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Rodriguez‐Valadez JM, Tahsin M, Masharani U, Park M, Hunink MGM, Yeboah J, Li L, Weber E, Berkalieva A, Avezaat L, Max W, Fleischmann KE, Ferket BS. Potential Mediators for Treatment Effects of Novel Diabetes Medications on Cardiovascular and Renal Outcomes: A Meta-Regression Analysis. J Am Heart Assoc 2024; 13:e032463. [PMID: 38362889 PMCID: PMC11010086 DOI: 10.1161/jaha.123.032463] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/06/2023] [Accepted: 11/30/2023] [Indexed: 02/17/2024]
Abstract
BACKGROUND Prior research suggests clinical effects of glucagon-like peptide-1 receptor agonists (GLP-1RAs) and sodium-glucose cotransporter-2 inhibitors (SGLT2is) are mediated by changes in glycated hemoglobin, body weight, systolic blood pressure, hematocrit, and urine albumin-creatinine ratio. We aimed to confirm these findings using a meta-analytic approach. METHODS AND RESULTS We updated a systematic review of 9 GLP-1RA and 13 SGLT2i trials and summarized longitudinal mediator data. We obtained hazard ratios (HRs) for cardiovascular, renal, and mortality outcomes. We performed linear mixed-effects modeling of LogHRs versus changes in potential mediators and investigated differences in meta-regression associations among drug classes using interaction terms. HRs generally became more protective with greater glycated hemoglobin reduction among GLP-1RA trials, with average HR improvements of 20% to 30%, reaching statistical significance for major adverse cardiovascular events (ΔHR, 23%; P=0.02). Among SGLT2i trials, associations with HRs were not significant and differed from GLP1-RA trials for major adverse cardiovascular events (Pinteraction=0.04). HRs for major adverse cardiovascular events, myocardial infarction, and stroke became less efficacious (ΔHR, -15% to -34%), with more weight loss for SGLT2i but not for GLP-1RA trials (ΔHR, 4%-7%; Pinteraction<0.05). Among 5 SGLT2i trials with available data, HRs for stroke became less efficacious with larger increases in hematocrit (ΔHR, 123%; P=0.09). No changes in HRs by systolic blood pressure (ΔHR, -11% to 9%) and urine albumin-creatinine ratio (ΔHR, -1% to 4%) were found for any outcome. CONCLUSIONS We confirmed increased efficacy findings for major adverse cardiovascular events with reduction in glycated hemoglobin for GLP1-RAs. Further research is needed on the potential loss of cardiovascular benefits with increased weight loss and hematocrit for SGLT2i.
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Affiliation(s)
- José M. Rodriguez‐Valadez
- Institute for Healthcare Delivery Science, Icahn School of Medicine at Mount SinaiNew YorkNYUSA
- Department of Population Health Science and Policy, Icahn School of Medicine at Mount SinaiNew YorkNYUSA
| | - Malak Tahsin
- Department of Population Health Science and Policy, Icahn School of Medicine at Mount SinaiNew YorkNYUSA
| | - Umesh Masharani
- Department of MedicineUniversity of CaliforniaSan FranciscoCAUSA
| | - Meyeon Park
- Department of MedicineUniversity of CaliforniaSan FranciscoCAUSA
- Division of NephrologyUniversity of CaliforniaSan FranciscoCAUSA
| | - M. G. Myriam Hunink
- Department of EpidemiologyErasmus MCRotterdamthe Netherlands
- Department of RadiologyErasmus MCRotterdamthe Netherlands
- Center for Health Decision Sciences, Harvard TH Chan School of Public HealthBostonMAUSA
| | - Joseph Yeboah
- Section of Cardiovascular Medicine, Internal MedicineWake Forest University School of MedicineWinston SalemNCUSA
| | - Lihua Li
- Institute for Healthcare Delivery Science, Icahn School of Medicine at Mount SinaiNew YorkNYUSA
- Department of Population Health Science and Policy, Icahn School of Medicine at Mount SinaiNew YorkNYUSA
| | - Ellerie Weber
- Department of Population Health Science and Policy, Icahn School of Medicine at Mount SinaiNew YorkNYUSA
| | - Asem Berkalieva
- Institute for Healthcare Delivery Science, Icahn School of Medicine at Mount SinaiNew YorkNYUSA
- Department of Population Health Science and Policy, Icahn School of Medicine at Mount SinaiNew YorkNYUSA
| | - Luuk Avezaat
- Department of EpidemiologyErasmus MCRotterdamthe Netherlands
| | - Wendy Max
- Institute for Health & Aging and Department of Social and Behavioral SciencesUniversity of CaliforniaSan FranciscoCAUSA
| | - Kirsten E. Fleischmann
- Department of MedicineUniversity of CaliforniaSan FranciscoCAUSA
- Division of CardiologyUniversity of CaliforniaSan FranciscoCAUSA
| | - Bart S. Ferket
- Institute for Healthcare Delivery Science, Icahn School of Medicine at Mount SinaiNew YorkNYUSA
- Department of Population Health Science and Policy, Icahn School of Medicine at Mount SinaiNew YorkNYUSA
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2
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Rodriguez-Valadez JM, Tahsin M, Fleischmann KE, Masharani U, Yeboah J, Park M, Li L, Weber E, Li Y, Berkalieva A, Max W, Hunink MM, Ferket BS. Cardiovascular and Renal Benefits of Novel Diabetes Drugs by Baseline Cardiovascular Risk: A Systematic Review, Meta-analysis, and Meta-regression. Diabetes Care 2023; 46:1300-1310. [PMID: 37220263 PMCID: PMC10234755 DOI: 10.2337/dc22-0772] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [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: 04/19/2022] [Accepted: 02/27/2023] [Indexed: 05/25/2023]
Abstract
BACKGROUND Eligibility for glucagon-like peptide 1 receptor agonists (GLP-1RA) and sodium-glucose cotransporter 2 inhibitors (SGLT2i) has been expanded to patients with diabetes at lower cardiovascular risk, but whether treatment benefits differ by risk levels is not clear. PURPOSE To investigate whether patients with varying risks differ in cardiovascular and renal benefits from GLP-1RA and SGLT2i with use of meta-analysis and meta-regression. DATA SOURCES We performed a systematic review using PubMed through 7 November 2022. STUDY SELECTION We included reports of GLP-1RA and SGLT2i confirmatory randomized trials in adult patients with safety or efficacy end point data. DATA EXTRACTION Hazard ratio (HR) and event rate data were extracted for mortality, cardiovascular, and renal outcomes. DATA SYNTHESIS We analyzed 9 GLP-1RA and 13 SGLT2i trials comprising 154,649 patients. Summary HRs were significant for cardiovascular mortality (GLP-1RA 0.87 and SGLT2i 0.86), major adverse cardiovascular events (0.87 and 0.88), heart failure (0.89 and 0.70), and renal (0.84 and 0.65) outcomes. For stroke, efficacy was significant for GLP-1RA (0.84) but not for SGLT2i (0.92). Associations between control arm cardiovascular mortality rates and HRs were nonsignificant. Five-year absolute risk reductions (0.80-4.25%) increased to 11.6% for heart failure in SGLT2i trials in patients with high risk (Pslope < 0.001). For GLP1-RAs, associations were nonsignificant. LIMITATIONS Analyses were limited by lack of patient-level data, consistency in end point definitions, and variation in cardiovascular mortality rates for GLP-1RA trials. CONCLUSIONS Relative effects of novel diabetes drugs are preserved across baseline cardiovascular risk, whereas absolute benefits increase at higher risks, particularly regarding heart failure. Our findings suggest a need for baseline risk assessment tools to identify variation in absolute treatment benefits and improve decision-making.
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Affiliation(s)
- José M. Rodriguez-Valadez
- Institute for Healthcare Delivery Science, Department of Population Health Science and Policy, Icahn School of Medicine at Mount Sinai, New York, NY
| | - Malak Tahsin
- Institute for Healthcare Delivery Science, Department of Population Health Science and Policy, Icahn School of Medicine at Mount Sinai, New York, NY
| | - Kirsten E. Fleischmann
- Division of Cardiology, Department of Medicine, University of California San Francisco, San Francisco, CA
| | - Umesh Masharani
- Department of Medicine, University of California, San Francisco, CA
| | - Joseph Yeboah
- Section of Cardiovascular Medicine, Internal Medicine, Wake Forest University School of Medicine, Winston Salem, NC
| | - Meyeon Park
- Department of Medicine, University of California, San Francisco, CA
| | - Lihua Li
- Institute for Healthcare Delivery Science, Department of Population Health Science and Policy, Icahn School of Medicine at Mount Sinai, New York, NY
| | - Ellerie Weber
- Department of Population Health Science and Policy, Icahn School of Medicine at Mount Sinai, New York, NY
| | - Yan Li
- Department of Population Health Science and Policy, Icahn School of Medicine at Mount Sinai, New York, NY
| | - Asem Berkalieva
- Institute for Healthcare Delivery Science, Department of Population Health Science and Policy, Icahn School of Medicine at Mount Sinai, New York, NY
| | - Wendy Max
- Institute for Health & Aging and Department of Social and Behavioral Sciences, University of California, San Francisco, CA
| | - M.G. Myriam Hunink
- Departments of Epidemiology and Radiology, Erasmus MC, Rotterdam, the Netherlands
- Center for Health Decision Science, Harvard T.H. Chan School of Public Health, Boston, MA
| | - Bart S. Ferket
- Institute for Healthcare Delivery Science, Department of Population Health Science and Policy, Icahn School of Medicine at Mount Sinai, New York, NY
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Suba S, Hoffmann TJ, Fleischmann KE, Schell-Chaple H, Marcus GM, Prasad P, Hu X, Badilini F, Pelter MM. Evaluation of premature ventricular complexes during in-hospital ECG monitoring as a predictor of ventricular tachycardia in an intensive care unit cohort. Res Nurs Health 2023. [PMID: 37127543 DOI: 10.1002/nur.22314] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/24/2022] [Revised: 03/17/2023] [Accepted: 04/15/2023] [Indexed: 05/03/2023]
Abstract
In-hospital electrocardiographic (ECG) monitors are typically configured to alarm for premature ventricular complexes (PVCs) due to the potential association of PVCs with ventricular tachycardia (VT). However, no contemporary hospital-based studies have examined the association of PVCs with VT. Hence, the benefit of PVC monitoring in hospitalized patients is largely unknown. This secondary analysis used a large PVC alarm data set to determine whether PVCs identified during continuous ECG monitoring were associated with VT, in-hospital cardiac arrest (IHCA), and/or death in a cohort of adult intensive care unit patients. Six PVC types were examined (i.e., isolated, bigeminy, trigeminy, couplets, R-on-T, and run PVCs) and were compared between patients with and without VT, IHCA, and/or death. Of 445 patients, 48 (10.8%) had VT; 11 (2.5%) had IHCA; and 49 (11%) died. Isolated and run PVC counts were higher in the VT group (p = 0.03 both), but group differences were not seen for the other four PVC types. The regression models showed no significant associations between any of the six PVC types and VT or death, although confidence intervals were wide. Due to the small number of cases, we were unable to test for associations between PVCs and IHCA. Our findings suggest that we should question the clinical relevance of activating PVC alarms as a forewarning of VT, and more work should be done with larger sample sizes. A more precise characterization of clinically relevant PVCs that might be associated with VT is warranted.
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Affiliation(s)
- Sukardi Suba
- School of Nursing, University of Rochester, Rochester, New York, USA
| | - Thomas J Hoffmann
- Department of Epidemiology and Biostatistics, School of Medicine, and Office of Research, School of Nursing, University of California, San Francisco (UCSF), San Francisco, California, USA
| | - Kirsten E Fleischmann
- Department of Medicine, School of Medicine, University of California, San Francisco, San Francisco, California, USA
| | - Hildy Schell-Chaple
- Center for Nursing Excellence & Innovation, UCSF Medical Center, San Francisco, California, USA
| | - Gregory M Marcus
- Department of Medicine, School of Medicine, University of California, San Francisco, San Francisco, California, USA
| | - Priya Prasad
- Department of Medicine, School of Medicine, University of California, San Francisco, San Francisco, California, USA
| | - Xiao Hu
- Nell Hodgson Woodruff School of Nursing, Biomedical Informatics, School of Medicine, and Computer Science, College of Arts and Sciences, Emory University, Atlanta, Georgia, USA
| | - Fabio Badilini
- Department of Physiological Nursing, Center for Physiologic Research, School of Nursing, University of California, San Francisco, San Francisco, California, USA
| | - Michele M Pelter
- Department of Physiological Nursing, Center for Physiologic Research, School of Nursing, University of California, San Francisco, San Francisco, California, USA
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Rodriguez Valadez JM, Tahsin M, Masharani U, Park M, Hunink MM, Yeboah J, Li L, Weber E, Li Y, Berkalieva A, Avezaat L, Max W, Fleischmann KE, Ferket BS. Abstract P140: Potential Mediators for Cardiovascular Benefits of Novel Diabetes Medications: A Meta-Regression Analysis. Circulation 2023. [DOI: 10.1161/circ.147.suppl_1.p140] [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: 03/15/2023]
Abstract
Background:
Prior research suggests cardiovascular (CV) benefits of glucose-lowering interventions may be mediated by changes in hemoglobin A1c (HbA1c), bodyweight, systolic blood pressure (SBP), hematocrit, and urine albumin-creatinine ratio (uACR). We evaluated the heterogeneity of CV benefits by these potential mediators for sodium-glucose transporter 2 inhibitors (SGLT2i) and glucagon-like peptide 1 receptor agonists (GLP-1RAs) using a meta-analytic approach.
Methods:
We performed a systematic review and meta-regression analyses of 12 SGLT2i and 9 GLP-1RA CV outcome trials using linear mixed models of treatment efficacy measured as log hazard ratios (HRs) vs changes in potential mediators. We extracted follow-up mediator data for treatment and control, preferably at 12 months post randomization. Outcomes included MI, stroke, and MACE (a composite of MI, stroke, or CV death). We investigated slope differences between drug classes using interaction terms and likelihood-ratio tests.
Results:
Treatment efficacy for MACE improved with more HbA1c reduction among GLP-1RA (slope .26; P
slope
.02) but not among SGLT2i trials (slope -.22; P
slope
.39; P
interaction
.06), see
Figure
. Treatment efficacy for MACE, MI, and stroke decreased with more weight loss for SGLT2i (slope –.17, –.29, –.39; P
slope
<.05) but not for GLP-1RA trials (slope .05, .03, .07; P
slope
.30, .62, .32). Slopes differed significantly between drug classes: P
interaction
<.05. For stroke, we observed a trend of less treatment efficacy with increases in hematocrit among five SGLT2i trials with available data (slope .96; P
slope
.07). We did not find any indication of mediation effects by SBP and uACR for SGLT2i or GLP-1RAs (slopes -.11 -.07; P
slopes
≥ .05).
Conclusion:
We confirm previous findings of increased CV benefits with reductions in HbA1c for GLP1-RAs. Further research is needed to investigate the potential loss of SGLT2i efficacy with greater weight loss and increase in hematocrit.
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Affiliation(s)
| | | | | | | | | | | | - Lihua Li
- Icahn Sch of Medicine at MtSinai, NYC, NY
| | | | - Yan Li
- Icahn Sch of Medicine at MtSinai, New York, NY
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Suba S, Hoffmann TJ, Fleischmann KE, Schell-Chaple H, Prasad P, Marcus GM, Badilini F, Hu X, Pelter MM. Premature ventricular complexes during continuous electrocardiographic monitoring in the intensive care unit: Occurrence rates and associated patient characteristics. J Clin Nurs 2022. [PMID: 35712789 DOI: 10.1111/jocn.16408] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2022] [Revised: 03/25/2022] [Accepted: 06/01/2022] [Indexed: 11/27/2022]
Abstract
AIMS AND OBJECTIVES This study examined the occurrence rate of specific types of premature ventricular complex (PVC) alarms and whether patient demographic and/or clinical characteristics were associated with PVC occurrences. BACKGROUND Because PVCs can signal myocardial irritability, in-hospital electrocardiographic (ECG) monitors are typically configured to alert nurses when they occur. However, PVC alarms are common and can contribute to alarm fatigue. A better understanding of occurrences of PVCs could help guide alarm management strategies. DESIGN A secondary quantitative analysis from an alarm study. METHODS The Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) checklist was followed. Seven PVC alarm types (vendor-specific) were described, and included isolated, couplet, bigeminy, trigeminy, run PVC (i.e. VT >2), R-on-T and PVCs/min. Negative binomial and hurdle regression analyses were computed to examine the association of patient demographic and clinical characteristics with each PVC type. RESULTS A total of 797,072 PVC alarms (45,271 monitoring hours) occurred in 446 patients, including six who had disproportionately high PVC alarm counts (40% of the total alarms). Isolated PVCs were the most frequent type (81.13%) while R-on-T were the least common (0.29%). Significant predictors associated with higher alarms rates: older age (isolated PVCs, bigeminy and couplets); male sex and presence of PVCs on the 12-lead ECG (isolated PVCs). Hyperkalaemia at ICU admission was associated with a lower R-on-T type PVCs. CONCLUSIONS Only a few distinct demographic and clinical characteristics were associated with the occurrence rate of PVC alarms. Further research is warranted to examine whether PVCs were associated with adverse outcomes, which could guide alarm management strategies to reduce unnecessary PVC alarms. RELEVANCE TO CLINICAL PRACTICE Targeted alarm strategies, such as turning off certain PVC-type alarms and evaluating alarm trends in the first 24 h of admission in select patients, might add to the current practice of alarm management.
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Affiliation(s)
- Sukardi Suba
- School of Nursing, University of Rochester, Rochester, New York, USA
| | - Thomas J Hoffmann
- Department of Epidemiology and Biostatistics, School of Medicine, and Office of Research, School of Nursing, University of California, San Francisco (UCSF), San Francisco, California, USA
| | | | - Hildy Schell-Chaple
- Center for Nursing Excellence & Innovation, UCSF Medical Center, San Francisco, California, USA
| | - Priya Prasad
- Department of Medicine, School of Medicine, UCSF, San Francisco, California, USA
| | - Gregory M Marcus
- Department of Medicine, School of Medicine, UCSF, San Francisco, California, USA
| | - Fabio Badilini
- Department of Physiological Nursing, School of Nursing, UCSF, San Francisco, California, USA
| | - Xiao Hu
- School of Nursing, Emory University, Atlanta, Georgia, USA
| | - Michele M Pelter
- Department of Physiological Nursing, School of Nursing, UCSF, San Francisco, California, USA
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Ferket BS, Hunink MM, Masharani U, Max W, Yeboah J, Burke GL, Fleischmann KE. Lifetime Cardiovascular Disease Risk by Coronary Artery Calcium Score in Individuals With and Without Diabetes: An Analysis From the Multi-Ethnic Study of Atherosclerosis. Diabetes Care 2022; 45:975-982. [PMID: 35168253 PMCID: PMC9114718 DOI: 10.2337/dc21-1607] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/02/2021] [Accepted: 01/24/2022] [Indexed: 02/03/2023]
Abstract
OBJECTIVE To assess lifetime cardiovascular disease (CVD) risk by coronary artery calcium (CAC) score in individuals with diabetes from the Multi-Ethnic Study of Atherosclerosis (MESA) and compare risk with that in individuals without diabetes. RESEARCH DESIGN AND METHODS We developed a microsimulation model with well, diabetes, post-CVD, and death health states using multivariable time-dependent Cox regression with age as time scale. We initially used 10-year follow-up data of 6,769 MESA participants, including coronary heart disease (CHD) (n = 272), heart failure (n = 201), stroke (n = 186), and competing death (n = 619) and assessed predictive validity at 15 years. We externally validated the model in matched National Health and Nutrition Examination Survey (NHANES) participants. Subsequently, we predicted CVD risk until age 100 years by diabetes, 10-year pooled cohort equations risk, and CAC score category (0, 1-100, or 100+). RESULTS The model showed good calibration and discriminative performance at 15 years, with discrimination indices 0.71-0.78 across outcomes. In the NHANES cohort, predicted 15-year mortality risk corresponded well with Kaplan-Meier risk, especially for those with diabetes: 29.6% (95% CI 24.9-34.8) vs. 32.4% (95% CI 27.2-37.2), respectively. Diabetes increased lifetime CVD risk, similar to shifting one CAC category upward (from 0 to 1-100 or from 1-100 to 100+). Patients with diabetes and CAC score of 0 had a lifetime CVD risk that overlapped with that of individuals without diabetes who were at low 10-year pooled cohort equations risk (<7.5%). CONCLUSIONS Patients with diabetes carry a spectrum of CVD risk. CAC scoring may improve decisions for preventive interventions for patients with diabetes by better delineating lifetime CVD risk.
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Affiliation(s)
- Bart S. Ferket
- Department of Population Health Science and Policy, Icahn School of Medicine at Mount Sinai, New York, NY
| | - M.G. Myriam Hunink
- Departments of Epidemiology and Radiology, Erasmus University Medical Center, Rotterdam, the Netherlands
- Center for Health Decision Sciences, Harvard T.H. Chan School of Public Health, Boston, MA
| | - Umesh Masharani
- Department of Medicine, University of California San Francisco, San Francisco, CA
| | - Wendy Max
- Institute for Health & Aging and Department of Social and Behavioral Sciences, University of California San Francisco, San Francisco, CA
| | - Joseph Yeboah
- Heart and Vascular Center of Excellence, Wake Forest Baptist Health, Winston Salem, NC
| | - Gregory L. Burke
- Division of Public Health, Wake Forest School of Medicine, Winston Salem, NC
| | - Kirsten E. Fleischmann
- Division of Cardiology, Department of Medicine, University of California San Francisco, San Francisco, CA
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Ferket BS, Hunink MGM, Masharani U, Max W, Yeboah J, Fleischmann KE. Long-term Predictions of Incident Coronary Artery Calcium to 85 Years of Age for Asymptomatic Individuals With and Without Type 2 Diabetes. Diabetes Care 2021; 44:1664-1671. [PMID: 34078663 DOI: 10.2337/dc20-1960] [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] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/05/2020] [Accepted: 03/29/2021] [Indexed: 02/03/2023]
Abstract
OBJECTIVE To examine the utility of repeated computed tomography (CT) coronary artery calcium (CAC) testing, we assessed risks of detectable CAC and its cardiovascular consequences in individuals with and without type 2 diabetes ages 45-85 years. RESEARCH DESIGN AND METHODS We included 5,836 individuals (618 with type 2 diabetes, 2,972 without baseline CAC) from the Multi-Ethnic Study of Atherosclerosis. With logistic and Cox regression we evaluated the impact of type 2 diabetes, diabetes treatment duration, and other predictors on prevalent and incident CAC. We used time-dependent Cox modeling of follow-up data (median 15.9 years) for two repeat CT exams and cardiovascular events to assess the association of CAC at follow-up CT with cardiovascular events. RESULTS For 45 year olds with type 2 diabetes, the likelihood of CAC at baseline was 23% vs. 17% for those without. Median age at incident CAC was 52.2 vs. 62.3 years for those with and without diabetes, respectively. Each 5 years of diabetes treatment increased the odds and hazard rate of CAC by 19% (95% CI 8-33) and 22% (95% CI 6-41). Male sex, White ethnicity/race, hypertension, hypercholesterolemia, obesity, and low serum creatinine also increased CAC. CAC at follow-up CT independently increased coronary heart disease rates. CONCLUSIONS We estimated cumulative CAC incidence to age 85 years. Patients with type 2 diabetes develop CAC at a younger age than those without diabetes. Because incident CAC is associated with increased coronary heart disease risk, the value of periodic CAC-based risk assessment in type 2 diabetes should be evaluated.
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Affiliation(s)
- Bart S Ferket
- Department of Population Health Science and Policy, Icahn School of Medicine at Mount Sinai, New York, NY
| | - M G Myriam Hunink
- Departments of Epidemiology and Radiology, Erasmus MC, Rotterdam, the Netherlands.,Center for Health Decision Science, Harvard T.H. Chan School of Public Health, Harvard University, Boston, MA
| | - Umesh Masharani
- Department of Medicine, University of California San Francisco, San Francisco, CA
| | - Wendy Max
- Institute for Health & Aging and Department of Social and Behavioral Sciences, University of California San Francisco, San Francisco, CA
| | - Joseph Yeboah
- Heart and Vascular Center of Excellence, Wake Forest Baptist Health, Winston Salem, NC
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Morey JR, Jiang S, Klein S, Max W, Masharani U, Fleischmann KE, Hunink MGM, Ferket BS. Estimating Long-Term Health Utility Scores and Expenditures for Cardiovascular Disease From the Medical Expenditure Panel Survey. Circ Cardiovasc Qual Outcomes 2021; 14:e006769. [PMID: 33761758 DOI: 10.1161/circoutcomes.120.006769] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND Long-term health utility scores and costs used in cost-effectiveness analyses of cardiovascular disease prevention and management can be inconsistent, outdated, or invalid for the diverse population of the United States. Our aim was to develop a user friendly, standardized, publicly available code and catalog to derive more valid long-term values for health utility and expenditures following cardiovascular disease events. METHODS Individual-level Short Form-12 version 2 health-related quality of life and expenditure data were obtained from the pooled 2011 to 2016 Medical Expenditure Panel Surveys. We developed code using the R programming language to estimate preference-weighted Short Form-6D utility scores from the Short Form-12 for quality-adjusted life year calculations and predict annual health care expenditures. Result predictors included cardiovascular disease diagnosis (myocardial infarction, ischemic stroke, heart failure, cardiac dysrhythmias, angina pectoris, and peripheral artery disease), sociodemographic factors, and comorbidity variables. RESULTS The cardiovascular disease diagnoses with the lowest utility scores were heart failure (0.635 [95% CI, 0.615-0.655]), angina pectoris (0.649 [95% CI, 0.630-0.667]), and ischemic stroke (0.649 [95% CI, 0.635-0.663]). The highest annual expenditures were for heart failure ($20 764 [95% CI, $17 500-$24 027]), angina pectoris ($18 428 [95% CI, $16 102-$20 754]), and ischemic stroke ($16 925 [95% CI, $15 672-$20 616]). CONCLUSIONS The developed code and catalog may improve the quality and comparability of cost-effectiveness analyses by providing standardized methods for extracting long-term health utility scores and expenditures from Medical Expenditure Panel Survey data, which are more current and representative of the US population than previous sources.
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Affiliation(s)
- Jacob R Morey
- Department of Population Health Science and Policy, Icahn School of Medicine at Mount Sinai, New York, NY (J.R.M., B.S.F.)
| | - Shangqing Jiang
- The Comparative Health Outcomes, Policy and Economics (CHOICE) Institute, University of Washington, Seattle (S.J.)
| | - Sharon Klein
- Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, East Garden City, NY (S.K.)
| | - Wendy Max
- Institute for Health and Aging and Department of Social and Behavioral Sciences (W.M.), University of California, San Francisco
| | - Umesh Masharani
- Department of Medicine (U.M., K.E.F.), University of California, San Francisco
| | | | - M G Myriam Hunink
- Departments of Epidemiology and Radiology, Erasmus MC, Rotterdam, the Netherlands (M.G.M.H.).,Center for Health Decision Science, Harvard T.H. Chan School of Public Health, Harvard University, Boston, MA (M.G.M.H.)
| | - Bart S Ferket
- Department of Population Health Science and Policy, Icahn School of Medicine at Mount Sinai, New York, NY (J.R.M., B.S.F.)
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Psotka MA, Rushakoff J, Glantz SA, De Marco T, Fleischmann KE. The Association Between Secondhand Smoke Exposure and Survival for Patients With Heart Failure. J Card Fail 2020; 26:745-750. [DOI: 10.1016/j.cardfail.2019.12.008] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2019] [Revised: 11/27/2019] [Accepted: 12/17/2019] [Indexed: 11/29/2022]
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Zhang J, Gajjala S, Agrawal P, Tison GH, Hallock LA, Beussink-Nelson L, Lassen MH, Fan E, Aras MA, Jordan C, Fleischmann KE, Melisko M, Qasim A, Shah SJ, Bajcsy R, Deo RC. Fully Automated Echocardiogram Interpretation in Clinical Practice. Circulation 2018; 138:1623-1635. [PMID: 30354459 PMCID: PMC6200386 DOI: 10.1161/circulationaha.118.034338] [Citation(s) in RCA: 415] [Impact Index Per Article: 69.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/14/2018] [Accepted: 08/07/2018] [Indexed: 02/01/2023]
Abstract
BACKGROUND Automated cardiac image interpretation has the potential to transform clinical practice in multiple ways, including enabling serial assessment of cardiac function by nonexperts in primary care and rural settings. We hypothesized that advances in computer vision could enable building a fully automated, scalable analysis pipeline for echocardiogram interpretation, including (1) view identification, (2) image segmentation, (3) quantification of structure and function, and (4) disease detection. METHODS Using 14 035 echocardiograms spanning a 10-year period, we trained and evaluated convolutional neural network models for multiple tasks, including automated identification of 23 viewpoints and segmentation of cardiac chambers across 5 common views. The segmentation output was used to quantify chamber volumes and left ventricular mass, determine ejection fraction, and facilitate automated determination of longitudinal strain through speckle tracking. Results were evaluated through comparison to manual segmentation and measurements from 8666 echocardiograms obtained during the routine clinical workflow. Finally, we developed models to detect 3 diseases: hypertrophic cardiomyopathy, cardiac amyloid, and pulmonary arterial hypertension. RESULTS Convolutional neural networks accurately identified views (eg, 96% for parasternal long axis), including flagging partially obscured cardiac chambers, and enabled the segmentation of individual cardiac chambers. The resulting cardiac structure measurements agreed with study report values (eg, median absolute deviations of 15% to 17% of observed values for left ventricular mass, left ventricular diastolic volume, and left atrial volume). In terms of function, we computed automated ejection fraction and longitudinal strain measurements (within 2 cohorts), which agreed with commercial software-derived values (for ejection fraction, median absolute deviation=9.7% of observed, N=6407 studies; for strain, median absolute deviation=7.5%, n=419, and 9.0%, n=110) and demonstrated applicability to serial monitoring of patients with breast cancer for trastuzumab cardiotoxicity. Overall, we found automated measurements to be comparable or superior to manual measurements across 11 internal consistency metrics (eg, the correlation of left atrial and ventricular volumes). Finally, we trained convolutional neural networks to detect hypertrophic cardiomyopathy, cardiac amyloidosis, and pulmonary arterial hypertension with C statistics of 0.93, 0.87, and 0.85, respectively. CONCLUSIONS Our pipeline lays the groundwork for using automated interpretation to support serial patient tracking and scalable analysis of millions of echocardiograms archived within healthcare systems.
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Affiliation(s)
- Jeffrey Zhang
- Cardiovascular Research Institute (J.Z., R.C.D.)
- Department of Electrical Engineering and Computer Science, University of California, Berkeley (J.Z., P.A., L.A.H., R.B.)
| | | | - Pulkit Agrawal
- Department of Electrical Engineering and Computer Science, University of California, Berkeley (J.Z., P.A., L.A.H., R.B.)
| | - Geoffrey H. Tison
- Department of Medicine (G.H.T., M.H.L., E.F., M.A.A., C.J., K.E.F., R.C.D.)
| | - Laura A. Hallock
- Department of Electrical Engineering and Computer Science, University of California, Berkeley (J.Z., P.A., L.A.H., R.B.)
| | - Lauren Beussink-Nelson
- Department of Medicine, Division of Cardiology, Feinberg Cardiovascular Research Institute, Northwestern University Feinberg School of Medicine, Chicago, IL (L.B.-N., M.M., A.Q., S.J.S.)
| | - Mats H. Lassen
- Department of Medicine (G.H.T., M.H.L., E.F., M.A.A., C.J., K.E.F., R.C.D.)
| | - Eugene Fan
- Department of Medicine (G.H.T., M.H.L., E.F., M.A.A., C.J., K.E.F., R.C.D.)
| | - Mandar A. Aras
- Department of Medicine (G.H.T., M.H.L., E.F., M.A.A., C.J., K.E.F., R.C.D.)
| | - ChaRandle Jordan
- Department of Medicine (G.H.T., M.H.L., E.F., M.A.A., C.J., K.E.F., R.C.D.)
| | | | - Michelle Melisko
- Department of Medicine, Division of Cardiology, Feinberg Cardiovascular Research Institute, Northwestern University Feinberg School of Medicine, Chicago, IL (L.B.-N., M.M., A.Q., S.J.S.)
| | - Atif Qasim
- Department of Medicine, Division of Cardiology, Feinberg Cardiovascular Research Institute, Northwestern University Feinberg School of Medicine, Chicago, IL (L.B.-N., M.M., A.Q., S.J.S.)
| | - Sanjiv J. Shah
- Department of Medicine, Division of Cardiology, Feinberg Cardiovascular Research Institute, Northwestern University Feinberg School of Medicine, Chicago, IL (L.B.-N., M.M., A.Q., S.J.S.)
| | - Ruzena Bajcsy
- Department of Electrical Engineering and Computer Science, University of California, Berkeley (J.Z., P.A., L.A.H., R.B.)
| | - Rahul C. Deo
- Cardiovascular Research Institute (J.Z., R.C.D.)
- Department of Medicine (G.H.T., M.H.L., E.F., M.A.A., C.J., K.E.F., R.C.D.)
- Institute for Human Genetics (R.C.D.)
- Institute for Computational Health Sciences (R.C.D.)
- Center for Digital Health Innovation (R.C.D.)
- California Institute for Quantitative Biosciences, San Francisco (R.C.D.)
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11
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Sha SJ, Miller ZA, Min SW, Zhou Y, Brown J, Mitic LL, Karydas A, Koestler M, Tsai R, Corbetta-Rastelli C, Lin S, Hare E, Fields S, Fleischmann KE, Powers R, Fitch R, Martens LH, Shamloo M, Fagan AM, Farese RV, Pearlman R, Seeley W, Miller BL, Gan L, Boxer AL. An 8-week, open-label, dose-finding study of nimodipine for the treatment of progranulin insufficiency from GRN gene mutations. Alzheimers Dement (N Y) 2017; 3:507-512. [PMID: 29124108 PMCID: PMC5671622 DOI: 10.1016/j.trci.2017.08.002] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
Introduction Frontotemporal lobar degeneration-causing mutations in the progranulin (GRN) gene reduce progranulin protein (PGRN) levels, suggesting that restoring PGRN in mutation carriers may be therapeutic. Nimodipine, a Food and Drug Administration-approved blood-brain barrier-penetrant calcium channel blocker, increased PGRN levels in PGRN-deficient murine models. We sought to assess safety and tolerability of oral nimodipine in human GRN mutation carriers. Methods We performed an open-label, 8-week, dose-finding, phase 1 clinical trial in eight GRN mutation carriers to assess the safety and tolerability of nimodipine and assayed fluid and radiologic markers to investigate therapeutic endpoints. Results There were no serious adverse events; however, PGRN concentrations (cerebrospinal fluid and plasma) did not change significantly following treatment (percent changes of -5.2 ± 10.9% in plasma and -10.2 ± 7.8% in cerebrospinal fluid). Measurable atrophy within the left middle frontal gyrus was observed over an 8-week period. Discussion While well tolerated, nimodipine treatment did not alter PGRN concentrations or secondary outcomes.
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Affiliation(s)
- Sharon J Sha
- Memory and Aging Center, Department of Neurology, UCSF Weill Institute for Neurosciences, University of California, San Francisco, San Francisco, CA
| | - Zachary A Miller
- Memory and Aging Center, Department of Neurology, UCSF Weill Institute for Neurosciences, University of California, San Francisco, San Francisco, CA
| | - Sang-Won Min
- Gladstone Institute of Neurodegenerative Disease, San Francisco, CA
| | - Yungui Zhou
- Gladstone Institute of Neurodegenerative Disease, San Francisco, CA
| | - Jesse Brown
- Memory and Aging Center, Department of Neurology, UCSF Weill Institute for Neurosciences, University of California, San Francisco, San Francisco, CA
| | - Laura L Mitic
- Memory and Aging Center, Department of Neurology, UCSF Weill Institute for Neurosciences, University of California, San Francisco, San Francisco, CA.,Bluefield Project to Cure Frontotemporal Dementia, San Francisco, CA
| | - Anna Karydas
- Memory and Aging Center, Department of Neurology, UCSF Weill Institute for Neurosciences, University of California, San Francisco, San Francisco, CA
| | - Mary Koestler
- Memory and Aging Center, Department of Neurology, UCSF Weill Institute for Neurosciences, University of California, San Francisco, San Francisco, CA
| | - Richard Tsai
- Memory and Aging Center, Department of Neurology, UCSF Weill Institute for Neurosciences, University of California, San Francisco, San Francisco, CA
| | - Chiara Corbetta-Rastelli
- Memory and Aging Center, Department of Neurology, UCSF Weill Institute for Neurosciences, University of California, San Francisco, San Francisco, CA
| | - Sophie Lin
- Memory and Aging Center, Department of Neurology, UCSF Weill Institute for Neurosciences, University of California, San Francisco, San Francisco, CA
| | - Emma Hare
- Memory and Aging Center, Department of Neurology, UCSF Weill Institute for Neurosciences, University of California, San Francisco, San Francisco, CA
| | - Scott Fields
- Investigational Drug Service, UCSF Medical Center, San Francisco, CA
| | - Kirsten E Fleischmann
- Division of Cardiology, University of California, School of Medicine, San Francisco, CA
| | - Ryan Powers
- Memory and Aging Center, Department of Neurology, UCSF Weill Institute for Neurosciences, University of California, San Francisco, San Francisco, CA
| | - Ryan Fitch
- Memory and Aging Center, Department of Neurology, UCSF Weill Institute for Neurosciences, University of California, San Francisco, San Francisco, CA
| | | | - Mehrdad Shamloo
- Institute for Neuro-Innovation and Translational Neurosciences, Stanford, CA
| | - Anne M Fagan
- Alzheimer's Disease Research Center, Washington University School of Medicine, St. Louis, MO
| | - Robert V Farese
- Gladstone Institute of Cardiovascular Disease, San Francisco, CA
| | - Rodney Pearlman
- Bluefield Project to Cure Frontotemporal Dementia, San Francisco, CA
| | - William Seeley
- Memory and Aging Center, Department of Neurology, UCSF Weill Institute for Neurosciences, University of California, San Francisco, San Francisco, CA
| | - Bruce L Miller
- Memory and Aging Center, Department of Neurology, UCSF Weill Institute for Neurosciences, University of California, San Francisco, San Francisco, CA
| | - Li Gan
- Gladstone Institute of Neurodegenerative Disease, San Francisco, CA
| | - Adam L Boxer
- Memory and Aging Center, Department of Neurology, UCSF Weill Institute for Neurosciences, University of California, San Francisco, San Francisco, CA
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12
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Lee JS, Gonzales R, Vittinghoff E, Corbett KK, Fleischmann KE, Sehgal N, Auerbach AD. Appropriate Reconciliation of Cardiovascular Medications After Elective Surgery and Postdischarge Acute Hospital and Ambulatory Visits. J Hosp Med 2017; 12:723-730. [PMID: 28914276 DOI: 10.12788/jhm.2808] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
OBJECTIVE To describe appropriate discharge reconciliation of cardiovascular medications and assess associations with postdischarge healthcare utilization in surgical patients. DESIGN Retrospective cohort study from January 2007 to December 2011. SETTING An academic medical center. PATIENTS Seven hundred and fifty-two adults undergoing elective noncardiac surgery and taking antiplatelet agents, beta-blockers, renin-angiotensin system inhibitors, or statin lipid-lowering agents before surgery. MEASUREMENTS Primary predictor: appropriate discharge reconciliation of preoperative cardiovascular medications (continuation without documented contraindications). Primary outcomes: acute hospital visits (emergency department visits or hospitalizations) and unplanned ambulatory visits (primary care or surgical) at 30 days after surgery. RESULTS Preoperative medications were appropriately reconciled in 436 (58.0%) patients. For individual medications, appropriate discharge reconciliation occurred for 156 of the 327 patients on antiplatelet agents (47.7%), 507 of the 624 patients on beta-blockers (81.3%), 259 of the 361 patients on renin-angiotensin system inhibitors (71.8%), and 302 of the 406 patients on statins (74.4%). In multivariable analyses, appropriate reconciliation of all preoperative medications was not associated with acute hospital (adjusted odds ratio [AOR], 0.94; 95% confidence interval [CI], 0.63-1.41) or unplanned ambulatory visits (AOR, 1.48; 95% CI, 0.94-2.35). Appropriate reconciliation of statin therapy was associated with lower odds of acute hospital visits (AOR, 0.47; 95% CI, 0.26-0.85). There were no other statistically significant associations between appropriate reconciliation of individual medications and either outcome. CONCLUSIONS Although large gaps in appropriate discharge reconciliation of chronic cardiovascular medications were common in patients undergoing elective surgery, these gaps were not consistently associated with postdischarge acute hospital or ambulatory visits.
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Affiliation(s)
- Jonathan S Lee
- Division of General Internal Medicine, University of California San Francisco, San Francisco, California, USA.
| | - Ralph Gonzales
- Division of General Internal Medicine, University of California San Francisco, San Francisco, California, USA
| | - Eric Vittinghoff
- Department of Epidemiology and Biostatistics, University of California San Francisco, San Francisco, California, USA
| | - Kitty K Corbett
- School of Public Health and Health Systems, University of Waterloo, Waterloo, Ontario, Canada
| | - Kirsten E Fleischmann
- Division of Cardiology, University of California San Francisco, San Francisco, California, USA
| | - Neil Sehgal
- Division of Hospital Medicine, University of California San Francisco, San Francisco, California, USA
| | - Andrew D Auerbach
- Division of Hospital Medicine, University of California San Francisco, San Francisco, California, USA
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Ferket BS, Hunink MGM, Khanji M, Agarwal I, Fleischmann KE, Petersen SE. Cost-effectiveness of the polypill versus risk assessment for prevention of cardiovascular disease. Heart 2017; 103:483-491. [PMID: 28077465 DOI: 10.1136/heartjnl-2016-310529] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/27/2016] [Revised: 11/29/2016] [Accepted: 12/02/2016] [Indexed: 02/01/2023] Open
Abstract
OBJECTIVE There is an international trend towards recommending medication to prevent cardiovascular disease (CVD) in individuals at increasingly lower cardiovascular risk. We assessed the cost-effectiveness of a population approach with a polypill including a statin (simvastatin 20 mg) and three antihypertensive agents (amlodipine 2.5 mg, losartan 25 mg and hydrochlorothiazide 12.5 mg) and periodic risk assessment with different risk thresholds. METHODS We developed a microsimulation model for lifetime predictions of CVD events, diabetes, and death in 259 146 asymptomatic UK Biobank participants aged 40-69 years. We assessed incremental costs and quality-adjusted life-years (QALYs) for polypill scenarios with the same combination of agents and doses but differing for starting age, and periodic risk assessment with 10-year CVD risk thresholds of 10% and 20%. RESULTS Restrictive risk assessment, in which statins and antihypertensives were prescribed when risk exceeded 20%, was the optimal strategy gaining 123 QALYs (95% credible interval (CI) -173 to 387) per 10 000 individuals at an extra cost of £1.45 million (95% CI 0.89 to 1.94) as compared with current practice. Although less restrictive risk assessment and polypill scenarios prevented more CVD events and attained larger survival gains, these benefits were offset by the additional costs and disutility of daily medication use. Lowering the risk threshold for prescription of statins to 10% was economically unattractive, costing £40 000 per QALY gained. Starting the polypill from age 60 onwards became the most cost-effective scenario when annual drug prices were reduced below £240. All polypill scenarios would save costs at prices below £50. CONCLUSIONS Periodic risk assessment using lower risk thresholds is unlikely to be cost-effective. The polypill would become cost-effective if drug prices were reduced.
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Affiliation(s)
- Bart S Ferket
- Department of Population Health Science and Policy, Institute for Healthcare Delivery Science, Icahn School of Medicine at Mount Sinai, New York, New York, USA.,Department of Epidemiology, Erasmus MC, Rotterdam, The Netherlands.,Department of Radiology, Erasmus MC, Rotterdam, The Netherlands
| | - M G Myriam Hunink
- Department of Epidemiology, Erasmus MC, Rotterdam, The Netherlands.,Department of Radiology, Erasmus MC, Rotterdam, The Netherlands.,Center for Health Decision Science, Harvard T.H. Chan School of Public Health, Boston, Massachusetts, USA
| | - Mohammed Khanji
- William Harvey Research Institute and NIHR Cardiovascular Biomedical Research Unit at Barts, Queen Mary University of London, London, UK
| | - Isha Agarwal
- Department of Epidemiology, Harvard T.H. Chan School of Public Health, Boston, Massachusetts, USA
| | | | - Steffen E Petersen
- William Harvey Research Institute and NIHR Cardiovascular Biomedical Research Unit at Barts, Queen Mary University of London, London, UK
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14
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Hunink MGM, Fleischmann KE. The Role of Randomized and Nonrandomized Studies in Evaluating Diagnostic Strategies. Ann Intern Med 2016; 165:61-62. [PMID: 27159031 DOI: 10.7326/m16-0811] [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: 11/22/2022] Open
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15
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van Waardhuizen CN, Khanji MY, Genders TS, Ferket BS, Fleischmann KE, Hunink MM, Petersen SE. Comparative cost-effectiveness of non-invasive imaging tests in patients presenting with chronic stable chest pain with suspected coronary artery disease: a systematic review. Eur Heart J Qual Care Clin Outcomes 2016; 2:245-260. [DOI: 10.1093/ehjqcco/qcw029] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/21/2016] [Accepted: 05/27/2016] [Indexed: 02/05/2023]
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16
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van Kempen BJH, Ferket BS, Steyerberg EW, Max W, Myriam Hunink MG, Fleischmann KE. Comparing the cost-effectiveness of four novel risk markers for screening asymptomatic individuals to prevent cardiovascular disease (CVD) in the US population. Int J Cardiol 2015; 203:422-31. [PMID: 26547049 DOI: 10.1016/j.ijcard.2015.10.171] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/16/2015] [Revised: 10/17/2015] [Accepted: 10/19/2015] [Indexed: 10/22/2022]
Abstract
BACKGROUND High sensitivity CRP (hsCRP), coronary artery calcification on CT (CT calcium), carotid artery intima media thickness on ultrasound (cIMT) and ankle-brachial index (ABI) improve prediction of cardiovascular disease (CVD) risk, but the benefit of screening with these novel risk markers in the U.S. population is unclear. METHODS AND RESULTS A microsimulation model evaluating lifelong cost-effectiveness for individuals aged 40-85 at intermediate risk of CVD, using 2003-2004 NHANES-III (N=3736), Framingham Heart Study, U.S. Vital Statistics, meta-analyses of independent predictive effects of the four novel risk markers and treatment effects was constructed. Using both an intention-to-treat (assumes adherence <100% and incorporates disutility from taking daily medications) and an as-treated (100% adherence and no disutility) analysis, quality adjusted life years (QALYs), lifetime costs (2014 US $), and incremental cost-effectiveness ratios (ICER in $/QALY gained) of screening with hsCRP, CT coronary calcium, cIMT and ABI were established compared with current practice, full adherence to current guidelines, and ubiquitous statin therapy. In the intention-to-treat analysis in men, screening with CT calcium was cost effective ($32,900/QALY) compared with current practice. In women, screening with hsCRP was cost effective ($32,467/QALY). In the as-treated analysis, statin therapy was both more effective and less costly than all other strategies for both men and women. CONCLUSIONS When a substantial disutility from taking daily medication is assumed, screening men with CT coronary calcium is likely to be cost-effective whereas screening with hsCRP has value in women. The individual perceived disutility for taking daily medication should play a key role in the decision.
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Affiliation(s)
- Bob J H van Kempen
- Department of Epidemiology, Erasmus MC, Rotterdam, The Netherlands; Department of Radiology, Erasmus MC, Rotterdam, The Netherlands
| | - Bart S Ferket
- Department of Population Health Science and Policy, Icahn School of Medicine at Mount Sinai, USA
| | | | - Wendy Max
- Institute for Health & Aging and Department of Social and Behavioral Sciences, University of California, San Francisco, CA, USA
| | - M G Myriam Hunink
- Department of Epidemiology, Erasmus MC, Rotterdam, The Netherlands; Department of Radiology, Erasmus MC, Rotterdam, The Netherlands; Department of Health Policy and Management, Harvard School of Public Health, Boston, MA, USA.
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17
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Jamé S, Wittenberg E, Potter MB, Fleischmann KE. The new lipid guidelines: what do primary care clinicians think? Am J Med 2015; 128:914.e5-914.e10. [PMID: 25837518 PMCID: PMC4664185 DOI: 10.1016/j.amjmed.2015.02.013] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.8] [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: 11/18/2014] [Revised: 02/18/2015] [Accepted: 02/22/2015] [Indexed: 11/27/2022]
Abstract
BACKGROUND Little is known about the opinions of primary care clinicians regarding the newly released 2013 American College of Cardiology/American Heart Association (ACC/AHA) Guidelines for the Prevention of Primary and Secondary Atherosclerotic Disease. This survey was created to assess the awareness, attitudes, and practices of primary care clinicians on adoption of the new guidelines and to explore obstacles to implementation and suggestions for improving shared decision-making. METHODS Six hundred practicing clinicians within the San Francisco Bay Area Collaborative Research Network were invited to participate in this cross-sectional, Internet-based pilot survey of primary care clinicians. These survey data were collected in March 2014, approximately 4 months after the release of the new guidelines and 1 month after the release of the ACC/AHA risk estimator application. RESULTS One hundred eighty-three clinicians responded to the survey. Of those respondents, 176 (96%) were aware of the guidelines. The majority (64%) reported implementing the new guidelines with at least some of their patients, while a minority (25%) reported adopting the guidelines for many of their patients. Disagreeing with the guidelines was the main hindrance to adoption. CONCLUSIONS While many primary care clinicians are aware of the new guidelines, a substantial proportion has yet to implement them into their clinical practice, and obstacles remain for full adoption. Further understanding of clinicians' views, opinions, and needs is necessary to optimize the approach to lipid management and ensure integration into current practice.
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Affiliation(s)
- Sina Jamé
- Department of Medicine, University of California, San Francisco (UCSF), San Francisco
| | - Eve Wittenberg
- Center for Health Decision Science, Harvard School of Public Health, Boston, Mass
| | - Michael B Potter
- Department of Family and Community Medicine, UCSF, San Francisco
| | - Kirsten E Fleischmann
- Department of Medicine, University of California, San Francisco (UCSF), San Francisco; Division of Cardiology, Department of Medicine, UCSF, San Francisco.
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18
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Genders TS, Petersen SE, Pugliese F, Dastidar AG, Fleischmann KE, Nieman K, Hunink MM. The optimal imaging strategy for patients with stable chest pain: a cost-effectiveness analysis. Ann Intern Med 2015; 162:474-84. [PMID: 25844996 DOI: 10.7326/m14-0027] [Citation(s) in RCA: 55] [Impact Index Per Article: 6.1] [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: 11/22/2022] Open
Abstract
BACKGROUND The optimal imaging strategy for patients with stable chest pain is uncertain. OBJECTIVE To determine the cost-effectiveness of different imaging strategies for patients with stable chest pain. DESIGN Microsimulation state-transition model. DATA SOURCES Published literature. TARGET POPULATION 60-year-old patients with a low to intermediate probability of coronary artery disease (CAD). TIME HORIZON Lifetime. PERSPECTIVE The United States, the United Kingdom, and the Netherlands. INTERVENTION Coronary computed tomography (CT) angiography, cardiac stress magnetic resonance imaging, stress single-photon emission CT, and stress echocardiography. OUTCOME MEASURES Lifetime costs, quality-adjusted life-years (QALYs), and incremental cost-effectiveness ratios. RESULTS OF BASE-CASE ANALYSIS The strategy that maximized QALYs and was cost-effective in the United States and the Netherlands began with coronary CT angiography, continued with cardiac stress imaging if angiography found at least 50% stenosis in at least 1 coronary artery, and ended with catheter-based coronary angiography if stress imaging induced ischemia of any severity. For U.K. men, the preferred strategy was optimal medical therapy without catheter-based coronary angiography if coronary CT angiography found only moderate CAD or stress imaging induced only mild ischemia. In these strategies, stress echocardiography was consistently more effective and less expensive than other stress imaging tests. For U.K. women, the optimal strategy was stress echocardiography followed by catheter-based coronary angiography if echocardiography induced mild or moderate ischemia. RESULTS OF SENSITIVITY ANALYSIS Results were sensitive to changes in the probability of CAD and assumptions about false-positive results. LIMITATIONS All cardiac stress imaging tests were assumed to be available. Exercise electrocardiography was included only in a sensitivity analysis. Differences in QALYs among strategies were small. CONCLUSION Coronary CT angiography is a cost-effective triage test for 60-year-old patients who have nonacute chest pain and a low to intermediate probability of CAD. PRIMARY FUNDING SOURCE Erasmus University Medical Center.
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Affiliation(s)
- Tessa S.S. Genders
- From Erasmus University Medical Center, Rotterdam, the Netherlands; University of London, London, United Kingdom; UCSF Medical Center, San Francisco, California; and Harvard University, Boston, Massachusetts
| | - Steffen E. Petersen
- From Erasmus University Medical Center, Rotterdam, the Netherlands; University of London, London, United Kingdom; UCSF Medical Center, San Francisco, California; and Harvard University, Boston, Massachusetts
| | - Francesca Pugliese
- From Erasmus University Medical Center, Rotterdam, the Netherlands; University of London, London, United Kingdom; UCSF Medical Center, San Francisco, California; and Harvard University, Boston, Massachusetts
| | - Amardeep G. Dastidar
- From Erasmus University Medical Center, Rotterdam, the Netherlands; University of London, London, United Kingdom; UCSF Medical Center, San Francisco, California; and Harvard University, Boston, Massachusetts
| | - Kirsten E. Fleischmann
- From Erasmus University Medical Center, Rotterdam, the Netherlands; University of London, London, United Kingdom; UCSF Medical Center, San Francisco, California; and Harvard University, Boston, Massachusetts
| | - Koen Nieman
- From Erasmus University Medical Center, Rotterdam, the Netherlands; University of London, London, United Kingdom; UCSF Medical Center, San Francisco, California; and Harvard University, Boston, Massachusetts
| | - M.G. Myriam Hunink
- From Erasmus University Medical Center, Rotterdam, the Netherlands; University of London, London, United Kingdom; UCSF Medical Center, San Francisco, California; and Harvard University, Boston, Massachusetts
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19
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Affiliation(s)
- Mitchell A. Psotka
- />Department of Medicine, Division of Cardiology, University of California San Francisco, San Francisco, CA USA
| | - Kirsten E. Fleischmann
- />Department of Medicine, Division of Cardiology, University of California San Francisco, San Francisco, CA USA
- />UCSF School of Medicine, Box 0124, 505 Parnassus Ave., San Francisco, CA 94143-0124 USA
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20
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Fleisher LA, Fleischmann KE, Auerbach AD, Barnason SA, Beckman JA, Bozkurt B, Davila-Roman VG, Gerhard-Herman MD, Holly TA, Kane GC, Marine JE, Nelson MT, Spencer CC, Thompson A, Ting HH, Uretsky BF, Wijeysundera DN. 2014 ACC/AHA guideline on perioperative cardiovascular evaluation and management of patients undergoing noncardiac surgery: executive summary: a report of the American College of Cardiology/American Heart Association Task Force on practice guidelines. Developed in collaboration with the American College of Surgeons, American Society of Anesthesiologists, American Society of Echocardiography, American Society of Nuclear Cardiology, Heart Rhythm Society, Society for Cardiovascular Angiography and Interventions, Society of Cardiovascular Anesthesiologists, and Society of Vascular Medicine Endorsed by the Society of Hospital Medicine. J Nucl Cardiol 2015; 22:162-215. [PMID: 25523415 DOI: 10.1007/s12350-014-0025-z] [Citation(s) in RCA: 110] [Impact Index Per Article: 12.2] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
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Fleisher LA, Fleischmann KE, Auerbach AD, Barnason SA, Beckman JA, Bozkurt B, Davila-Roman VG, Gerhard-Herman MD, Holly TA, Kane GC, Marine JE, Nelson MT, Spencer CC, Thompson A, Ting HH, Uretsky BF, Wijeysundera DN. 2014 ACC/AHA guideline on perioperative cardiovascular evaluation and management of patients undergoing noncardiac surgery: a report of the American College of Cardiology/American Heart Association Task Force on practice guidelines. J Am Coll Cardiol 2014; 64:e77-137. [PMID: 25091544 DOI: 10.1016/j.jacc.2014.07.944] [Citation(s) in RCA: 806] [Impact Index Per Article: 80.6] [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: 02/07/2023]
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Wijeysundera DN, Duncan D, Nkonde-Price C, Virani SS, Washam JB, Fleischmann KE, Fleisher LA. Perioperative beta blockade in noncardiac surgery: a systematic review for the 2014 ACC/AHA guideline on perioperative cardiovascular evaluation and management of patients undergoing noncardiac surgery: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines. Circulation 2014; 130:2246-64. [PMID: 25085964 DOI: 10.1161/cir.0000000000000104] [Citation(s) in RCA: 91] [Impact Index Per Article: 9.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
OBJECTIVE To review the literature systematically to determine whether initiation of beta blockade within 45 days prior to noncardiac surgery reduces 30-day cardiovascular morbidity and mortality rates. METHODS PubMed (up to April 2013), Embase (up to April 2013), Cochrane Central Register of Controlled Trials (up to March 2013), and conference abstracts (January 2011 to April 2013) were searched for randomized controlled trials (RCTs) and cohort studies comparing perioperative beta blockade with inactive control during noncardiac surgery. Pooled relative risks (RRs) were calculated under the random-effects model. We conducted subgroup analyses to assess how the DECREASE-I (Dutch Echocardiographic Cardiac Risk Evaluation Applying Stress Echocardiography), DECREASE-IV, and POISE-1 (Perioperative Ischemic Evaluation) trials influenced our conclusions. RESULTS We identified 17 studies, of which 16 were RCTs (12 043 participants) and 1 was a cohort study (348 participants). Aside from the DECREASE trials, all other RCTs initiated beta blockade within 1 day or less prior to surgery. Among RCTs, beta blockade decreased nonfatal myocardial infarction (MI) (RR: 0.69; 95% confidence interval [CI]: 0.58 to 0.82) but increased nonfatal stroke (RR: 1.76; 95% CI: 1.07 to 2.91), hypotension (RR: 1.47; 95% CI: 1.34 to 1.60), and bradycardia (RR: 2.61; 95% CI: 2.18 to 3.12). These findings were qualitatively unchanged after the DECREASE and POISE-1 trials were excluded. Effects on mortality rate differed significantly between the DECREASE trials and other trials. Beta blockers were associated with a trend toward reduced all-cause mortality rate in the DECREASE trials (RR: 0.42; 95% CI: 0.15 to 1.22) but with increased all-cause mortality rate in other trials (RR: 1.30; 95% CI: 1.03 to 1.64). Beta blockers reduced cardiovascular mortality rate in the DECREASE trials (RR: 0.17; 95% CI: 0.05 to 0.64) but were associated with trends toward increased cardiovascular mortality rate in other trials (RR: 1.25; 95% CI: 0.92 to 1.71). These differences were qualitatively unchanged after the POISE-1 trial was excluded. CONCLUSIONS Perioperative beta blockade started within 1 day or less before noncardiac surgery prevents nonfatal MI but increases risks of stroke, death, hypotension, and bradycardia. Without the controversial DECREASE studies, there are insufficient data on beta blockade started 2 or more days prior to surgery. Multicenter RCTs are needed to address this knowledge gap.
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Fleisher LA, Fleischmann KE, Auerbach AD, Barnason SA, Beckman JA, Bozkurt B, Davila-Roman VG, Gerhard-Herman MD, Holly TA, Kane GC, Marine JE, Nelson MT, Spencer CC, Thompson A, Ting HH, Uretsky BF, Wijeysundera DN. 2014 ACC/AHA guideline on perioperative cardiovascular evaluation and management of patients undergoing noncardiac surgery: executive summary: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines. Circulation 2014; 130:2215-45. [PMID: 25085962 DOI: 10.1161/cir.0000000000000105] [Citation(s) in RCA: 447] [Impact Index Per Article: 44.7] [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: 12/15/2022]
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Fleisher LA, Fleischmann KE, Auerbach AD, Barnason SA, Beckman JA, Bozkurt B, Davila-Roman VG, Gerhard-Herman MD, Holly TA, Kane GC, Marine JE, Nelson MT, Spencer CC, Thompson A, Ting HH, Uretsky BF, Wijeysundera DN. 2014 ACC/AHA guideline on perioperative cardiovascular evaluation and management of patients undergoing noncardiac surgery: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines. Circulation 2014; 130:e278-333. [PMID: 25085961 DOI: 10.1161/cir.0000000000000106] [Citation(s) in RCA: 209] [Impact Index Per Article: 20.9] [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: 12/28/2022]
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Ferket BS, van Kempen BJH, Hunink MGM, Agarwal I, Kavousi M, Franco OH, Steyerberg EW, Max W, Fleischmann KE. Predictive value of updating Framingham risk scores with novel risk markers in the U.S. general population. PLoS One 2014; 9:e88312. [PMID: 24558385 PMCID: PMC3928195 DOI: 10.1371/journal.pone.0088312] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/28/2013] [Accepted: 01/07/2014] [Indexed: 11/22/2022] Open
Abstract
Background According to population-based cohort studies CT coronary calcium score (CTCS), carotid intima-media thickness (cIMT), high-sensitivity C- reactive protein (CRP), and ankle-brachial index (ABI) are promising novel risk markers for improving cardiovascular risk assessment. Their impact in the U.S. general population is however uncertain. Our aim was to estimate the predictive value of four novel cardiovascular risk markers for the U.S. general population. Methods and Findings Risk profiles, CRP and ABI data of 3,736 asymptomatic subjects aged 40 or older from the National Health and Nutrition Examination Survey (NHANES) 2003–2004 exam were used along with predicted CTCS and cIMT values. For each subject, we calculated 10-year cardiovascular risks with and without each risk marker. Event rates adjusted for competing risks were obtained by microsimulation. We assessed the impact of updated 10-year risk scores by reclassification and C-statistics. In the study population (mean age 56±11 years, 48% male), 70% (80%) were at low (<10%), 19% (14%) at intermediate (≥10–<20%), and 11% (6%) at high (≥20%) 10-year CVD (CHD) risk. Net reclassification improvement was highest after updating 10-year CVD risk with CTCS: 0.10 (95%CI 0.02–0.19). The C-statistic for 10-year CVD risk increased from 0.82 by 0.02 (95%CI 0.01–0.03) with CTCS. Reclassification occurred most often in those at intermediate risk: with CTCS, 36% (38%) moved to low and 22% (30%) to high CVD (CHD) risk. Improvements with other novel risk markers were limited. Conclusions Only CTCS appeared to have significant incremental predictive value in the U.S. general population, especially in those at intermediate risk. In future research, cost-effectiveness analyses should be considered for evaluating novel cardiovascular risk assessment strategies.
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Affiliation(s)
- Bart S Ferket
- Department of Epidemiology, Erasmus MC, Rotterdam, the Netherlands ; Department of Radiology, Erasmus MC, Rotterdam, the Netherlands
| | - Bob J H van Kempen
- Department of Epidemiology, Erasmus MC, Rotterdam, the Netherlands ; Department of Radiology, Erasmus MC, Rotterdam, the Netherlands
| | - M G Myriam Hunink
- Department of Epidemiology, Erasmus MC, Rotterdam, the Netherlands ; Department of Radiology, Erasmus MC, Rotterdam, the Netherlands ; Department of Health Policy and Management, Harvard School of Public Health, Boston, Massachusetts, United States of America
| | - Isha Agarwal
- Department of Epidemiology, Harvard School of Public Health, Boston, Massachusetts, United States of America
| | - Maryam Kavousi
- Department of Epidemiology, Erasmus MC, Rotterdam, the Netherlands
| | - Oscar H Franco
- Department of Epidemiology, Erasmus MC, Rotterdam, the Netherlands
| | | | - Wendy Max
- Institute for Health & Aging and Department of Social and Behavioral Sciences, University of California San Francisco, San Francisco, California, United States of America
| | - Kirsten E Fleischmann
- Division of Cardiology, University of California San Francisco, San Francisco, California, United States of America
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Rahbar AS, Azadani PN, Thatipelli S, Fleischmann KE, Nguyen N, Lee BK. Risk factors and prognosis for clot formation on cardiac device leads. Pacing Clin Electrophysiol 2013; 36:1294-300. [PMID: 23844971 DOI: 10.1111/pace.12210] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/05/2013] [Revised: 05/14/2012] [Accepted: 05/16/2013] [Indexed: 11/28/2022]
Abstract
BACKGROUND Clot formation on cardiac device leads is poorly understood. We sought to determine how often clot is seen on device leads by transthoracic echo (TTE), identify risk factors, and to describe the natural history of this phenomenon. METHODS We reviewed 71,888 echocardiographic studies performed at the University of California, San Francisco from 2005 to 2011. We searched for cases where clot was found adhered to a device lead with no diagnosis of endocarditis. For every case, three age-matched controls with a device but no clot were selected from the echo database. RESULTS We found 15 cases with clot adhered to a device lead among 1,086 patients with devices who had TTE (1.4%). In univariate analysis, females had more than four times greater odds of having a clot on their device lead and patients with a history of atrial fibrillation (AF) had an eight times greater odds. Percentage mode switch was also associated with clot formation. Only AF was still associated with clot formation after multivariate analysis. Follow-up data were available for nine of 15 patients. All nine patients had intensification of their anticoagulant/antiplatelet regimen following clot discovery. Complete resolution or shrinkage of clot was observed in eight of nine patients. The one case with no change was a patient who continued taking only aspirin (higher dose) after clot discovery. None of the nine patients had embolic phenomenon. CONCLUSION Patients with AF are at higher risk for clot formation on device leads. After clot detection, treatment with anticoagulants usually results in resolution of the clot without embolic phenomenon.
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Affiliation(s)
- Ata Soleimani Rahbar
- Cardiac Electrophysiology Section, Division of Cardiology, University of California, San Francisco, School of Medicine, San Francisco, California
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Zègre Hemsey JK, Dracup K, Fleischmann KE, Sommargren CE, Paul SM, Drew BJ. Prehospital electrocardiographic manifestations of acute myocardial ischemia independently predict adverse hospital outcomes. J Emerg Med 2013; 44:955-61. [PMID: 23357378 DOI: 10.1016/j.jemermed.2012.07.089] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/01/2011] [Revised: 04/23/2012] [Accepted: 07/13/2012] [Indexed: 11/29/2022]
Abstract
BACKGROUND Prehospital electrocardiography (PH ECG) is becoming the standard of care for patients activating Emergency Medical Services for symptoms of acute coronary syndrome (ACS). Little is known about the prognostic value of ischemia found on PH ECG. OBJECTIVE The purpose of this study was to determine whether manifestations of acute myocardial ischemia on PH ECG are predictive of adverse hospital outcomes. METHODS This study was a retrospective analysis of all PH ECGs recorded in 630 patients who called 911 for symptoms of ACS and were enrolled in a prospective clinical trial. ST-segment monitoring software was added to the PH ECG device with automatic storage and transmission of ECGs to the destination Emergency Department. Patient medical records were reviewed for adverse hospital outcomes. RESULTS In 630 patients who called 911 for ACS symptoms, 270 (42.9%) had PH ECG evidence of ischemia. Overall, 37% of patients with PH ECG ischemia had adverse hospital outcomes compared with 27% of patients without PH ECG ischemia (p < 0.05). Those with PH ECG ischemia were 1.55 times more likely to have adverse hospital outcomes than those without PH ECG ischemia (95% CI 1.09-2.21; p < 0.05), after controlling for other predictors of adverse hospital outcomes (i.e., age, sex, and medical history). CONCLUSIONS Evidence of ischemia on PH ECG is an independent predictor of adverse hospital outcomes. ST-segment monitoring in the prehospital setting can identify high-risk patients with symptoms of ACS and provide important prognostic information at presentation to the Emergency Department.
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Affiliation(s)
- Jessica K Zègre Hemsey
- Department of Physiological Nursing, University of California, San Francisco, School of Nursing, San Francisco, California, USA
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Genders TS, Petersen SE, Pugliese F, Dastidar AG, Fleischmann KE, Nieman K, Hunink M. Stress myocardial perfusion cardiac magnetic resonance imaging vs. coronary CT angiography in the diagnostic work-up of patients with stable chest pain: comparative effectiveness and costs. J Cardiovasc Magn Reson 2013. [PMCID: PMC3559647 DOI: 10.1186/1532-429x-15-s1-o9] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022] Open
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Genders TSS, Ferket BS, Dedic A, Galema TW, Mollet NRA, de Feyter PJ, Fleischmann KE, Nieman K, Hunink MGM. Coronary computed tomography versus exercise testing in patients with stable chest pain: comparative effectiveness and costs. Int J Cardiol 2012; 167:1268-75. [PMID: 22520158 DOI: 10.1016/j.ijcard.2012.03.151] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.8] [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: 09/20/2011] [Revised: 02/23/2012] [Accepted: 03/18/2012] [Indexed: 12/13/2022]
Abstract
BACKGROUND To determine the comparative effectiveness and costs of a CT-strategy and a stress-electrocardiography-based strategy (standard-of-care; SOC-strategy) for diagnosing coronary artery disease (CAD). METHODS A decision analysis was performed based on a well-documented prospective cohort of 471 outpatients with stable chest pain with follow-up combined with best-available evidence from the literature. Outcomes were correct classification of patients as CAD- (no obstructive CAD), CAD+ (obstructive CAD without revascularization) and indication for Revascularization (using a combination reference standard), diagnostic costs, lifetime health care costs, and quality-adjusted life years (QALY). Parameter uncertainty was analyzed using probabilistic sensitivity analysis. RESULTS For men (and women), diagnostic cost savings were €245 (€252) for the CT-strategy as compared to the SOC-strategy. The CT-strategy classified 82% (88%) of simulated men (women) in the appropriate disease category, whereas 83% (85%) were correctly classified by the SOC-strategy. The long-term cost-effectiveness analysis showed that the SOC-strategy was dominated by the CT-strategy, which was less expensive (-€229 in men, -€444 in women) and more effective (+0.002 QALY in men, +0.005 in women). The CT-strategy was cost-saving (-€231) but also less effective compared to SOC (-0.003 QALY) in men with a pre-test probability of ≥ 70%. The CT-strategy was cost-effective in 100% of simulations, except for men with a pre-test probability ≥ 70% in which case it was 59%. CONCLUSIONS The results suggest that a CT-based strategy is less expensive and equally effective compared to SOC in all women and in men with a pre-test probability <70%.
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Affiliation(s)
- Tessa S S Genders
- Department of Epidemiology, Erasmus University Medical Center, Rotterdam, The Netherlands
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Hwang B, Fleischmann KE, Howie-Esquivel J, Stotts NA, Dracup K. Caregiving for patients with heart failure: impact on patients' families. Am J Crit Care 2011; 20:431-41; quiz 442. [PMID: 22045140 DOI: 10.4037/ajcc2011472] [Citation(s) in RCA: 63] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/22/2023]
Abstract
BACKGROUND Factors that affect the impact of caregiving on patients' family members who provide care to patients with heart failure have not been adequately addressed. In addition, social support and positive aspects of caregiving have received little attention. OBJECTIVE To identify factors associated with the impact of caregiving. METHODS Self-report data were collected from 76 dyads of patients with heart failure and their family caregivers. Clinical data were obtained from medical records. RESULTS A sense of less family support for caregiving was associated with a higher New York Heart Association class of heart failure, being a nonspousal caregiver, lower caregivers' perceived control, and less social support. More disruption of caregivers' schedules was associated with higher class of heart failure, more care tasks, and less social support. Greater impact of caregiving on caregivers' health was related to more recent patient hospitalization, lower caregivers' perceived control, and less social support. Nonwhite caregivers and caregivers whose family member had fewer emergency department visits felt more positive about caregiving than did other caregivers. Social support had a moderating effect on the relationship between patients' comorbid conditions and positive aspects of caregiving. CONCLUSIONS Caregiving has both positive and negative effects on family caregivers of patients with heart failure. The findings suggest the need for interventions to increase caregivers' sense of control and social support. Family caregivers may need additional support immediately after patient hospitalizations to minimize the negative impact of caregiving.
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Affiliation(s)
- Boyoung Hwang
- Boyoung Hwang is an assistant adjunct professor in the School of Nursing, University of California, Los Angeles. Jill Howie-Esquivel is an assistant professor, Nancy A. Stotts is a professor emeritus, and Kathleen Dracup is a professor in the School of Nursing, and Kirsten E. Fleischmann is a professor in the School of Medicine, University of California, San Francisco
| | - Kirsten E. Fleischmann
- Boyoung Hwang is an assistant adjunct professor in the School of Nursing, University of California, Los Angeles. Jill Howie-Esquivel is an assistant professor, Nancy A. Stotts is a professor emeritus, and Kathleen Dracup is a professor in the School of Nursing, and Kirsten E. Fleischmann is a professor in the School of Medicine, University of California, San Francisco
| | - Jill Howie-Esquivel
- Boyoung Hwang is an assistant adjunct professor in the School of Nursing, University of California, Los Angeles. Jill Howie-Esquivel is an assistant professor, Nancy A. Stotts is a professor emeritus, and Kathleen Dracup is a professor in the School of Nursing, and Kirsten E. Fleischmann is a professor in the School of Medicine, University of California, San Francisco
| | - Nancy A. Stotts
- Boyoung Hwang is an assistant adjunct professor in the School of Nursing, University of California, Los Angeles. Jill Howie-Esquivel is an assistant professor, Nancy A. Stotts is a professor emeritus, and Kathleen Dracup is a professor in the School of Nursing, and Kirsten E. Fleischmann is a professor in the School of Medicine, University of California, San Francisco
| | - Kathleen Dracup
- Boyoung Hwang is an assistant adjunct professor in the School of Nursing, University of California, Los Angeles. Jill Howie-Esquivel is an assistant professor, Nancy A. Stotts is a professor emeritus, and Kathleen Dracup is a professor in the School of Nursing, and Kirsten E. Fleischmann is a professor in the School of Medicine, University of California, San Francisco
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van Kempen BJ, Spronk S, Koller MT, Elias-Smale SE, Fleischmann KE, Ikram MA, Krestin GP, Hofman A, Witteman JC, Hunink MM. Comparative Effectiveness and Cost-Effectiveness of Computed Tomography Screening for Coronary Artery Calcium in Asymptomatic Individuals. J Am Coll Cardiol 2011; 58:1690-701. [DOI: 10.1016/j.jacc.2011.05.056] [Citation(s) in RCA: 61] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/29/2011] [Revised: 05/11/2011] [Accepted: 05/14/2011] [Indexed: 01/07/2023]
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Fleischmann KE, Zègre-Hemsey J, Drew BJ. The new universal definition of myocardial infarction criteria improve electrocardiographic diagnosis of acute coronary syndrome. J Electrocardiol 2011; 44:69-73. [PMID: 21168005 DOI: 10.1016/j.jelectrocard.2010.10.037] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/11/2010] [Indexed: 11/16/2022]
Abstract
INTRODUCTION/METHODS To assess whether revised electrocardiographic (ECG) criteria improve emergency department identification of patients with acute myocardial infarction (MI) or unstable angina (UA) and predict outcome, we studied 120 patients with a nondiagnostic initial ECG by prior criteria. Electrocardiograms were read in a blinded fashion months apart with standard and then revised criteria, and analyzed by χ(2) and logistic regression analysis. RESULTS In 12 subjects (10%), the initial ECG was now interpreted as diagnostic of ischemia. Eleven (92%) had an MI, 1 had UA (8%), and none had a noncardiac diagnosis. Ischemic ECG changes were strongly associated with MI or UA (P = .003). At 1-year follow-up, ECG changes diagnostic of ischemia were associated with a trend toward higher mortality (25% vs 7%, P = .07), but after adjustment for clinical factors, ECG changes were not an independent predictor of 1-year mortality. CONCLUSIONS Revision of the ECG criteria for ischemia was associated with enhanced diagnostic performance and identified a subset of patients at higher risk.
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Affiliation(s)
- Kirsten E Fleischmann
- Department of Medicine, University of California-San Francisco, 505 Parnassus Ave., San Francisco, CA 94143-0124, USA.
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Fleisher LA, Beckman JA, Brown KA, Calkins H, Chaikof EL, Fleischmann KE, Freeman WK, Froehlich JB, Kasper EK, Kersten JR, Riegel B, Robb JF. 2009 ACCF/AHA focused update on perioperative beta blockade incorporated into the ACC/AHA 2007 guidelines on perioperative cardiovascular evaluation and care for noncardiac surgery. J Am Coll Cardiol 2009; 54:e13-e118. [PMID: 19926002 DOI: 10.1016/j.jacc.2009.07.010] [Citation(s) in RCA: 232] [Impact Index Per Article: 15.5] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
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Fleisher LA, Beckman JA, Brown KA, Calkins H, Chaikof EL, Fleischmann KE, Freeman WK, Froehlich JB, Kasper EK, Kersten JR, Riegel B, Robb JF. 2009 ACCF/AHA Focused Update on Perioperative Beta Blockade Incorporated Into the ACC/AHA 2007 Guidelines on Perioperative Cardiovascular Evaluation and Care for Noncardiac Surgery. Circulation 2009; 120:e169-276. [PMID: 19884473 DOI: 10.1161/circulationaha.109.192690] [Citation(s) in RCA: 209] [Impact Index Per Article: 13.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/04/2023]
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Fleischmann KE, Beckman JA, Buller CE, Calkins H, Fleisher LA, Freeman WK, Froehlich JB, Kasper EK, Kersten JR, Robb JF, Valentine RJ. 2009 ACCF/AHA focused update on perioperative beta blockade: a report of the American college of cardiology foundation/American heart association task force on practice guidelines. Circulation 2009; 120:2123-51. [PMID: 19884474 DOI: 10.1161/circulationaha.109.192689] [Citation(s) in RCA: 70] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
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Fleischmann KE, Lamas GA, Mangione CM, Goldman L. Response to, "Atrial fibrillation and quality of life". Am Heart J 2009. [DOI: 10.1016/j.ahj.2009.09.011] [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: 11/17/2022]
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Fleischmann KE, Orav EJ, Lamas GA, Mangione CM, Schron EB, Lee KL, Goldman L. Atrial fibrillation and quality of life after pacemaker implantation for sick sinus syndrome: data from the Mode Selection Trial (MOST). Am Heart J 2009; 158:78-83.e2. [PMID: 19540395 DOI: 10.1016/j.ahj.2009.02.023] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/12/2008] [Accepted: 02/26/2009] [Indexed: 10/20/2022]
Abstract
BACKGROUND In the Mode Selection Trial (MOST) of 2,010 patients with sinus node dysfunction, dual-chamber-paced patients had less atrial fibrillation (AF) and heart failure and had slightly improved health-related quality of life (QOL) compared with rate modulated right ventricular-paced patients. Our objective was to assess the impact of AF on QOL within MOST. METHODS We analyzed serial QOL measures (Short Form-36, Specific Activity Scale, time trade-off) in 3 groups: (1) those without AF; (2) those with paroxysmal AF (PAF), but not chronic AF (CAF); and (3) those with CAF. We carried forward the last known QOL before crossover for all subsequent time points in patients randomized to rate modulated right ventricular pacing who crossed over to dual-chamber pacing for severe pacemaker syndrome. RESULTS Three hundred seventeen patients (15.8%) had AF in the year after implantation, 206 patients within 3 months (191 PAF, 15 CAF), and another 159 (124 PAF, 35 CAF) between 3 and 12 months. There were no significant differences among groups in individual Short Form-36 subscales or time trade-off scores at 12 months as compared with baseline or 3 months. Cardiovascular health status was better at 12 months as compared with baseline or 3 months in those without AF. CONCLUSIONS Atrial fibrillation after pacemaker implantation in elderly patients with sick sinus syndrome was not a major determinant of QOL. However, there was a trend toward better cardiovascular functional status in patients without AF.
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Fleisher LA, Beckman JA, Brown KA, Calkins H, Chaikof E, Fleischmann KE, Freeman WK, Froehlich JB, Kasper EK, Kersten JR, Riegel B, Robb JF, Smith SC, Jacobs AK, Adams CD, Anderson JL, Antman EM, Buller CE, Creager MA, Ettinger SM, Faxon DP, Fuster V, Halperin JL, Hiratzka LF, Hunt SA, Lytle BW, Nishimura R, Ornato JP, Page RL, Riegel B, Tarkington LG, Yancy CW. ACC/AHA 2007 guidelines on perioperative cardiovascular evaluation and care for noncardiac surgery: executive summary: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Writing Committee to Revise the 2002 Guidelines on Perioperative Cardiovascular Evaluation for Noncardiac Surgery). Anesth Analg 2008; 106:685-712. [PMID: 18292406 DOI: 10.1213/01/ane.0000309024.28586.70] [Citation(s) in RCA: 156] [Impact Index Per Article: 9.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
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Drew BJ, Schindler DM, Zegre JK, Fleischmann KE, Lux RL. Estimated body surface potential maps in emergency department patients with unrecognized transient myocardial ischemia. J Electrocardiol 2008; 40:S15-20. [PMID: 17993313 DOI: 10.1016/j.jelectrocard.2007.05.032] [Citation(s) in RCA: 12] [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] [Received: 04/07/2007] [Accepted: 05/30/2007] [Indexed: 10/22/2022]
Abstract
BACKGROUND We report on 5 patients who presented to the emergency department (ED) with chest pain, had negative serum troponin levels, and were discharged with a presumed noncardiac diagnosis. Thereafter, retrospective analysis of Holter monitoring data recorded for a clinical trial revealed ST events indicative of transient myocardial ischemia that was unrecognized clinically. STUDY AIM The purpose of this analysis was to determine whether initial body surface potential maps estimated from optimal ischemia electrode sites estimated body surface potential map (EBSPM) showed signs of ischemia in the missed ischemia group that could have prevented misdiagnosis. METHODS This is a secondary analysis of data from a prospective clinical trial in which patients were attached to 2 Holter monitor devices for simultaneous recordings. One Holter device recorded a standard Mason-Likar 12-lead electrocardiogram (ECG) and the other recorded a 10-electrode lead set considered optimal for ischemia detection. A body surface potential map was then estimated from the optimal lead set. RESULTS At 1 year, 2 of the 5 patients with missed ischemia died and a third had an acute myocardial infarction (MI) (40% mortality, 60% death/nonfatal MI). In comparison, 1-year mortality was 5.7% in 159 similar patients treated for unstable angina at the same institution over the same period (P = .037). The initial standard ECG showed no abnormalities in 3 patients and showed left ventricular hypertrophy in 1. The fifth patient with a history of recent MI had slight ST elevation in leads III and aVF and Q waves that were considered indicative of recent (not acute) MI. EBSPM data recorded at the time of ED presentation matched the standard ECG (normal in 3, left ventricular hypertrophy or inconclusive in 2). During transient ischemia, all 5 EBSPMs showed areas of ischemia overlapping with standard electrode sites. CONCLUSION Patients evaluated in the ED for chest pain are at high risk for death or nonfatal MI if they have ischemic events with continuous ST-segment monitoring that are unrecognized clinically. In this small cohort with unrecognized ischemia, the initial body surface potential maps estimated from optimal ischemia electrode sites did not improve on 12-lead ST-segment monitoring to identify this high-risk group.
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Affiliation(s)
- Barbara J Drew
- Department of Physiological Nursing, University of California, San Francisco, CA 94143-0610, USA.
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Shusterman V, Goldberg A, Schindler DM, Fleischmann KE, Lux RL, Drew BJ. Dynamic tracking of ischemia in the surface electrocardiogram. J Electrocardiol 2008; 40:S179-86. [PMID: 17993319 DOI: 10.1016/j.jelectrocard.2007.06.015] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/05/2007] [Accepted: 06/06/2007] [Indexed: 11/24/2022]
Abstract
BACKGROUND Accurate detection of the earliest signs of ischemia on the surface electrocardiogram (ECG) is essential for timely diagnosis and management of potentially life-threatening ischemic events. Yet, accuracy of ischemia analysis in ECG monitors remains suboptimal because of a number of confounding factors, including changes in body position and other artifacts. Hence, the goals of this study were (1) to examine the duration and time course of ischemic events and (2) to compare ECG changes caused by "true" ischemic events with those caused by changes in body position. Continuous, 12-lead Holter ECGs obtained from patients who presented to the emergency department with chest pain and enrolled in the Ischemia Monitoring and Mapping in the Emergency Department in Appropriate Triage and Evaluation of Acute Ischemic Myocardium study were analyzed. Holter recordings were initiated within the first 40 minutes after patients' arrival to the emergency department. Here we present preliminary results. METHODS Twelve patients (age, 59 +/- 16 years; 5 women, 2 with a final diagnosis of non-ST-segment elevation myocardial infarction, 4 with unstable angina, and 6 with other cardiovascular diseases), in whom ischemic ST deviations were identified on Holter data, underwent 4 consecutive, 2-minute recordings in the following body positions: (1) supine, (2) on the left side, (3) on the right side, and (4) sitting (or standing) upright. After baseline correction, beat-to-beat changes in QRS and ST-T segments were examined in all 8 channels and the root-mean-square curve by using an adaptive algorithm that computes the slope, amplitude, duration, area, and the Karhunen-Loève-derived representation of the corresponding segment. To prevent possible biases toward patients with more frequent ischemic events, a single index event was chosen for analysis in each patient. There were 3 ST-elevation events and 9 ST-depression events; these events reached the maximum ST deviation 11 +/- 8 hours (mean +/- SD) after the beginning of the recording. RESULTS AND CONCLUSIONS In most patients with transient myocardial ischemia, the microvolt-level, subthreshold deviation of the ST segment developed gradually, over 15 to 20 minutes, until it reached the maximum, superthreshold level. Despite the different ischemia localizations, the root-mean-square curve allowed accurate detection of significant changes in the ST segment in the studied group (Friedman analysis of variance for repeated measurements over a 1-hour interval). Changes in body position could be identified by tracking dynamics of the QRS pattern/axis. Adaptive algorithms for tracking of the ST dynamics with simultaneous tracking of the patterns of QRS complexes to discriminate the true and "false"-positive events are presented and discussed.
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Ren X, Hsu PYF, Dulbecco FL, Fleischmann KE, Gold WM, Redberg RF, Schiller NB. Remote second-hand tobacco exposure in flight attendants is associated with systemic but not pulmonary hypertension. Cardiol J 2008; 15:338-343. [PMID: 18698542] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/26/2023] Open
Abstract
BACKGROUND Second-hand tobacco smoke has been associated with cardiopulmonary dysfunction. We sought to examine the residual effects of remote second-hand smoke exposure on resting and exercise cardiopulmonary hemodynamics. We hypothesized that remote secondhand smoke exposure results in persistent cardiopulmonary hemodynamic abnormalities. METHODS Participants were non-smoking flight attendants who worked in airline cabins prior to the in-flight tobacco ban. Participants underwent clinical evaluations and completed smoke exposure questionnaires. We used Doppler echocardiography to measure pulmonary artery systolic pressure (PASP) and pulmonary vascular resistance (PVR) at rest and during supine bicycle ergometer exercise, using the validated formula TRV/VTIRVOT x 10 + 0.16, where VTIRVOT is the velocity time integral at the right ventricular outflow tract and TRV is the tricuspid regurgitation velocity. The group was divided into quartiles according to the degree of smoke exposure. Analysis of variance was used to determine the differences in hemodynamic outcomes. RESULTS Seventy-nine flight attendants were included in our analysis. Baseline characteristics among participants in each quartile of smoke exposure were similar except for history of systemic hypertension, which was more prevalent in the highest quartile. Peak exercise PASP rose to the same degree in all test groups (mean PASP 44 mm Hg, p = 0.25), and PVR increased by approximately 27% in all quartiles. There was no significant difference in pulmonary artery systolic pressure or pulmonary vascular resistance among quartiles of smoke exposure. CONCLUSIONS We found that remote heavy second-hand smoke exposure from in-flight tobacco is associated with systemic hypertension but does not have demonstrable pulmonary hemodynamic consequences.
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Affiliation(s)
- Xiushui Ren
- Division of Cardiology, California Pacific Medical Center, San Francisco, CA 94115, USA.
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Fleisher LA, Beckman JA, Brown KA, Calkins H, Chaikof EL, Chaikof E, Fleischmann KE, Freeman WK, Froehlich JB, Kasper EK, Kersten JR, Riegel B, Robb JF, Smith SC, Jacobs AK, Adams CD, Anderson JL, Antman EM, Buller CE, Creager MA, Ettinger SM, Faxon DP, Fuster V, Halperin JL, Hiratzka LF, Hunt SA, Lytle BW, Nishimura R, Ornato JP, Page RL, Riegel B, Tarkington LG, Yancy CW. ACC/AHA 2007 Guidelines on Perioperative Cardiovascular Evaluation and Care for Noncardiac Surgery: Executive Summary: A Report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Writing Committee to Revise the 2002 Guidelines on Perioperative Cardiovascular Evaluation for Noncardiac Surgery) Developed in Collaboration With the American Society of Echocardiography, American Society of Nuclear Cardiology, Heart Rhythm Society, Society of Cardiovascular Anesthesiologists, Society for Cardiovascular Angiography and Interventions, Society for Vascular Medicine and Biology, and Society for Vascular Surgery. J Am Coll Cardiol 2007; 50:e159-241. [PMID: 17950159 DOI: 10.1016/j.jacc.2007.09.003] [Citation(s) in RCA: 257] [Impact Index Per Article: 15.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/04/2023]
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Fleisher LA, Beckman JA, Brown KA, Calkins H, Chaikof E, Fleischmann KE, Freeman WK, Froehlich JB, Kasper EK, Kersten JR, Riegel B, Robb JF, Smith SC, Jacobs AK, Adams CD, Anderson JL, Antman EM, Buller CE, Creager MA, Ettinger SM, Faxon DP, Fuster V, Halperin JL, Hiratzka LF, Hunt SA, Lytle BW, Nishimura R, Ornato JP, Page RL, Riegel B, Tarkington LG, Yancy CW. ACC/AHA 2007 Guidelines on Perioperative Cardiovascular Evaluation and Care for Noncardiac Surgery: Executive Summary. Circulation 2007; 116:1971-96. [PMID: 17901356 DOI: 10.1161/circulationaha.107.185700] [Citation(s) in RCA: 501] [Impact Index Per Article: 29.5] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
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Fleisher LA, Beckman JA, Brown KA, Calkins H, Chaikof E, Fleischmann KE, Freeman WK, Froehlich JB, Kasper EK, Kersten JR, Riegel B, Robb JF, Smith SC, Jacobs AK, Adams CD, Anderson JL, Antman EM, Buller CE, Creager MA, Ettinger SM, Faxon DP, Fuster V, Halperin JL, Hiratzka LF, Hunt SA, Lytle BW, Nishimura R, Ornato JP, Page RL, Tarkington LG, Yancy CW. ACC/AHA 2007 Guidelines on Perioperative Cardiovascular Evaluation and Care for Noncardiac Surgery. Circulation 2007; 116:e418-99. [PMID: 17901357 DOI: 10.1161/circulationaha.107.185699] [Citation(s) in RCA: 377] [Impact Index Per Article: 22.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
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Heijenbrok-Kal MH, Fleischmann KE, Hunink MGM. Stress echocardiography, stress single-photon-emission computed tomography and electron beam computed tomography for the assessment of coronary artery disease: a meta-analysis of diagnostic performance. Am Heart J 2007; 154:415-23. [PMID: 17719283 DOI: 10.1016/j.ahj.2007.04.061] [Citation(s) in RCA: 113] [Impact Index Per Article: 6.6] [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: 02/20/2006] [Accepted: 04/29/2007] [Indexed: 11/29/2022]
Abstract
BACKGROUND Many studies have been published on the diagnostic performance of noninvasive tests for the assessment of coronary artery disease. The objective of the present study was to compare the published literature on the diagnostic performance of stress echocardiography, stress single-photon-emission computed tomography (SPECT), and electron beam computed tomography (EBCT). METHODS Meta-analytic studies on the diagnostic performance of imaging tests for coronary artery disease were searched in the Cochrane Library, PubMed, and bibliographies of selected articles. Sensitivities, specificities, and diagnostic odds ratios of the source studies were calculated per modality. Taking into account differences between studies, a random effects summary receiver operating characteristic analysis was performed. RESULTS We analyzed the data of 351 patient series, which were reported in 11 meta-analyses. The sensitivity of EBCT was significantly higher than that of stress SPECT, which had a significantly higher sensitivity than stress echocardiography (respectively, 93.1% [95% confidence interval, 90.7-95.6], 88.1 [95% confidence interval, 86.6-89.6], and 79.1% [95% confidence interval, 77.6-80.5]). The specificity of stress echocardiography was significantly higher than that of stress SPECT, which had a significantly higher specificity than EBCT (respectively, 87.1% [95% confidence interval, 85.7-88.5], 73.0% [95% confidence interval, 69.1-76.9], and 54.5% [95% confidence interval, 45.3-63.8]). The diagnostic odds ratios did not differ significantly between the 3 modalities, which resulted in one underlying summary receiver operating characteristic curve. CONCLUSIONS This study suggests that there are no significant differences in the overall diagnostic performance between stress echocardiography, stress SPECT, and EBCT for the diagnosis of coronary artery disease. However, differences exist in sensitivity and specificity estimates, which may make each modality useful in different settings.
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Affiliation(s)
- Majanka H Heijenbrok-Kal
- Department of Epidemiology and Biostatistics, Erasmus MC-University Medical Center Rotterdam, Rotterdam, The Netherlands.
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Fleisher LA, Beckman JA, Brown KA, Calkins H, Chaikof EL, Fleischmann KE, Freeman WK, Froehlich JB, Kasper EK, Kersten JR, Riegel B, Robb JF. ACC/AHA 2006 guideline update on perioperative cardiovascular evaluation for noncardiac surgery: focused update on perioperative beta-blocker therapy--a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Writing Committee to Update the 2002 Guidelines on Perioperative Cardiovascular Evaluation for Noncardiac Surgery). Anesth Analg 2007; 104:15-26. [PMID: 17179239 DOI: 10.1213/01.ane.0000243335.31748.22] [Citation(s) in RCA: 48] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
The American College of Cardiology/American Heart Association (ACC/AHA) Task Force on Practice Guidelines makes every effort to avoid any actual, potential, or perceived conflict of interest that might arise as a result of an industry relationship or personal interest of the writing committee. Specifically, all members of the writing committee, as well as peer reviewers of the document, were asked to provide disclosure statements of all such relationships that might be perceived as real or potential conflicts of interest. These statements are reviewed by the parent task force, reported orally to all members of the writing committee at each meeting, and updated and reviewed by the writing committee as changes occur. Please see Appendix 1 for author relationships with industry and Appendix 2 for peer reviewer relationships with industry. These guidelines attempt to define practices that meet the needs of most patients in most circumstances. These guideline recommendations reflect a consensus of expert opinion after a thorough review of the available, current scientific evidence and are intended to improve patient care. If these guidelines are used as the basis for regulatory/payer decisions, the ultimate goal is quality of care and serving the patient's best interests. The ultimate judgment regarding care of a particular patient must be made by the healthcare provider and patient in light of all the circumstances presented by that patient.
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Metz LD, Beattie M, Hom R, Redberg RF, Grady D, Fleischmann KE. The Prognostic Value of Normal Exercise Myocardial Perfusion Imaging and Exercise Echocardiography. J Am Coll Cardiol 2007; 49:227-37. [PMID: 17222734 DOI: 10.1016/j.jacc.2006.08.048] [Citation(s) in RCA: 368] [Impact Index Per Article: 21.6] [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: 02/16/2006] [Revised: 08/23/2006] [Accepted: 08/28/2006] [Indexed: 11/24/2022]
Abstract
OBJECTIVES The purpose of this work was to determine the prognostic value of normal exercise myocardial perfusion imaging (MPI) tests and exercise echocardiography tests, and to determine the prognostic value of these imaging modalities in women and men. BACKGROUND Exercise MPI and exercise echocardiography provide prognostic information that is useful in the risk stratification of patients with suspected coronary artery disease (CAD). METHODS We searched the PubMed, Cochrane, and DARE databases between January 1990 and May 2005, and reviewed bibliographies of articles obtained. We included prospective cohort studies of subjects who underwent exercise MPI or exercise echocardiography for known or suspected CAD, and provided data on primary outcomes of myocardial infarction (MI) and cardiac death with at least 3 months of follow-up. Secondary outcomes (unstable angina, revascularization procedures) were abstracted if provided. Studies performed exclusively in patients with CAD were excluded. RESULTS The negative predictive value (NPV) for MI and cardiac death was 98.8% (95% confidence interval [CI] 98.5 to 99.0) over 36 months of follow-up for MPI, and 98.4% (95% CI 97.9 to 98.9) over 33 months for echocardiography. The corresponding annualized event rates were 0.45% per year for MPI and 0.54% per year for echocardiography. In subgroup analyses, annualized event rates were <1% for each MPI isotope, and were similar for women and men. For secondary events, MPI and echocardiography had annualized event rates of 1.25% and 0.95%, respectively. CONCLUSIONS Both exercise MPI and exercise echocardiography have high NPVs for primary and secondary cardiac events. The prognostic utility of both modalities is similar for both men and women.
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Affiliation(s)
- Louise D Metz
- Department of Medicine, New York University School of Medicine, New York, New York, USA
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Fleisher LA, Beckman JA, Brown KA, Calkins H, Chaikof E, Fleischmann KE, Freeman WK, Froehlich JB, Kasper EK, Kersten JR, Riegel B, Robb JF, Smith SC, Jacobs AK, Adams CD, Anderson JL, Antman EM, Faxon DP, Fuster V, Halperin JL, Hiratzka LF, Hunt SA, Lytle BW, Nishimura R, Page RL, Riegel B. ACC/AHA 2006 guideline update on perioperative cardiovascular evaluation for noncardiac surgery: focused update on perioperative beta-blocker therapy: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Writing Committee to Update the 2002 Guidelines on Perioperative Cardiovascular Evaluation for Noncardiac Surgery): developed in collaboration with the American Society of Echocardiography, American Society of Nuclear Cardiology, Heart Rhythm Society, Society of Cardiovascular Anesthesiologists, Society for Cardiovascular Angiography and Interventions, and Society for Vascular Medicine and Biology. Circulation 2006; 113:2662-74. [PMID: 16754815 DOI: 10.1161/circulationaha.106.176009] [Citation(s) in RCA: 129] [Impact Index Per Article: 7.2] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
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Fleisher LA, Beckman JA, Brown KA, Calkins H, Chaikof E, Fleischmann KE, Freeman WK, Froehlich JB, Kasper EK, Kersten JR, Riegel B, Robb JF, Smith SC, Jacobs AK, Adams CD, Anderson JL, Antman EM, Faxon DP, Fuster V, Halperin JL, Hiratzka LF, Hunt SA, Lytle BW, Nishimura R, Page RL, Riegel B. ACC/AHA 2006 Guideline Update on Perioperative Cardiovascular Evaluation for Noncardiac Surgery: Focused Update on Perioperative Beta-Blocker Therapy. J Am Coll Cardiol 2006; 47:2343-55. [PMID: 16750714 DOI: 10.1016/j.jacc.2006.02.028] [Citation(s) in RCA: 99] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
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Fleischmann KE, Orav EJ, Lamas GA, Mangione CM, Schron E, Lee KL, Goldman L. Pacemaker implantation and quality of life in the Mode Selection Trial (MOST). Heart Rhythm 2006; 3:653-9. [PMID: 16731465 DOI: 10.1016/j.hrthm.2006.02.1031] [Citation(s) in RCA: 59] [Impact Index Per Article: 3.3] [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: 09/22/2005] [Accepted: 02/24/2006] [Indexed: 10/24/2022]
Abstract
BACKGROUND Dual-chamber pacemakers restore AV synchrony compared with ventricular pacemakers, but the effects on health-related quality of life (QOL) are uncertain. OBJECTIVES The purpose of this study was to assess the effect of pacemaker implantation, clinical factors, and pacing mode on QOL. METHODS The Mode Selection Trial (MOST) randomized 2,010 patients with sinus node dysfunction to rate-modulated right ventricular (VVIR) or dual-chamber (DDDR) pacing. A longitudinal analysis of serial QOL measures (Short Form-36 [SF-36], Specific Activity Scale, and time trade-off utility) was performed. In patients who crossed over from VVIR to DDDR because of severe pacemaker syndrome, the last known QOL prior to crossover was carried forward. RESULTS Pacemaker implantation resulted in substantial improvement in almost all QOL measures. Subjects 75 years or older experienced significantly less improvement in functional status and physical component summary scores than did younger subjects. In longitudinal analyses of the effect of pacing mode on QOL, significant improvement in three SF-36 subscales was observed with DDDR pacing compared with VVIR pacing: role physical [62.8 points (95% confidence interval [CI] 60.2, 65.5) vs 56.4 (95% CI 53.7, 59.1)], role emotional [85.0 (95% CI 82.9, 87.0) vs 81.9 (95% CI 79.9, 84.0)], and vitality [51.8 (95% CI 50.3, 53.3) vs 49.3 (95% CI 47.8, 50.7)], but not in other SF-36 subscales, the Specific Activity Scale, or utilities. The gains in QOL were larger than the declines associated with 1 year of aging but smaller than those associated with heart failure. CONCLUSION Pacemaker implantation improved health-related QOL. The mode selected was associated with much smaller, but significant, improvements in several domains, particularly role physical function.
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