 07/02/2017] [Indexed: 01/18/2023] Open
Affiliation(s)
- Stephanie M Madonis
- Department of General Internal Medicine, Geisinger Medical Center, Danville, Pennsylvania, USA
| | - Kimberly A Skelding
- Department of Cardiology, Geisinger Medical Center, Danville, Pennsylvania, USA
| | - Madhur Roberts
- Department of Cardiology, Piedmont Heart Institute, Atlanta, Georgia, USA
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Al-Azizi KM, Skelding KA. Renin angiotensin system inhibitors: a panacea for heart disease? J Thorac Dis 2017; 9:1437-1439. [PMID: 28740651 DOI: 10.21037/jtd.2017.05.65] [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: 11/06/2022]
Affiliation(s)
- Karim M Al-Azizi
- Department of Cardiology, Geisinger Health System, Danville, Pennsylvania, USA
| | - Kimberly A Skelding
- Department of Cardiology, Geisinger Health System, Danville, Pennsylvania, USA
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Dewey FE, Murray MF, Overton JD, Habegger L, Leader JB, Fetterolf SN, O'Dushlaine C, Van Hout CV, Staples J, Gonzaga-Jauregui C, Metpally R, Pendergrass SA, Giovanni MA, Kirchner HL, Balasubramanian S, Abul-Husn NS, Hartzel DN, Lavage DR, Kost KA, Packer JS, Lopez AE, Penn J, Mukherjee S, Gosalia N, Kanagaraj M, Li AH, Mitnaul LJ, Adams LJ, Person TN, Praveen K, Marcketta A, Lebo MS, Austin-Tse CA, Mason-Suares HM, Bruse S, Mellis S, Phillips R, Stahl N, Murphy A, Economides A, Skelding KA, Still CD, Elmore JR, Borecki IB, Yancopoulos GD, Davis FD, Faucett WA, Gottesman O, Ritchie MD, Shuldiner AR, Reid JG, Ledbetter DH, Baras A, Carey DJ. Distribution and clinical impact of functional variants in 50,726 whole-exome sequences from the DiscovEHR study. Science 2017; 354:354/6319/aaf6814. [PMID: 28008009 DOI: 10.1126/science.aaf6814] [Citation(s) in RCA: 364] [Impact Index Per Article: 52.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/14/2016] [Accepted: 11/16/2016] [Indexed: 11/02/2022]
Abstract
The DiscovEHR collaboration between the Regeneron Genetics Center and Geisinger Health System couples high-throughput sequencing to an integrated health care system using longitudinal electronic health records (EHRs). We sequenced the exomes of 50,726 adult participants in the DiscovEHR study to identify ~4.2 million rare single-nucleotide variants and insertion/deletion events, of which ~176,000 are predicted to result in a loss of gene function. Linking these data to EHR-derived clinical phenotypes, we find clinical associations supporting therapeutic targets, including genes encoding drug targets for lipid lowering, and identify previously unidentified rare alleles associated with lipid levels and other blood level traits. About 3.5% of individuals harbor deleterious variants in 76 clinically actionable genes. The DiscovEHR data set provides a blueprint for large-scale precision medicine initiatives and genomics-guided therapeutic discovery.
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Affiliation(s)
| | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | - Korey A Kost
- Geisinger Health System, Danville, PA 17822, USA
| | | | | | - John Penn
- Regeneron Genetics Center, Tarrytown, NY 10591, USA
| | | | | | | | | | | | | | | | | | | | - Matthew S Lebo
- Laboratory for Molecular Medicine, Cambridge, MA 02139, USA
| | | | | | | | - Scott Mellis
- Regeneron Pharmaceuticals, Tarrytown, NY 10591, USA
| | | | - Neil Stahl
- Regeneron Pharmaceuticals, Tarrytown, NY 10591, USA
| | | | | | | | | | | | | | | | | | | | | | | | | | | | | | - Aris Baras
- Regeneron Genetics Center, Tarrytown, NY 10591, USA
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Al-Azizi KM, Alabbady AM, Burnside JA, Stella JJ, Green SM, Scott TD, Blankenship JC, Skelding KA. CRT-800.26 Validation of the Contrast Induced Nephropathy Risk Score In Patients Undergoing Transcatheter Aortic Valve Replacement. JACC Cardiovasc Interv 2017. [DOI: 10.1016/j.jcin.2016.12.233] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Al-Azizi K, Alabbady AM, Burnside JA, Stella JJ, Green SM, Scott TD, Blankenship JC, Skelding KA. CRT-800.28 The CIN-IT Study: - Contrast Induced Nephropathy In Patients Undergoing Transcatheter Aortic Valve Replacement. JACC Cardiovasc Interv 2017. [DOI: 10.1016/j.jcin.2016.12.235] [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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Abstract
Over the past four decades advances in the interventional cardiology field have led to growing indications for percutaneous coronary interventions (PCIs). With increasing numbers of complex and high-risk PCIs performed in today’s catheterization laboratories, cardiogenic shock is encountered more frequently than ever before emphasizing the need for proper knowledge of different adjunct hemodynamic support devices available on the market. We aim to review the percutaneously-placed left ventricular assisting devices available to catheterization laboratories in the US for use in high-risk PCIs, their indications, contraindications, limitations, and review of the most prominent literature.
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Skelding KA, Yakubov SJ, Kleiman NS, Reardon MJ, Adams DH, Huang J, Forrest JK, Popma JJ. Transcatheter Aortic Valve Replacement Versus Surgery in Women at High Risk for Surgical Aortic Valve Replacement (from the CoreValve US High Risk Pivotal Trial). Am J Cardiol 2016; 118:560-6. [PMID: 27381665 DOI: 10.1016/j.amjcard.2016.05.051] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/22/2016] [Revised: 05/13/2016] [Accepted: 05/13/2016] [Indexed: 11/26/2022]
Abstract
The objective of this study was to compare outcomes in women after surgical aortic valve replacement (SAVR) versus transcatheter aortic valve replacement (TAVR) using a self-expanding prosthesis in patients with severe aortic stenosis who were at high risk for SAVR. Although registries and meta-analyses have suggested that TAVR is of considerable benefit in women, perhaps even more so than in men, a rigorous evaluation of TAVR with a self-expanding valve versus SAVR in women from a randomized trial has not been performed. Patients with severe aortic stenosis were randomized 1:1 to either TAVR or SAVR. Outcomes at 1 year are reported. Treatment was attempted in a total of 353 women (183 TAVR and 170 SAVR). Baseline characteristics and predicted risk of the 2 groups were comparable, although the frequency of diabetes mellitus was lower in patients undergoing TAVR (33.3% vs 45.3%; p = 0.02). TAVR-treated patients experienced a statistically significant 1-year survival advantage compared with SAVR patients (12.7% vs 21.8%; p = 0.03). The composite all-cause mortality or major stroke rate also favored TAVR (14.9% vs 24.2%; p = 0.04). Quality of life, as measured by the Kansas City Cardiomyopathy Questionnaire summary score, for both the TAVR and SAVR groups increased significantly from baseline to 1 year. In conclusion, female TAVR patients had lower 1-year mortality and lower 1-year all-cause mortality or major stroke compared with women undergoing SAVR, with both cohorts experiencing improved quality of life. Further studies specifically in women are warranted to validate these findings.
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Forrest JK, Adams DH, Popma JJ, Reardon MJ, Deeb GM, Yakubov SJ, Hermiller JB, Huang J, Skelding KA, Lansky A. Transcatheter Aortic Valve Replacement in Women Versus Men (from the US CoreValve Trials). Am J Cardiol 2016; 118:396-402. [PMID: 27346591 DOI: 10.1016/j.amjcard.2016.05.013] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/07/2016] [Revised: 05/05/2016] [Accepted: 05/05/2016] [Indexed: 10/21/2022]
Abstract
Treatment for severe symptomatic aortic stenosis has changed significantly in recent years due to advances in transcatheter aortic valve replacement (TAVR). Recent studies with the CoreValve prosthesis have demonstrated superior results compared with surgical aortic valve replacement in patients at increased risk for surgery, but there are limited data on gender-related differences in patient characteristics and outcomes with this device. We compared baseline characteristics and clinical outcomes in women and men undergoing TAVR with the CoreValve prosthesis. A total of 3,687 patients (1,708 women and 1,979 men) were included. At baseline, women tended to be slightly older and to have increased frailty, but they had fewer cardiac co-morbidities, higher left ventricular systolic function, less coronary artery disease, and fewer previous strokes. All-cause mortality was 5.9% for women and 5.8% for men at 30 days (p = 0.87) and 24.1% and 21.3%, respectively, at 1 year (p = 0.08). The incidence of stroke was 5.7% in women and 4.0% in men at 30 days (p = 0.02) and 9.3% and 7.7%, respectively, at 1 year (p = 0.05). Women had a higher incidence of bleeding, including more life-threatening bleeds, and a greater incidence of major vascular complications than men at 30 days. Device success was achieved in 86.9% of women and 86.1% of men (p = 0.50). In conclusion, although there were significant baseline differences and procedure-related complications between women and men undergoing TAVR with the CoreValve prosthesis, this analysis found no significant difference in 30-day or 1-year mortality.
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Kahlon TS, Barn K, Akram MMA, Blankenship JC, Bower-Stout C, Carey DJ, Sun H, Tompkins Weber K, Skelding KA, Scott TD, Green SM, Berger PB. Impact of pre-hospital electrocardiograms on time to treatment and one year outcome in a rural regional ST-segment elevation myocardial infarction network. Catheter Cardiovasc Interv 2016; 89:245-251. [DOI: 10.1002/ccd.26567] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/25/2015] [Accepted: 04/10/2016] [Indexed: 12/21/2022]
Affiliation(s)
| | | | | | | | | | | | - Haiyan Sun
- Geisinger Medical Center; Danville Pennsylvania
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Chetcuti SJ, Deeb GM, Skelding KA, Casale A, Waksman R, Bafi A, Oh JK, Yakubov S, Reardon MJ, Adams D, Popma J. TCT-636 Self-Expanding TAVR in Patients with Low-Gradient, Low Output Aortic Stenosis: 12 Month Results from the CoreValve US Expanded Use Study. J Am Coll Cardiol 2015. [DOI: 10.1016/j.jacc.2015.08.655] [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: 11/24/2022]
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Forrest JK, Lansky A, Maini B, Skelding KA, Casale A, Fail PS, Popma J. TCT-623 Transcatheter Aortic Valve Replacement In Women Versus Men: An Analysis of the CoreValve US Pivotal and Continued Access Trials. J Am Coll Cardiol 2015. [DOI: 10.1016/j.jacc.2015.08.642] [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: 11/16/2022]
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23
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Wang TY, Grines C, Ortega R, Dai D, Jacobs AK, Skelding KA, Mauri L, Mehran R. Women in interventional cardiology: Update in percutaneous coronary intervention practice patterns and outcomes of female operators from the National Cardiovascular Data Registry®. Catheter Cardiovasc Interv 2015; 87:663-8. [DOI: 10.1002/ccd.26118] [Citation(s) in RCA: 33] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/20/2015] [Accepted: 07/05/2015] [Indexed: 11/11/2022]
Affiliation(s)
- Tracy Y. Wang
- Duke Clinical Research Institute, Duke University Medical Center; Durham North Carolina
| | - Cindy Grines
- Detroit Medical Center Cardiovascular Institute; Detroit Michigan
| | - Rebecca Ortega
- Duke Clinical Research Institute, Duke University Medical Center; Durham North Carolina
| | - David Dai
- Duke Clinical Research Institute, Duke University Medical Center; Durham North Carolina
| | | | | | - Laura Mauri
- Brigham and Women's Hospital, Harvard Medical School; Boston Massachusetts
| | - Roxana Mehran
- Icahn School of Medicine at Mount Sinai; New York New York
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Skelding KA, Casale A, Yakubov S, Reardon M, Adams D, Popma J. TRANSCATHETER AORTIC VALVE REPLACEMENT VERSUS SURGERY IN WOMEN AT HIGH RISK FOR SURGICAL AORTIC VALVE REPLACEMENT: A SUBGROUP ANALYSIS OF THE COREVALVE US HIGH RISK PIVOTAL TRIAL. J Am Coll Cardiol 2015. [DOI: 10.1016/s0735-1097(15)61946-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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25
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Baker NC, O'Connell EW, Htun WW, Sun H, Green SM, Skelding KA, Blankenship JC, Scott TD, Berger PB. Safety of coronary angiography and percutaneous coronary intervention via the radial versus femoral route in patients on uninterrupted oral anticoagulation with warfarin. Am Heart J 2014; 168:537-44. [PMID: 25262264 DOI: 10.1016/j.ahj.2014.06.016] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/12/2014] [Accepted: 06/28/2014] [Indexed: 11/29/2022]
Abstract
OBJECTIVE To evaluate access site and other bleeding complications associated with radial versus femoral access in patients receiving oral anticoagulation (OAC) with warfarin. BACKGROUND Patients receiving OAC with warfarin undergoing coronary angiography and percutaneous coronary intervention (PCI) may have OAC continued despite the risk of bleeding. To what extent arterial access site impacts bleeding in such patients is not well studied. METHODS Over 6 years, we identified 255 consecutive patients in whom warfarin was continued who underwent coronary angiography with an international normalized ratio >1.8. A total of 97 patients also underwent PCI at the same setting (27% femoral vs 73% radial). The primary outcome was Bleeding Academic Research Consortium bleeds; a secondary end point was frequency of access site complications in the 72 hours post-PCI. Complications were evaluated based on the initial access site attempted. RESULTS Minimal baseline clinical characteristics differences existed between the groups. International normalized ratio was significantly higher in the radial group (2.42 ± 0.67 vs 2.24 ± 0.49, P = .02). Bivalirudin use was greater during radial PCI than femoral (76% vs 42%, P < .05), whereas unfractionated heparin alone was greater during femoral PCI than radial (46% vs 18%, P < .05). No significant difference was seen in the primary end point between femoral (2.8%) and radial (1.6%, P = .54) during coronary angiography alone. However, PCI via the femoral artery had significantly more Bleeding Academic Research Consortium bleeding (19.2% vs 1.4%, P = .005) and transfusions (15% vs 0%, P = .004) than via the radial artery. Patients who underwent PCI using radial access were less likely to have any vascular or bleeding complications (1% vs 23%, P = .001). CONCLUSIONS Patients who underwent coronary angiography during uninterrupted OAC had similar bleeding rates regardless of access site. However, when PCI was performed, radial access was associated with fewer bleeding and vascular complications than the femoral approach. CONDENSED ABSTRACT We retrospectively identified 255 consecutive patients on warfarin who underwent coronary angiography, 97 of whom underwent a percutaneous coronary intervention. The data reveal a reduction in Bleeding Academic Research Consortium bleeds (1.6% vs 8.1%, P = .02) with radial versus femoral access. The radial approach was associated with an overall lower rate of any vascular or bleeding complication than the femoral approach during percutaneous coronary intervention (1% vs 23%, P = .001).
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Affiliation(s)
- Nevin C Baker
- Department of Cardiology, Geisinger Medical Center, Danville, PA
| | - Erik W O'Connell
- Department of General Internal Medicine, Geisinger Medical Center, Danville, PA
| | - Wah Wah Htun
- Department of Cardiology, Geisinger Medical Center, Danville, PA
| | - Haiyan Sun
- Center for Health Research, Geisinger Medical Center, Danville, PA
| | - Sandy M Green
- Department of Cardiology, Geisinger Medical Center, Danville, PA
| | | | | | - Thomas D Scott
- Department of Cardiology, Geisinger Medical Center, Danville, PA
| | - Peter B Berger
- Department of Cardiology, Geisinger Medical Center, Danville, PA; Cardiovascular Center for Clinical Research, Geisinger Medical Center, Danville, PA.
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Kumar AHS, Martin K, Doyle B, Huang CL, Pillai GKM, Ali MT, Skelding KA, Wang S, Gleeson BM, Jahangeer S, Ritman EL, Russell SJ, Caplice NM. Intravascular cell delivery device for therapeutic VEGF-induced angiogenesis in chronic vascular occlusion. Biomaterials 2014; 35:9012-22. [PMID: 25096850 DOI: 10.1016/j.biomaterials.2014.07.016] [Citation(s) in RCA: 7] [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] [Received: 05/16/2014] [Accepted: 07/10/2014] [Indexed: 10/24/2022]
Abstract
Site specific targeting remains elusive for gene and stem cell therapies in the cardiovascular field. One promising option involves use of devices that deliver larger and more sustained cell/gene payloads to specific disease sites using the versatility of percutaneous vascular access technology. Smooth muscle cells (SMCs) engineered to deliver high local concentrations of an angiogenic molecule (VEGF) were placed in an intravascular cell delivery device (ICDD) in a porcine model of chronic total occlusion (CTO) involving ameroid placement on the proximal left circumflex (LCx) artery. Implanted SMC were retained within the ICDD and were competent for VEGF production in vitro and in vivo. Following implantation, micro-CT analyses revealed that ICDD-VEGF significantly enhanced vasa vasora microvessel density with a concomitant increase in tissue VEGF protein levels and formation of endothelial cell colonies suggesting increased angiogenic potential. ICDD-VEGF markedly enhanced regional blood flow determined by microsphere and contrast CT analysis translating to a functional improvement in regional wall motion and global left ventricular (LV) systolic and diastolic function. Our data indicate robust, clinically relevant angiogenesis can be achieved in a human scale porcine chronic vascular occlusion model following ICDD-VEGF-based delivery of angiogenic cells. This may have implications for percutaneous delivery of numerous therapeutic factors promoting creation of microvascular bypass networks in chronic vaso-occlusive diseases.
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Affiliation(s)
- Arun H S Kumar
- Centre for Research in Vascular Biology (CRVB), Biosciences Institute, University College Cork, Cork, Ireland
| | - Kenneth Martin
- Centre for Research in Vascular Biology (CRVB), Biosciences Institute, University College Cork, Cork, Ireland
| | - Brendan Doyle
- Division of Cardiovascular Diseases, Molecular Medicine Program, Mayo Clinic, Rochester, MN, USA
| | - Chien-Ling Huang
- Centre for Research in Vascular Biology (CRVB), Biosciences Institute, University College Cork, Cork, Ireland
| | - Gopala-Krishnan M Pillai
- Centre for Research in Vascular Biology (CRVB), Biosciences Institute, University College Cork, Cork, Ireland
| | - Mohammed T Ali
- Centre for Research in Vascular Biology (CRVB), Biosciences Institute, University College Cork, Cork, Ireland
| | - Kimberly A Skelding
- Division of Cardiovascular Diseases, Molecular Medicine Program, Mayo Clinic, Rochester, MN, USA
| | - Shaohua Wang
- Division of Cardiovascular Diseases, Molecular Medicine Program, Mayo Clinic, Rochester, MN, USA
| | - Birgitta M Gleeson
- Centre for Research in Vascular Biology (CRVB), Biosciences Institute, University College Cork, Cork, Ireland
| | - Saleem Jahangeer
- Cork Cancer Research Centre, Biosciences Institute, University College Cork, Cork, Ireland
| | - Erik L Ritman
- Department of Physiology and Biomedical Engineering, Mayo Clinic, Rochester, MN, USA
| | - Stephen J Russell
- Division of Hematology, Molecular Medicine Program, Mayo Clinic, Rochester, MN, USA
| | - Noel M Caplice
- Centre for Research in Vascular Biology (CRVB), Biosciences Institute, University College Cork, Cork, Ireland; Division of Cardiovascular Diseases, Molecular Medicine Program, Mayo Clinic, Rochester, MN, USA.
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Rao SV, Tremmel JA, Gilchrist IC, Shah PB, Gulati R, Shroff AR, Crisco V, Woody W, Zoghbi G, Duffy PL, Sanghvi K, Krucoff MW, Pyne CT, Skelding KA, Patel T, Pancholy SB. Best practices for transradial angiography and intervention: a consensus statement from the society for cardiovascular angiography and intervention's transradial working group. Catheter Cardiovasc Interv 2013; 83:228-36. [PMID: 24123781 DOI: 10.1002/ccd.25209] [Citation(s) in RCA: 148] [Impact Index Per Article: 13.5] [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: 09/09/2013] [Accepted: 09/12/2013] [Indexed: 01/22/2023]
Affiliation(s)
- Sunil V Rao
- Duke University Medical Center, Durham, North Carolina
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Yost GW, Puher SL, Graham J, Scott TD, Skelding KA, Berger PB, Blankenship JC. Readmission in the 30 days after percutaneous coronary intervention. JACC Cardiovasc Interv 2013; 6:237-44. [PMID: 23517834 DOI: 10.1016/j.jcin.2012.10.015] [Citation(s) in RCA: 46] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/22/2012] [Revised: 10/24/2012] [Accepted: 10/27/2012] [Indexed: 10/27/2022]
Abstract
OBJECTIVES This study sought to identify the frequency and etiology of readmission within 30 days of percutaneous coronary intervention (PCI) in a large integrated healthcare system. BACKGROUND One-fifth of Medicare patients are readmitted within 30 days of hospitalization. Identifying the causes of readmission may help identify strategies to prevent readmission. METHODS All patients undergoing PCI (elective, urgent, and emergent) at our center between January 1, 2007, and April 12, 2010, were prospectively entered into the American College of Cardiology National Cardiovascular Data Registry. Patients readmitted to any hospital within 30 days of the index procedure were identified using an administrative database and telephone follow-up. Individual charts were reviewed independently by 2 investigators; disagreements regarding the cause for readmission were resolved by a third investigator. RESULTS During the study period, 3,255 PCI were performed, and 262 patients (8.0%) were readmitted within 30 days. Of these, 261 (99.6%) had medical records available for review. Reasons for readmission included: complications related to the PCI (n = 31, 11.9%); non-PCI cardiac causes related to index admission (n = 93, 35.6%); noncardiac causes related to index admission (n = 34, 13%); causes unrelated to the index admission (n = 103, 39.5%). Multivariable logistic regression modeling revealed that female sex, advanced age, peripheral arterial disease, prior valvular surgery, and PCI complications during the index procedure were associated with 30-day readmission. CONCLUSIONS Readmissions within 30 days due to complications related to PCI performed on index admission are rare (0.9% of all PCI) and are an infrequent cause of readmission (<12% of readmissions). Thirty-day readmission after PCI should not be used as a quality metric of PCI performance.
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Affiliation(s)
- Gregory W Yost
- Department of Cardiology, Geisinger Medical Center, Danville, PA 17822, USA
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29
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Buchanan GL, Chieffo A, Mehilli J, Mikhail GW, Mauri F, Presbitero P, Grinfeld L, Petronio AS, Skelding KA, Hoye A, Mehran R, Morice MC. The occupational effects of interventional cardiology: results from the WIN for Safety survey. EUROINTERVENTION 2012; 8:658-63. [DOI: 10.4244/eijv8i6a103] [Citation(s) in RCA: 50] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
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30
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Suryadevara RS, Skelding KA. Vascular Complications in Women and the Radial Approach. Interv Cardiol Clin 2012; 1:207-211. [PMID: 28582094 DOI: 10.1016/j.iccl.2012.01.004] [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: 06/07/2023]
Abstract
Compared with medical therapy, percutaneous coronary intervention (PCI) is associated with higher bleeding rates and more vascular complications. Although the rate of complications is decreasing, female sex continues to be an independent risk factor. Radial access for PCI is as effective as femoral access but is associated with significantly fewer bleeding and vascular complications. Although women are at higher risk for bleeding and vascular complications than their male counterparts, the use of radial access has decreased the complications to a level in the which the difference becomes minimal. More quality improvement studies are needed to identify strategies for reducing complications in this high-risk population.
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Affiliation(s)
- Ramya Smitha Suryadevara
- Department of Cardiology, Geisinger Medical Center, 100 Academy Avenue, Danville, PA 17821, USA.
| | - Kimberly A Skelding
- Department of Cardiology, Geisinger Medical Center, 100 Academy Avenue, Danville, PA 17821, USA
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31
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Lansky AJ, Yaqub M, Sood P, Ying SW, Wang J, Caputo R, Farhat N, Applegate RJ, Skelding KA, Kereiakes DJ, Sudhir K, Stone GW. Performance of everolimus-eluting and paclitaxel-eluting coronary stents in women: 2-year outcomes from the SPIRIT IV trial. Cardiovascular Revascularization Medicine 2011. [DOI: 10.1016/j.carrev.2011.04.267] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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Best PJM, Skelding KA, Mehran R, Chieffo A, Kunadian V, Madan M, Mikhail GW, Mauri F, Takahashi S, Honye J, Hernández-Antolín R, Weiner BH. SCAI consensus document on occupational radiation exposure to the pregnant cardiologist and technical personnel. Heart Lung Circ 2011; 20:83-90. [PMID: 21241961 DOI: 10.1016/j.hlc.2010.11.006] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
Concerns regarding radiation exposure and its effects during pregnancy are often quoted as an important barrier preventing many women from pursuing a career in Interventional Cardiology. Finding the true risk of radiation exposure from performing cardiac catheterisation procedures can be challenging and guidelines for pregnancy exposure have been inadequate. The Women in Innovations group of Cardiologists with endorsement of the Society for Cardiovascular Angiography and Interventions aim to provide guidance in this publication by describing the risk of radiation exposure to pregnant physicians and cardiac catheterisation personnel, to educate on appropriate radiation monitoring and to encourage mechanisms to reduce radiation exposure. Current data do not suggest a significant increased risk to the foetus of pregnant women in the cardiac catheterisation laboratory and thus do not justify precluding pregnant physicians from performing procedures in the cardiac catheterisation laboratory. However, radiation exposure amongst pregnant physicians should be properly monitored and adequate radiation safety measures are still warranted.
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Affiliation(s)
- Patricia J M Best
- Department of Internal Medicine and Cardiovascular Diseases, Mayo Clinic, Rochester, MN, USA.
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Best PJM, Skelding KA, Mehran R, Chieffo A, Kunadian V, Madan M, Mikhail GW, Mauri F, Takahashi S, Honye J, Hernández-Antolín R, Weiner BH. SCAI consensus document on occupational radiation exposure to the pregnant cardiologist and technical personnel. Catheter Cardiovasc Interv 2011; 77:232-41. [DOI: 10.1002/ccd.22877] [Citation(s) in RCA: 49] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/13/2010] [Accepted: 10/14/2010] [Indexed: 11/05/2022]
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Blankenship JC, Scott TD, Skelding KA, Haldis TA, Tompkins-Weber K, Sledgen MY, Donegan MA, Buckley JW, Sartorius JA, Hodgson JM, Berger PB. Door-to-Balloon Times Under 90 Min Can Be Routinely Achieved for Patients Transferred for ST-Segment Elevation Myocardial Infarction Percutaneous Coronary Intervention in a Rural Setting. J Am Coll Cardiol 2011; 57:272-9. [PMID: 21232663 DOI: 10.1016/j.jacc.2010.06.056] [Citation(s) in RCA: 79] [Impact Index Per Article: 6.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/18/2010] [Revised: 05/31/2010] [Accepted: 06/06/2010] [Indexed: 10/18/2022]
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Blankenship JC, Skelding KA, Scott TD, Berger PB, Parise H, Brodie BR, Witzenbichler B, Gaugliumi G, Peruga JZ, Lansky AJ, Mehran R, Stone GW. Predictors of reperfusion delay in patients with acute myocardial infarction undergoing primary percutaneous coronary intervention from the HORIZONS-AMI trial. Am J Cardiol 2010; 106:1527-33. [PMID: 21094350 DOI: 10.1016/j.amjcard.2010.07.033] [Citation(s) in RCA: 38] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/05/2010] [Revised: 07/22/2010] [Accepted: 07/23/2010] [Indexed: 11/24/2022]
Abstract
Primary percutaneous coronary intervention (PCI) is the optimal method of reperfusion when performed expeditiously. Factors contributing to delays in PCI for ST-segment elevation myocardial infarction (STEMI) have not been thoroughly characterized or quantified. We sought to identify the factors associated with the delays to reperfusion in patients with STEMI undergoing primary PCI. Primary PCI was performed in 3,340 patients with STEMI in the international, multicenter Harmonizing Outcomes with Revascularization and Stents in Acute Myocardial Infarction trial. Multivariate analysis was used to identify independent predictors of delay in achieving reperfusion from 38 baseline and procedural variables. A total of 905 patients (27.1%) presented to non-PCI hospitals and were subsequently transferred; the remainder presented to PCI hospitals. The most powerful independent predictor of the interval from symptom onset to arrival at the PCI hospital and the first door-to-balloon time was an initial presentation at a non-PCI hospital (median incremental 58- and 54-minute delay, respectively, both p < 0.001). Other independent predictors of prolonged door-to-balloon times included presentation with respiratory failure (42-minute incremental delay, p = 0.003), presentation during off-work hours (11-minute incremental delay, p < 0.001), and co-morbid conditions such as diabetes and heart failure. In conclusion, among patients undergoing primary PCI, presentation to a non-PCI hospital was the variable associated with the greatest delay to reperfusion. Systems of care that encourage ambulance diagnosis and direct delivery of patients with STEMI to a PCI hospital might shorten the overall door-to-balloon times and improve the clinical outcomes.
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Skelding KA, Gerhard GS, Vlachos H, Selzer F, Kelsey SF, Chu X, Erdman R, Williams DO, Kip KE. Association of an INSIG2 obesity allele with cardiovascular phenotypes is gender and age dependent. BMC Cardiovasc Disord 2010; 10:46. [PMID: 20920244 PMCID: PMC2958931 DOI: 10.1186/1471-2261-10-46] [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] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/11/2010] [Accepted: 09/29/2010] [Indexed: 12/02/2022] Open
Abstract
Background The INSIG2 gene has been implicated in cholesterol metabolism and a single nucleotide polymorphism (SNP) near INSIG2 has been shown to be associated with obesity. We sought to determine the relationship of the INSIG2 SNP to cardiovascular disease (CVD) related phenotypes. Methods and Results Nine hundred forty six patients undergoing percutaneous coronary intervention (PCI) in wave 5 of the multicenter NHLBI Dynamic Registry were genotyped using RT-PCR/TaqMan/allelic discrimination for the rs7566605 SNP near the INSIG2 gene. Clinical variables analyzed include demographics, medical history, and procedural details. The prevalence of peripheral vascular disease (PVD) was significantly higher in older men (≥65 years) who were either homozygous or carriers of the obesity/lipid risk allele ("C") compared to non-carriers (odds ratio 3.4, p = 0.013) using a logistic regression model incorporating history of hypercholesterolemia, history of hypertension, cerebrovascular disease, history of diabetes, and BMI. A similar relationship with cerebrovascular disease was found in older (>65) women (odds ratio 3.4, p = 0.013). The INSIG2 SNP was not associated with BMI, nor with other clinical variables. Conclusion Age and gender may influence the association of the INSIG2 obesity SNP with PVD and cerebrovascular disease in patients with pre-existing CVD.
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Affiliation(s)
- Kimberly A Skelding
- Weis Center for Research, Geisinger Medical Center, Danville, PA 17822, USA.
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Chieffo A, Hoye A, Mauri F, Mikhail G, Ammerer M, Grines C, Grinfeld L, Madan M, Presbitero P, Skelding KA, Weiner BH, Mehran R. Gender-based issues in interventional cardiology: a consensus statement from the Women in Innovations (WIN) initiative. Rev Esp Cardiol 2010; 63:200-8. [PMID: 20109417 DOI: 10.1016/s1885-5857(10)70038-4] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
Cardiovascular disease is the leading cause of mortality in women yet studies have suggested it is often under-recognized. Of particular concern is the apparent suboptimal treatment of women in comparison to men, with less revascularization and use of evidence-based medications. The Women in Innovations group of cardiologists, aims to highlight these issues and change perceptions to optimize the treatment of female patients with cardiovascular disease, support future research, and encourage and guide the training of female interventional cardiologists.
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Affiliation(s)
- Alaide Chieffo
- Invasive Cardiology Unit, San Raffaele Scientific Institute, Milan, Italy.
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Chieffo A, Hoye A, Mauri F, Mikhail G, Ammerer M, Grines C, Grinfeld L, Madan M, Presbitero P, Skelding KA, Weiner BH, Mehran R. Cuestiones relativas al sexo en cardiología intervencionista: declaración de consenso de la iniciativa Women in Innovations (WIN). Rev Esp Cardiol 2010. [DOI: 10.1016/s0300-8932(10)70038-5] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
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Chieffo A, Hoye A, Mauri F, Mikhail GW, Ammerer M, Grines C, Grinfeld L, Madan M, Presbitero P, Skelding KA, Weiner BH, Mehran R. Gender-based issues in interventional cardiology: A consensus statement from the Women in Innovations (WIN) Initiative. Catheter Cardiovasc Interv 2010; 75:145-52. [DOI: 10.1002/ccd.22327] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
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Blankenship JC, Skelding KA, Scott TD, Buckley J, Zimmerman DK, Temple A, Sartorius J, Jimenez E, Berger PB. ST-elevation myocardial infarction patients can be enrolled in randomized trials before emergent coronary intervention without sacrificing door-to-balloon time. Am Heart J 2009; 158:400-7. [PMID: 19699863 DOI: 10.1016/j.ahj.2009.06.022] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/14/2009] [Accepted: 06/21/2009] [Indexed: 10/20/2022]
Abstract
BACKGROUND Multicenter trials are necessary to compare the effectiveness of new drugs and devices for patients with ST-elevation myocardial infarction (STEMI) percutaneous coronary intervention (PCI). However, enrollment of STEMI patients in clinical trials could be detrimental to patients if it significantly delayed reperfusion therapy. We sought to determine whether STEMI patients treated with PCI could be enrolled in clinical trials without prolonging door-to-balloon times. METHODS At a single PCI center between October 17, 2004, and December 31, 2007, patients were enrolled in 1 of 4 trials requiring central enrollment and informed consent if (1) a study was actively enrolling, (2) the patient met inclusion/exclusion criteria, (3) and a study nurse was available. Median door-to-balloon times were compared for patients enrolled in clinical trials compared to those not enrolled. RESULTS Of 581 STEMI patients treated with PCI, 123 were enrolled in clinical trials and 458 were not. For patients transferred for PCI, community hospital door-to-balloon times were similar for research and nonresearch patients (104 vs 108 minutes, P = .4). For patients presenting directly to the PCI center, median door-to-balloon times were similar for research (55 minutes) and nonresearch patients (44 minutes, P = .5) after adjustment for age, culprit artery, and operator. CONCLUSIONS Patients with STEMI may be enrolled in clinical trials with no significant delay in achieving reperfusion. For patients presenting directly to the PCI center, median door-to-balloon times well under 90 minutes can be achieved even with enrollment into clinical trials.
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Lokhandwala JO, Best PJ, Butterfield JH, Skelding KA, Scott T, Blankenship JC, Buckley JW, Berger PB. Frequency of Allergic or Hematologic Adverse Reactions to Ticlopidine Among Patients With Allergic or Hematologic Adverse Reactions to Clopidogrel. Circ Cardiovasc Interv 2009; 2:348-51. [DOI: 10.1161/circinterventions.108.832964.108.832964] [Citation(s) in RCA: 29] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Affiliation(s)
- Juzar O. Lokhandwala
- From the Department of Cardiology (J.O.L., K.A.S., T.S., J.C.B., J.W.B., P.B.B.) and Center for Clinical Studies (P.B.B.), Geisinger Medical Center, Danville, Pa; and Divisions of Cardiovascular Diseases (P.J.M.B.) and Allergic Diseases (J.H.B.), Mayo Clinic, Rochester, Minn
| | - Patricia J.M. Best
- From the Department of Cardiology (J.O.L., K.A.S., T.S., J.C.B., J.W.B., P.B.B.) and Center for Clinical Studies (P.B.B.), Geisinger Medical Center, Danville, Pa; and Divisions of Cardiovascular Diseases (P.J.M.B.) and Allergic Diseases (J.H.B.), Mayo Clinic, Rochester, Minn
| | - Joseph H. Butterfield
- From the Department of Cardiology (J.O.L., K.A.S., T.S., J.C.B., J.W.B., P.B.B.) and Center for Clinical Studies (P.B.B.), Geisinger Medical Center, Danville, Pa; and Divisions of Cardiovascular Diseases (P.J.M.B.) and Allergic Diseases (J.H.B.), Mayo Clinic, Rochester, Minn
| | - Kimberly A. Skelding
- From the Department of Cardiology (J.O.L., K.A.S., T.S., J.C.B., J.W.B., P.B.B.) and Center for Clinical Studies (P.B.B.), Geisinger Medical Center, Danville, Pa; and Divisions of Cardiovascular Diseases (P.J.M.B.) and Allergic Diseases (J.H.B.), Mayo Clinic, Rochester, Minn
| | - Thomas Scott
- From the Department of Cardiology (J.O.L., K.A.S., T.S., J.C.B., J.W.B., P.B.B.) and Center for Clinical Studies (P.B.B.), Geisinger Medical Center, Danville, Pa; and Divisions of Cardiovascular Diseases (P.J.M.B.) and Allergic Diseases (J.H.B.), Mayo Clinic, Rochester, Minn
| | - James C. Blankenship
- From the Department of Cardiology (J.O.L., K.A.S., T.S., J.C.B., J.W.B., P.B.B.) and Center for Clinical Studies (P.B.B.), Geisinger Medical Center, Danville, Pa; and Divisions of Cardiovascular Diseases (P.J.M.B.) and Allergic Diseases (J.H.B.), Mayo Clinic, Rochester, Minn
| | - Jeremy W. Buckley
- From the Department of Cardiology (J.O.L., K.A.S., T.S., J.C.B., J.W.B., P.B.B.) and Center for Clinical Studies (P.B.B.), Geisinger Medical Center, Danville, Pa; and Divisions of Cardiovascular Diseases (P.J.M.B.) and Allergic Diseases (J.H.B.), Mayo Clinic, Rochester, Minn
| | - Peter B. Berger
- From the Department of Cardiology (J.O.L., K.A.S., T.S., J.C.B., J.W.B., P.B.B.) and Center for Clinical Studies (P.B.B.), Geisinger Medical Center, Danville, Pa; and Divisions of Cardiovascular Diseases (P.J.M.B.) and Allergic Diseases (J.H.B.), Mayo Clinic, Rochester, Minn
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Good CW, Blankenship JC, Scott TD, Skelding KA, Berger PB, Wood GC. Feasibility and safety of ad hoc percutaneous coronary intervention in the modern era. J Invasive Cardiol 2009; 21:194-200. [PMID: 19411717] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 05/27/2023]
Abstract
BACKGROUND The frequency of ad hoc percutaneous coronary intervention (PCI) varies among institutions and regions of the country. It is unclear what factors limit use of the ad hoc strategy. OBJECTIVE To define factors which limit the use of the ad hoc strategy. METHODS All patients who underwent PCI at our center in 2004 were reviewed. Patients who had emergent PCI for ST-elevation myocardial infarction (n = 188), those who had undergone diagnostic coronary angiography at a referring facility (n = 54), and those who had a repeat PCI after a previous ad hoc PCI (n = 19) were excluded. PCIs performed the same day as diagnostic angiography were considered "ad hoc"; all others were designated "staged". Demographic and procedural factors through hospital discharge were prospectively recorded. Logistic regression analysis was performed to identify correlates of ad hoc PCI, PCI success, and PCI complications. RESULTS Of the 580 PCI procedures eligible for analysis, 557 (96%) were ad hoc and 23 (4%) were staged. Patients undergoing staged PCI had more lesions treated, a higher rate of no-reflow and periprocedural myocardial infarction, and higher contrast volumes and fluoroscopic times. Logistic regression analysis revealed that patients with history of heart failure, renal insufficiency and a recent myocardial infarction were more likely to undergo a staged PCI. Patients undergoing a staged PCI and those who had previous bypass surgery were more likely to have an unsuccessful PCI procedure. CONCLUSION Most PCI procedures can be performed safely and effectively on the same day as diagnostic coronary angiography.
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Affiliation(s)
- Christopher W Good
- Department of Cardiology, Geisinger Medical Center, Danville, PA 17822, USA
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Hubbard CR, Blankenship JC, Scott TD, Skelding KA, Berger PB. Emergency pretreatment for contrast allergy before direct percutaneous coronary intervention for ST-elevation myocardial infarction. Am J Cardiol 2008; 102:1469-72. [PMID: 19026297 DOI: 10.1016/j.amjcard.2008.07.040] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/04/2008] [Revised: 07/21/2008] [Accepted: 07/22/2008] [Indexed: 11/13/2022]
Abstract
Patients with previous adverse contrast reactions occasionally present with ST-segment elevation myocardial infarction. Whether they can undergo catheterization safely using current contrast and medications is unknown. We reviewed catheterization laboratory records of all 501 patients (January 2005 to December 2006) presenting with ST-segment elevation myocardial infarction who underwent emergency coronary angiography. Six patients (1.2%) reported a previous contrast reaction including rash, acute bronchospasm, or anaphylaxis. All received a combination of intravenous steroids and H1 and H2 blockers in the emergency department or catheterization laboratory before catheterization. None of these had complications or evidence of allergy in any patient. In conclusion, some patients with previous contrast reaction may undergo emergency catheterization without adverse consequences, although the safety of this approach has not been proved.
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Affiliation(s)
- C Randall Hubbard
- Department of Cardiology, Geisinger Medical Center, Danville, PA, USA
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Kastrati A, Neumann FJ, Mehilli J, Byrne RA, Iijima R, Büttner HJ, Khattab AA, Schulz S, Blankenship JC, Pache J, Minners J, Seyfarth M, Graf I, Skelding KA, Dirschinger J, Richardt G, Berger PB, Schömig A. Bivalirudin versus unfractionated heparin during percutaneous coronary intervention. N Engl J Med 2008; 359:688-96. [PMID: 18703471 DOI: 10.1056/nejmoa0802944] [Citation(s) in RCA: 287] [Impact Index Per Article: 17.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/24/2023]
Abstract
BACKGROUND Whether bivalirudin is superior to unfractionated heparin in patients with stable or unstable angina who undergo percutaneous coronary intervention (PCI) after pretreatment with clopidogrel is unknown. METHODS We enrolled 4570 patients with stable or unstable angina (with normal levels of troponin T and creatine kinase MB) who were undergoing PCI after pretreatment with a 600-mg dose of clopidogrel at least 2 hours before the procedure; 2289 patients were randomly assigned in a double-blind manner to receive bivalirudin, and 2281 to receive unfractionated heparin. The primary end point was the composite of death, myocardial infarction, urgent target-vessel revascularization due to myocardial ischemia within 30 days after randomization, or major bleeding during the index hospitalization (with a net clinical benefit defined as a reduction in the incidence of the end point). The secondary end point was the composite of death, myocardial infarction, or urgent target-vessel revascularization. RESULTS The incidence of the primary end point was 8.3% (190 patients) in the bivalirudin group as compared with 8.7% (199 patients) in the unfractionated-heparin group (relative risk, 0.94; 95% confidence interval [CI], 0.77 to 1.15; P=0.57). The secondary end point occurred in 134 patients (5.9%) in the bivalirudin group and 115 patients (5.0%) in the unfractionated-heparin group (relative risk, 1.16; 95% CI, 0.91 to 1.49; P=0.23). The incidence of major bleeding was 3.1% (70 patients) in the bivalirudin group and 4.6% (104 patients) in the unfractionated-heparin group (relative risk, 0.66; 95% CI, 0.49 to 0.90; P=0.008). CONCLUSIONS In patients with stable and unstable angina who underwent PCI after pretreatment with clopidogrel, bivalirudin did not provide a net clinical benefit (i.e., it did not reduce the incidence of the composite end point of death, myocardial infarction, urgent target-vessel revascularization, or major bleeding) as compared with unfractionated heparin, but it did significantly reduce the incidence of major bleeding. (ClinicalTrials.gov number, NCT00262054.)
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Affiliation(s)
- Adnan Kastrati
- Deutsches Herzzentrum, Technische Universität, Munich, Germany.
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Doroodchi H, Abdolrasulnia M, Foster JA, Foster E, Turakhia MP, Skelding KA, Sagar K, Casebeer LL. Knowledge and attitudes of primary care physicians in the management of patients at risk for cardiovascular events. BMC Fam Pract 2008; 9:42. [PMID: 18611255 PMCID: PMC2474612 DOI: 10.1186/1471-2296-9-42] [Citation(s) in RCA: 67] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 04/16/2008] [Accepted: 07/08/2008] [Indexed: 11/18/2022]
Abstract
Background Adherence to clinical practice guidelines for management of cardiovascular disease (CVD) is suboptimal. The purposes of this study were to identify practice patterns and barriers among U.S. general internists and family physicians in regard to cardiovascular risk management, and examine the association between physician characteristics and cardiovascular risk management. Methods A case vignette survey focused on cardiovascular disease risk management was distributed to a random sample of 12,000 U.S. family physicians and general internists between November and December 2006. Results Responses from a total of 888 practicing primary care physicians who see 60 patients per week were used for analysis. In an asymptomatic patient at low risk for cardiovascular event, 28% of family physicians and 37% of general internists made guideline-based preventive choices for no antiplatelet therapy (p < .01). In a patient at high risk for cardiovascular event, 59% of family physicians and 56% of general internists identified the guideline-based goal for serum fasting LDL level (< 100 mg/dl). Guideline adherence was inversely related to years in practice and volume of patients seen. Cost of medications (87.7%), adherence to medications (74.1%), adequate time for counseling (55.7%), patient education tools (47.1%), knowledge and skills to recommend dietary changes (47.8%) and facilitate patient adherence (52.0%) were cited as significant barriers to CVD risk management. Conclusion Despite the benefits demonstrated for managing cardiovascular risks, gaps remain in primary care practitioners' management of risks according to guideline recommendations. Innovative educational approaches that address barriers may facilitate the implementation of guideline-based recommendations in CVD risk management.
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Abstract
Cardiovascular disease has a complex genetic and environmental origin. Single-gene mutations have been identified for a variety of disorders, including several forms of sudden cardiac death, atrial fibrillation, hypertrophic cardiomyopathy and coronary artery disease. The recent availability of haplotype data has further enabled genomic approaches to mapping genetic variants associated with the more common polygenic forms of cardiovascular disease. Genome-wide association studies have identified single nucleotide polymorphisms associated with coronary artery disease and are being applied to a variety of clinical problems such as in-stent restenosis. The combination of high-throughput genomic tools such as high density microarrays, genomic information such as sequence and haplotype data, and the careful clinical definition of phenotypes provides the framework for realizing the goals of personalized medicine.
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Affiliation(s)
| | - Glenn S Gerhard
- Geisinger Medical Center, 100 N. Academy Drive, Danville, PA 17822, USA
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Blankenship JC, Haldis TA, Wood GC, Skelding KA, Scott T, Menapace FJ. Rapid triage and transport of patients with ST-elevation myocardial infarction for percutaneous coronary intervention in a rural health system. Am J Cardiol 2007; 100:944-8. [PMID: 17826374 DOI: 10.1016/j.amjcard.2007.04.031] [Citation(s) in RCA: 26] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/16/2007] [Revised: 04/17/2007] [Accepted: 04/17/2007] [Indexed: 01/22/2023]
Abstract
This study was conducted to evaluate door-to-treatment times before and after the implementation of a rapid triage and transfer system for patients with ST-elevation myocardial infarction transferred from community hospitals to a rural angioplasty center for primary percutaneous coronary intervention (PCI). The system was developed in late 2004 and implemented at a rural percutaneous coronary intervention center in early 2005. Helicopter transport was available for 97% of requests for transfer from community hospitals. All patients with ST-elevation myocardial infarction transferred during 2004 and 2005 (n=226) were evaluated with respect to presentation and treatment times. Time from community hospital presentation to wire crossing decreased during the study from 205 to 105 minutes (p=0.0001). One fourth of patients were treated <90 minutes after presentation, and 2/3 were treated in <120 minutes. In conclusion, the implementation of a rapid triage, transfer, and treatment protocol can achieve a significant shortening of presentation-to-treatment times. Efficient community hospitals working with an efficient angioplasty center can achieve presentation-to-wire crossing times of <90 minutes for some patients.
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Affiliation(s)
- James C Blankenship
- Department of Cardiology, Geisinger Medical Center, Danville, Pennsylvania, USA.
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Skelding KA, Hubbard CR. Spontaneous coronary artery dissection related to menstruation. J Invasive Cardiol 2007; 19:E174-7. [PMID: 17541143] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 05/15/2023]
Abstract
We present the case of a young woman who developed an acute onset of classic cardiac symptoms, but because of her age and lack of risk factors, had a significant delay in transfer for cardiac catheterization. She was found to have spontaneous dissection of the left coronary system, eventually requiring emergent bypass surgery. The patient had recently began her menstrual period, and we speculate that hormonal fluctuations contributed to this process. The role of hormonal influences on the coronary vasculature is not entirely understood, but the incidence of spontaneous coronary dissection is higher in women, and is usually related to changes in hormones such as pregnancy and oral contraceptive use. We review the literature on spontaneous coronary dissection, the influence of hormones on the vasculature, as well as diagnosis and treatment options.
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Affiliation(s)
- Kimberly A Skelding
- Department of Cardiology, Geisinger Medical Center, Danville, PA 17822, USA.
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Skelding KA, Best PJM, Bartholomew BA, Lennon RJ, O'Neill WW, Rihal CS. Validation of a predictive risk score for radiocontrast-induced nephropathy following percutaneous coronary intervention. J Invasive Cardiol 2007; 19:229-33. [PMID: 17476039] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 05/15/2023]
Abstract
OBJECTIVE We sought to externally validate the William Beaumont Hospital (WBH) risk score for radiocontrast-induced nephropathy (RCIN) following percutaneous coronary intervention (PCI). Background. RCIN is associated with increased mortality and morbidity following PCI and accounts for increased hospital costs and length of stay. METHODS A total of 4,814 PCI procedures were used for validation of the WBH risk score, using a >1.0 mg/dl increase in serum creatinine (Cr) as the definition of RCIN. Clinical and procedural details were identified within the Mayo Clinic PCI registry. Multiple imputation was used to impute values where missing. Five imputation sets were created and averaged to compute the final estimate. RESULTS Follow-up Cr was available in 3,213 (67%) of procedures and RCIN occurred in 1.9% of cases. Baseline Cr clearance was missing in 13%. All other risk factors used to calculate the risk score were missing in 25% of the procedures. The risk score has the ability to discriminate well between patients at low and high risk of post-PCI RCIN; c-statistic = 0.86. In-hospital mortality occurred in 6.6% (4/61) with RCIN vs. 1.2% (37/3152) without RCIN. The odds ratio for in-hospital mortality is 5.3 (95% CI, 1.9, 15.0; p = 0.002) for those with RCIN vs. those without. CONCLUSIONS The WBH risk score can identify patients at high and low risk of RCIN following PCI. Use of this risk score can identify patients at high risk of RCIN development and direct the use of preventative measures to the highest-risk population, improving patient outcome and prognosis.
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Affiliation(s)
- Kimberly A Skelding
- Division of Cardiology, Geisinger Medical Center, Danville, Pennsylvania, USA.
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Mehta L, Devlin W, McCullough PA, O'Neill WW, Skelding KA, Stone GW, Boura JA, Grines CL. Impact of body mass index on outcomes after percutaneous coronary intervention in patients with acute myocardial infarction. Am J Cardiol 2007; 99:906-10. [PMID: 17398181 DOI: 10.1016/j.amjcard.2006.11.038] [Citation(s) in RCA: 93] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/10/2006] [Revised: 11/06/2006] [Accepted: 11/06/2006] [Indexed: 12/11/2022]
Abstract
Obesity is a widespread problem, particularly in the cardiovascular disease population. Obese patients have a lower incidence of cardiovascular mortality after elective percutaneous coronary interventions (PCIs); however, there is a paucity of data in the acute myocardial infarction (AMI) setting. This study investigated the effects of body mass index (BMI) on outcomes after percutaneous coronary revascularization in patients with AMI. Patients were categorized into 3 groups based on their BMI, i.e., normal, overweight, or obese. Most patients undergoing primary PCI for AMI (70%) were overweight or obese. Obese patients were significantly younger and more often diabetic, hypertensive, and hyperlipidemic compared with other groups. Angiographically, there was no difference in presence of multivessel disease, final Thrombolysis In Myocardial Infarction grade 3 flow, and presence of thrombus or dissection. Mortality was significantly lower in the hospital at 6 and 12 months in the obese group. Multivariate analysis demonstrated age>70 years, final Thrombolysis In Myocardial Infarction grade<3 flow, history of peripheral vascular disease, and ejection fraction to be the strongest predictors of mortality at 12 months. In conclusion, our data show that obese patients with AMI have a lower risk for in-hospital, 6-month, and 12-month mortality and cardiovascular events than patients with a normal BMI.
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Affiliation(s)
- Laxmi Mehta
- Division of Cardiology, William Beaumont Hospital, Royal Oak, Michigan, and University of Miami, FL, USA.
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