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Kelsey MD, Kelsey AM. Diagnosing Coronary Artery Disease in the Patient Presenting with Stable Ischemic Heart Disease: The Role of Anatomic versus Functional Testing. Med Clin North Am 2024; 108:427-439. [PMID: 38548455 DOI: 10.1016/j.mcna.2023.11.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/02/2024]
Abstract
There are unique advantages and disadvantages to functional versus anatomic testing in the work-up of patients who present with symptoms suggestive of obstructive coronary artery disease. Evaluation of these individuals starts with an assessment of pre-test probability, which guides subsequent testing decisions. The choice between anatomic and functional testing depends on this pre-test probability. In general, anatomic testing has particular utility among younger individuals and women; while functional testing can be helpful to rule-in ischemia and guide revascularization decisions. Ultimately, selection of the most appropriate test should be individualized to the patient and clinical scenario.
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Affiliation(s)
- Michelle D Kelsey
- Division of Cardiology, Department of Medicine, Duke University, 2301 Erwin Road, Durham, NC 27710, USA; Duke Clinical Research Institute, 300 West Morgan Street, Durham, NC 27701, USA.
| | - Anita M Kelsey
- Division of Cardiology, Department of Medicine, Duke University, 2301 Erwin Road, Durham, NC 27710, USA. https://twitter.com/AnitaKelseyMD
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Park DY, Hu JR, Jamil Y, Kelsey MD, Jones WS, Frampton J, Kochar A, Aronow WS, Damluji AA, Nanna MG. Shorter Dual Antiplatelet Therapy for Older Adults After Percutaneous Coronary Intervention: A Systematic Review and Network Meta-Analysis. JAMA Netw Open 2024; 7:e244000. [PMID: 38546647 PMCID: PMC10979312 DOI: 10.1001/jamanetworkopen.2024.4000] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/03/2023] [Accepted: 01/31/2024] [Indexed: 04/01/2024] Open
Abstract
Importance The optimal duration of dual antiplatelet therapy (DAPT) for older adults after percutaneous coronary intervention (PCI) is uncertain because they are simultaneously at higher risk for both ischemic and bleeding events. Objective To investigate the association of abbreviated DAPT with adverse clinical events among older adults after PCI. Data Sources The Cochrane Library, Google Scholar, Embase, MEDLINE, PubMed, Scopus, and Web of Science were searched from inception to August 9, 2023. Study Selection Randomized clinical trials comparing any 2 of 1, 3, 6, and 12 months of DAPT were included if they reported results for adults aged 65 years or older or 75 years or older. Data Extraction and Synthesis The Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) reporting guideline was used to abstract data and assess data quality. Risk ratios for each duration of DAPT were calculated with alternation of the reference group. Main Outcomes and Measures The primary outcome of interest was net adverse clinical events (NACE). Secondary outcomes were major adverse cardiovascular events (MACE) and bleeding. Results In 14 randomized clinical trials comprising 19 102 older adults, no differences were observed in the risks of NACE or MACE for 1, 3, 6, and 12 months of DAPT. However, 3 months of DAPT was associated with a lower risk of bleeding compared with 6 months of DAPT (relative risk [RR], 0.50 [95% CI, 0.29-0.84]) and 12 months of DAPT (RR, 0.57 [95% CI, 0.45-0.71]) among older adults. One month of DAPT was also associated with a lower risk of bleeding compared with 6 months of DAPT (RR, 0.68 [95% CI, 0.54-0.86]). Conclusions and Relevance In this systematic review and meta-analysis of different durations of DAPT for older adults after PCI, an abbreviated DAPT duration was associated with a lower risk of bleeding without any concomitant increase in the risk of MACE or NACE despite the concern for higher-risk coronary anatomy and comorbidities among older adults. This study, which represents the first network meta-analysis of this shortened treatment for older adults, suggests that clinicians may consider abbreviating DAPT for older adults.
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Affiliation(s)
- Dae Yong Park
- Department of Medicine, Cook County Health, Chicago, Illinois
| | - Jiun-Ruey Hu
- Section of Cardiovascular Medicine, Yale School of Medicine, New Haven, Connecticut
| | - Yasser Jamil
- Department of Medicine, Yale-Waterbury Hospital, Waterbury, Connecticut
| | - Michelle D. Kelsey
- Division of Cardiology, Duke University Medical Center, Durham, North Carolina
- Duke Clinical Research Institute, Durham, North Carolina
| | - W. Schuyler Jones
- Division of Cardiology, Duke University Medical Center, Durham, North Carolina
- Duke Clinical Research Institute, Durham, North Carolina
| | - Jennifer Frampton
- Section of Cardiovascular Medicine, Yale School of Medicine, New Haven, Connecticut
| | - Ajar Kochar
- Department of Cardiovascular Medicine, Brigham and Women’s Hospital, Harvard Medical School, Boston, Massachusetts
- Richard and Susan Smith Center for Outcomes Research in Cardiology, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts
| | - Wilbert S. Aronow
- Department of Cardiology, Westchester Medical Center, Valhalla, New York
| | - Abdulla A. Damluji
- Division of Cardiology, Johns Hopkins University School of Medicine, Baltimore, Maryland
- Inova Center of Outcomes Research, Inova Heart and Vascular Institute, Falls Church, Virginia
| | - Michael G. Nanna
- Section of Cardiovascular Medicine, Yale School of Medicine, New Haven, Connecticut
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Fazlalizadeh H, Khan MS, Fox ER, Douglas PS, Adams D, Blaha MJ, Daubert MA, Dunn G, van den Heuvel E, Kelsey MD, Martin RP, Thomas JD, Thomas Y, Judd SE, Vasan RS, Budoff MJ, Bloomfield GS. Closing the Last Mile Gap in Access to Multimodality Imaging in Rural Settings: Design of the Imaging Core of the Risk Underlying Rural Areas Longitudinal Study. Circ Cardiovasc Imaging 2024; 17:e015496. [PMID: 38377236 PMCID: PMC10883604 DOI: 10.1161/circimaging.123.015496] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/22/2024]
Abstract
Achieving optimal cardiovascular health in rural populations can be challenging for several reasons including decreased access to care with limited availability of imaging modalities, specialist physicians, and other important health care team members. Therefore, innovative solutions are needed to optimize health care and address cardiovascular health disparities in rural areas. Mobile examination units can bring imaging technology to underserved or remote communities with limited access to health care services. Mobile examination units can be equipped with a wide array of assessment tools and multiple imaging modalities such as computed tomography scanning and echocardiography. The detailed structural assessment of cardiovascular and lung pathology, as well as the detection of extracardiac pathology afforded by computed tomography imaging combined with the functional and hemodynamic assessments acquired by echocardiography, yield deep phenotyping of heart and lung disease for populations historically underrepresented in epidemiological studies. Moreover, by bringing the mobile examination unit to local communities, innovative approaches are now possible including engagement with local professionals to perform these imaging assessments, thereby augmenting local expertise and experience. However, several challenges exist before mobile examination unit-based examinations can be effectively integrated into the rural health care setting including standardizing acquisition protocols, maintaining consistent image quality, and addressing ethical and privacy considerations. Herein, we discuss the potential importance of cardiac multimodality imaging to improve cardiovascular health in rural regions, outline the emerging experience in this field, highlight important current challenges, and offer solutions based on our experience in the RURAL (Risk Underlying Rural Areas Longitudinal) cohort study.
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Affiliation(s)
- Hooman Fazlalizadeh
- Lundquist Institute, Harbor-University of California Los Angeles Medical Center, Torrance (H.F., M.J.B.)
| | - Muhammad Shahzeb Khan
- Division of Cardiology, Department of Medicine (M.S.K., P.S.D., M.A.D., M.D.K., G.S.B.), Duke University, Durham, NC
| | - Ervin R Fox
- Division of Cardiology, Department of Medicine University of Mississippi Medical Center, Jackson, MS (E.R.F.)
| | - Pamela S Douglas
- Division of Cardiology, Department of Medicine (M.S.K., P.S.D., M.A.D., M.D.K., G.S.B.), Duke University, Durham, NC
- Duke Clinical Research Institute (P.S.D., M.A.D., G.D., M.D.K., G.S.B.), Duke University, Durham, NC
| | - David Adams
- Caption Health, Inc, San Francisco, CA (D.A., R.P.M., Y.T.)
| | - Michael J Blaha
- Lundquist Institute, Harbor-University of California Los Angeles Medical Center, Torrance (H.F., M.J.B.)
| | - Melissa A Daubert
- Division of Cardiology, Department of Medicine (M.S.K., P.S.D., M.A.D., M.D.K., G.S.B.), Duke University, Durham, NC
- Duke Clinical Research Institute (P.S.D., M.A.D., G.D., M.D.K., G.S.B.), Duke University, Durham, NC
| | - Gary Dunn
- Duke Clinical Research Institute (P.S.D., M.A.D., G.D., M.D.K., G.S.B.), Duke University, Durham, NC
| | - Edwin van den Heuvel
- Department of Mathematics and Computer Science, Eindhoven University of Technology, The Netherlands (E.v.d.H.)
| | - Michelle D Kelsey
- Division of Cardiology, Department of Medicine (M.S.K., P.S.D., M.A.D., M.D.K., G.S.B.), Duke University, Durham, NC
- Duke Clinical Research Institute (P.S.D., M.A.D., G.D., M.D.K., G.S.B.), Duke University, Durham, NC
| | | | - James D Thomas
- Division of Cardiology, Department of Medicine, Northwestern University Feinberg School of Medicine, Chicago, IL (J.D.T.)
- Center for Artificial Intelligence, Northwestern Medicine Bluhm Cardiovascular Institute, Chicago, IL (J.D.T.)
| | - Yngvil Thomas
- Caption Health, Inc, San Francisco, CA (D.A., R.P.M., Y.T.)
| | - Suzanne E Judd
- Department of Biostatistics, University of Alabama at Birmingham (S.E.J.)
| | - Ramachandran S Vasan
- University of Texas Health Sciences Center, University of Texas School of Public Health, San Antonio (R.S.V.)
| | - Matthew J Budoff
- Division of Cardiology, John Hopkins University School of Medicine, Baltimore, MD (M.J.B.)
| | - Gerald S Bloomfield
- Division of Cardiology, Department of Medicine (M.S.K., P.S.D., M.A.D., M.D.K., G.S.B.), Duke University, Durham, NC
- Duke Clinical Research Institute (P.S.D., M.A.D., G.D., M.D.K., G.S.B.), Duke University, Durham, NC
- Duke Global Health Institute (G.S.B.), Duke University, Durham, NC
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Kelsey MD, Pagidipati NJ. Should We "RESPECT EPA" More Now? EPA and DHA for Cardiovascular Risk Reduction. Curr Cardiol Rep 2023; 25:1601-1609. [PMID: 37812346 DOI: 10.1007/s11886-023-01972-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 09/24/2023] [Indexed: 10/10/2023]
Abstract
PURPOSE OF REVIEW There has been much debate surrounding the use of omega-3 fatty acids, eicosapentaenoic acid (EPA) and docosahexaenoic acid (DHA), for cardiovascular (CV) risk reduction. RECENT FINDINGS Recent trials of EPA and DHA have offered conflicting evidence. Some demonstrate reduction in CV risk using EPA alone in select populations. Others have demonstrated no benefit, with potential for side effects, such as new-onset atrial fibrillation. Both EPA and DHA have favorable impact on lipids and inflammation, suggesting some biological plausibility for CV risk reduction. However, clinical trials of these agents have produced mixed results. Based on available evidence, EPA may work better for CV risk than DHA and EPA combined. The benefit of EPA seems to be dose dependent, though higher doses may have more side effects. Further research is needed to define the role of EPA and DHA in the landscape of CV risk reduction.
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Affiliation(s)
- Michelle D Kelsey
- Division of Cardiology, Department of Medicine, Duke University School of Medicine, Durham, NC, USA.
- Duke Clinical Research Institute, 300 W Morgan St, Durham, NC, 27710, USA.
| | - Neha J Pagidipati
- Division of Cardiology, Department of Medicine, Duke University School of Medicine, Durham, NC, USA
- Duke Clinical Research Institute, 300 W Morgan St, Durham, NC, 27710, USA
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Udelson JE, Kelsey MD, Nanna MG, Fordyce CB, Yow E, Clare RM, Mark DB, Patel MR, Rogers C, Curzen N, Pontone G, Maurovich-Horvat P, De Bruyne B, Greenwood JP, Marinescu V, Leipsic J, Stone GW, Ben-Yehuda O, Berry C, Hogan SE, Redfors B, Ali ZA, Byrne RA, Kramer CM, Yeh RW, Martinez B, Mullen S, Huey W, Anstrom KJ, Al-Khalidi HR, Chiswell K, Vemulapalli S, Douglas PS. Deferred Testing in Stable Outpatients With Suspected Coronary Artery Disease: A Prespecified Secondary Analysis of the PRECISE Randomized Clinical Trial. JAMA Cardiol 2023; 8:915-924. [PMID: 37610768 PMCID: PMC10448368 DOI: 10.1001/jamacardio.2023.2614] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/18/2023] [Accepted: 06/26/2023] [Indexed: 08/24/2023]
Abstract
Importance Guidelines recommend deferral of testing for symptomatic people with suspected coronary artery disease (CAD) and low pretest probability. To our knowledge, no randomized trial has prospectively evaluated such a strategy. Objective To assess process of care and health outcomes in people identified as minimal risk for CAD when testing is deferred. Design, Setting, and Participants This randomized, pragmatic effectiveness trial included prespecified subgroup analysis of the PRECISE trial at 65 North American and European sites. Participants identified as minimal risk by the validated PROMISE minimal risk score (PMRS) were included. Intervention Randomization to a precision strategy using the PMRS to assign those with minimal risk to deferred testing and others to coronary computed tomography angiography with selective computed tomography-derived fractional flow reserve, or to usual testing (stress testing or catheterization with PMRS masked). Randomization was stratified by PMRS risk. Main Outcome Composite of all-cause death, nonfatal myocardial infarction (MI), or catheterization without obstructive CAD through 12 months. Results Among 2103 participants, 422 were identified as minimal risk (20%) and randomized to deferred testing (n = 214) or usual testing (n = 208). Mean age (SD) was 46 (8.6) years; 304 were women (72%). During follow-up, 138 of those randomized to deferred testing never had testing (64%), whereas 76 had a downstream test (36%) (at median [IQR] 48 [15-78] days) for worsening (30%), uncontrolled (10%), or new symptoms (6%), or changing clinician preference (19%) or participant preference (10%). Results were normal for 96% of these tests. The primary end point occurred in 2 deferred testing (0.9%) and 13 usual testing participants (6.3%) (hazard ratio, 0.15; 95% CI, 0.03-0.66; P = .01). No death or MI was observed in the deferred testing participants, while 1 noncardiovascular death and 1 MI occurred in the usual testing group. Two participants (0.9%) had catheterizations without obstructive CAD in the deferred testing group and 12 (5.8%) with usual testing (P = .02). At baseline, 70% of participants had frequent angina and there was similar reduction of frequent angina to less than 20% at 12 months in both groups. Conclusion and Relevance In symptomatic participants with suspected CAD, identification of minimal risk by the PMRS guided a strategy of initially deferred testing. The strategy was safe with no observed adverse outcome events, fewer catheterizations without obstructive CAD, and similar symptom relief compared with usual testing. Trial Registration ClinicalTrials.gov Identifier: NCT03702244.
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Affiliation(s)
- James E. Udelson
- Division of Cardiology and the CardioVascular Center, Tufts Medical Center, Boston, Massachusetts
| | - Michelle D. Kelsey
- Duke Clinical Research Institute, Duke University School of Medicine, Durham, North Carolina
| | - Michael G. Nanna
- Section of Cardiovascular Medicine, Yale University School of Medicine, New Haven, Connecticut
| | - Christopher B. Fordyce
- Division of Cardiology, Department of Medicine, and Centre for Cardiovascular Innovation, University of British Columbia, Vancouver, British Columbia, Canada
| | - Eric Yow
- Duke Clinical Research Institute, Duke University School of Medicine, Durham, North Carolina
| | - Robert M. Clare
- Duke Clinical Research Institute, Duke University School of Medicine, Durham, North Carolina
| | - Daniel B. Mark
- Duke Clinical Research Institute, Duke University School of Medicine, Durham, North Carolina
| | - Manesh R. Patel
- Duke Clinical Research Institute, Duke University School of Medicine, Durham, North Carolina
- Division of Cardiology, Duke University School of Medicine, Durham, North Carolina
| | | | - Nick Curzen
- Faculty of Medicine, University of Southampton and Cardiothoracic Unit, University Hospital Southampton, Southampton, United Kingdom
| | - Gianluca Pontone
- Department of Perioperative Cardiology and Cardiovascular Imaging, Centro Cardiologico Monzino Instituto di Ricovero e Cura a Carattere Scientifico, Milan, Italy
| | - Pál Maurovich-Horvat
- MTA-SE Cardiovascular Imaging Research Group, Heart and Vascular Center, and Medical Imaging Centre, Semmelweis University, Budapest, Hungary
| | - Bernard De Bruyne
- Cardiovascular Center Aalst, Onze Lieve Vrouwziekenhuis-Clinic, Aalst, Belgium
- Department of Cardiology, Lausanne University Hospital, Lausanne, Switzerland
| | - John P. Greenwood
- Leeds Institute of Cardiovascular and Metabolic Medicine, University of Leeds, and Leeds Teaching Hospitals NHS Trust, Leeds, United Kingdom
| | - Victor Marinescu
- Midwest Cardiovascular Institute, Chicago Medical School, Edward-Elmhurst Health, Naperville, Illinois
- Edward-Elmhurst Health, Naperville, Illinois
| | - Jonathon Leipsic
- Departments of Radiology and Medicine (Cardiology), University of British Columbia, Vancouver, British Columbia, Canada
| | - Gregg W. Stone
- The Zena and Michael A. Wiener Cardiovascular Institute, Icahn School of Medicine at Mount Sinai, New York, New York
| | | | - Colin Berry
- British Heart Foundation Glasgow Cardiovascular Research Centre, University of Glasgow, United Kingdom
| | - Shea E. Hogan
- CPC Clinical Research, and University of Colorado School of Medicine, Aurora
| | - Bjorn Redfors
- Cardiovascular Research Foundation, New York, New York
- Department of Cardiology, Sahlgrenska University Hospital, Gothenburg, Sweden
| | - Ziad A. Ali
- St Francis Hospital & Heart Center, Roslyn, New York
| | - Robert A. Byrne
- Department of Cardiology and Cardiovascular Research Institute Dublin, Mater Private Network, Dublin, Ireland
- School of Pharmacy and Biomolecular Sciences, Royal College of Surgeons in Ireland, University of Medicine and Health Sciences, Dublin, Ireland
| | | | - Robert W. Yeh
- Richard A. and Susan F. Smith Center for Outcomes Research, Beth Israel Deaconess Medical Center, Boston, Massachusetts
| | - Beth Martinez
- Duke Clinical Research Institute, Duke University School of Medicine, Durham, North Carolina
| | | | | | | | - Hussein R. Al-Khalidi
- Department of Biostatistics and Bioinformatics, Duke Clinical Research Institute, Duke University School of Medicine, Durham, North Carolina
| | - Karen Chiswell
- Duke Clinical Research Institute, Duke University School of Medicine, Durham, North Carolina
| | - Sreekanth Vemulapalli
- Duke Clinical Research Institute, Duke University School of Medicine, Durham, North Carolina
- Division of Cardiology, Duke University School of Medicine, Durham, North Carolina
| | - Pamela S. Douglas
- Duke Clinical Research Institute, Duke University School of Medicine, Durham, North Carolina
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Douglas PS, Nanna MG, Kelsey MD, Yow E, Mark DB, Patel MR, Rogers C, Udelson JE, Fordyce CB, Curzen N, Pontone G, Maurovich-Horvat P, De Bruyne B, Greenwood JP, Marinescu V, Leipsic J, Stone GW, Ben-Yehuda O, Berry C, Hogan SE, Redfors B, Ali ZA, Byrne RA, Kramer CM, Yeh RW, Martinez B, Mullen S, Huey W, Anstrom KJ, Al-Khalidi HR, Vemulapalli S. Comparison of an Initial Risk-Based Testing Strategy vs Usual Testing in Stable Symptomatic Patients With Suspected Coronary Artery Disease: The PRECISE Randomized Clinical Trial. JAMA Cardiol 2023; 8:904-914. [PMID: 37610731 PMCID: PMC10448364 DOI: 10.1001/jamacardio.2023.2595] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/14/2023] [Accepted: 06/26/2023] [Indexed: 08/24/2023]
Abstract
Importance Trials showing equivalent or better outcomes with initial evaluation using coronary computed tomography angiography (cCTA) compared with stress testing in patients with stable chest pain have informed guidelines but raise questions about overtesting and excess catheterization. Objective To test a modified initial cCTA strategy designed to improve clinical efficiency vs usual testing (UT). Design, Setting, and Participants This was a pragmatic randomized clinical trial enrolling participants from December 3, 2018, to May 18, 2021, with a median of 11.8 months of follow-up. Patients from 65 North American and European sites with stable symptoms of suspected coronary artery disease (CAD) and no prior testing were randomly assigned 1:1 to precision strategy (PS) or UT. Interventions PS incorporated the Prospective Multicenter Imaging Study for the Evaluation of Chest Pain (PROMISE) minimal risk score to quantitatively select minimal-risk participants for deferred testing, assigning all others to cCTA with selective CT-derived fractional flow reserve (FFR-CT). UT included site-selected stress testing or catheterization. Site clinicians determined subsequent care. Main Outcomes and Measures Outcomes were clinical efficiency (invasive catheterization without obstructive CAD) and safety (death or nonfatal myocardial infarction [MI]) combined into a composite primary end point. Secondary end points included safety components of the primary outcome and medication use. Results A total of 2103 participants (mean [SD] age, 58.4 [11.5] years; 1056 male [50.2%]) were included in the study, and 422 [20.1%] were classified as minimal risk. The primary end point occurred in 44 of 1057 participants (4.2%) in the PS group and in 118 of 1046 participants (11.3%) in the UT group (hazard ratio [HR], 0.35; 95% CI, 0.25-0.50). Clinical efficiency was higher with PS, with lower rates of catheterization without obstructive disease (27 [2.6%]) vs UT participants (107 [10.2%]; HR, 0.24; 95% CI, 0.16-0.36). The safety composite of death/MI was similar (HR, 1.52; 95% CI, 0.73-3.15). Death occurred in 5 individuals (0.5%) in the PS group vs 7 (0.7%) in the UT group (HR, 0.71; 95% CI, 0.23-2.23), and nonfatal MI occurred in 13 individuals (1.2%) in the PS group vs 5 (0.5%) in the UT group (HR, 2.65; 95% CI, 0.96-7.36). Use of lipid-lowering (450 of 900 [50.0%] vs 365 of 873 [41.8%]) and antiplatelet (321 of 900 [35.7%] vs 237 of 873 [27.1%]) medications at 1 year was higher in the PS group compared with the UT group (both P < .001). Conclusions and Relevance An initial diagnostic approach to stable chest pain starting with quantitative risk stratification and deferred testing for minimal-risk patients and cCTA with selective FFR-CT in all others increased clinical efficiency relative to UT at 1 year. Additional randomized clinical trials are needed to verify these findings, including safety. Trial Registration ClinicalTrials.gov Identifier: NCT03702244.
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Affiliation(s)
- Pamela S. Douglas
- Duke Clinical Research Institute, Duke University School of Medicine, Durham, North Carolina
| | - Michael G. Nanna
- Section of Cardiovascular Medicine, Yale University School of Medicine, New Haven, Connecticut
| | - Michelle D. Kelsey
- Duke Clinical Research Institute, Duke University School of Medicine, Durham, North Carolina
| | - Eric Yow
- Duke Clinical Research Institute, Duke University School of Medicine, Durham, North Carolina
| | - Daniel B. Mark
- Duke Clinical Research Institute, Duke University School of Medicine, Durham, North Carolina
| | - Manesh R. Patel
- Duke Clinical Research Institute, Duke University School of Medicine, Durham, North Carolina
- Division of Cardiology, Duke University School of Medicine, Durham, North Carolina
| | | | - James E. Udelson
- Division of Cardiology and the CardioVascular Center, Tufts Medical Center, Boston, Massachusetts
| | - Christopher B. Fordyce
- Division of Cardiology, Department of Medicine, Centre for Cardiovascular Innovation, University of British Columbia, Vancouver, British Columbia, Canada
| | - Nick Curzen
- Faculty of Medicine, University of Southampton, Cardiothoracic Unit, University Hospital Southampton, Southampton, United Kingdom
| | - Gianluca Pontone
- Department of Perioperative Cardiology and Cardiovascular Imaging, Centro Cardiologico Monzino Instituto di Ricovero e Cura a Carattere Scientifico, Milan, Italy
- Department of Biomedical, Surgical and Dental Sciences, University of Milan, Milan, Italy
| | - Pál Maurovich-Horvat
- MTA-SE Cardiovascular Imaging Research Group, Heart and Vascular Center, Medical Imaging Centre, Semmelweis University, Budapest, Hungary
| | - Bernard De Bruyne
- Cardiovascular Center Aalst, Onze Lieve Vrouwziekenhuis Clinic, Aalst, Belgium
- Department of Cardiology, Lausanne University Hospital, Lausanne, Switzerland
| | - John P. Greenwood
- Leeds Institute of Cardiovascular and Metabolic Medicine, University of Leeds, Leeds Teaching Hospitals NHS Trust, United Kingdom
| | - Victor Marinescu
- Midwest Cardiovascular Institute, Chicago Medical School, Edward-Elmhurst Health, Naperville, Illinois
| | - Jonathon Leipsic
- Departments of Radiology and Medicine (Cardiology), University of British Columbia, Vancouver, British Columbia, Canada
| | - Gregg W. Stone
- The Zena and Michael A. Wiener Cardiovascular Institute, Icahn School of Medicine at Mount Sinai, New York, New York
| | | | - Colin Berry
- British Heart Foundation Glasgow Cardiovascular Research Centre, University of Glasgow, United Kingdom
| | - Shea E. Hogan
- CPC Clinical Research, University of Colorado School of Medicine, Aurora
| | - Bjorn Redfors
- Cardiovascular Research Foundation, New York, New York
- Department of Cardiology, Sahlgrenska University Hospital, Gothenburg, Sweden
| | - Ziad A. Ali
- St Francis Hospital & Heart Center, Roslyn, New York
| | - Robert A. Byrne
- Department of Cardiology, Cardiovascular Research Institute Dublin, Mater Private Network, Dublin, Ireland
- School of Pharmacy and Biomolecular Sciences, Royal College of Surgeons in Ireland, University of Medicine and Health Sciences, Dublin, Ireland
| | | | - Robert W. Yeh
- Richard A. and Susan F. Smith Center for Outcomes Research, Beth Israel Deaconess Medical Center, Boston, Massachusetts
| | - Beth Martinez
- Duke Clinical Research Institute, Duke University School of Medicine, Durham, North Carolina
| | | | | | | | - Hussein R. Al-Khalidi
- Duke Clinical Research Institute, Duke University School of Medicine, Durham, North Carolina
- Department of Biostatistics and Bioinformatics, Duke University School of Medicine, Durham, North Carolina
| | - Sreekanth Vemulapalli
- Duke Clinical Research Institute, Duke University School of Medicine, Durham, North Carolina
- Division of Cardiology, Duke University School of Medicine, Durham, North Carolina
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Kelsey MD, Newby LK. In statin-intolerant adults with, or at risk for, CV disease, bempedoic acid reduced MACE at a median 41 mo. Ann Intern Med 2023. [PMID: 37399554 DOI: 10.7326/j23-0044] [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: 07/05/2023] Open
Abstract
SOURCE CITATION Nissen SE, Lincoff MA, Brennan D, et al; CLEAR Outcomes Investigators. Bempedoic acid and cardiovascular outcomes in statin-intolerant patients. N Engl J Med. 2023;388:1353-1364. 36876740.
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Affiliation(s)
- Michelle D Kelsey
- Division of Cardiology and Duke Clinical Research Institute, Duke University, Durham, North Carolina, USA (M.D.K., L.K.N.)
| | - L Kristin Newby
- Division of Cardiology and Duke Clinical Research Institute, Duke University, Durham, North Carolina, USA (M.D.K., L.K.N.)
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Kelsey MD, Mulder H, Chiswell K, Lampron ZM, Nilles E, Kulinski JP, Joshi PH, Jones WS, Chamberlain AM, Leucker TM, Hwang W, Milks MW, Paranjape A, Obeid JS, Linton MF, Kent ST, Peterson ED, O'Brien EC, Pagidipati NJ. Contemporary patterns of lipoprotein(a) testing and associated clinical care and outcomes. Am J Prev Cardiol 2023; 14:100478. [PMID: 37025553 PMCID: PMC10070377 DOI: 10.1016/j.ajpc.2023.100478] [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: 11/14/2022] [Revised: 02/13/2023] [Accepted: 02/25/2023] [Indexed: 03/06/2023] Open
Abstract
Objective Elevated lipoprotein(a) [Lp(a)] is associated with atherosclerotic cardiovascular disease, yet little is known about Lp(a) testing patterns in real-world practice. The objective of this analysis was to determine how Lp(a) testing is used in clinical practice in comparison with low density lipoprotein cholesterol (LDL-C) testing alone, and to determine whether elevated Lp(a) level is associated with subsequent initiation of lipid-lowering therapy (LLT) and incident cardiovascular (CV) events. Methods This is an observational cohort study, based on lab tests administered between Jan 1, 2015 and Dec 31, 2019. We used electronic health record (EHR) data from 11 United States health systems participating in the National Patient-Centered Clinical Research Network (PCORnet). We created two cohorts for comparison: 1) the Lp(a) cohort, of adults with an Lp(a) test and 2) the LDL-C cohort, of 4:1 date- and site-matched adults with an LDL-C test, but no Lp(a) test. The primary exposure was the presence of an Lp(a) or LDL-C test result. In the Lp(a) cohort, we used logistic regression to assess the relationship between Lp(a) results in mass units (< 50, 50-100, and > 100mg/dL) and molar units (<125, 125-250, > 250nmol/L) and initiation of LLT within 3 months. We used multivariable adjusted Cox proportional hazards regression to evaluate these Lp(a) levels and time to composite CV hospitalization, including hospitalization for myocardial infarction, revascularization and ischemic stroke. Results Overall, 20,551 patients had Lp(a) test results and 2,584,773 patients had LDL-C test results (82,204 included in the matched LDL-C cohort). Compared with the LDL-C cohort, the Lp(a) cohort more frequently had prevalent ASCVD (24.3% vs. 8.5%) and multiple prior CV events (8.6% vs. 2.6%). Elevated Lp(a) was associated with greater odds of subsequent LLT initiation. Elevated Lp(a) reported in mass units was also associated with subsequent composite CV hospitalization [aHR (95% CI): Lp(a) 50-100mg/dL 1.25 (1.02-1.53), p<0.03, Lp(a) > 100mg/dL 1.23 (1.08-1.40), p<0.01]. Conclusion Lp(a) testing is relatively infrequent in health systems across the U.S. As new therapies for Lp(a) emerge, improved patient and provider education is needed to increase awareness of the utility of this risk marker.
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Affiliation(s)
- Michelle D. Kelsey
- Division of Cardiology, Department of Medicine, Duke University Medical Center, Durham, NC, USA
- Duke Clinical Research Institute, Durham, NC, USA
| | | | | | | | - Ester Nilles
- Duke Clinical Research Institute, Durham, NC, USA
| | - Jacquelyn P. Kulinski
- Department of Medicine, Division of Cardiology, Medical College of Wisconsin, Milwaukee, USA
| | - Parag H. Joshi
- Department of Medicine, Division of Cardiology, University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - W. Schuyler Jones
- Division of Cardiology, Department of Medicine, Duke University Medical Center, Durham, NC, USA
- Duke Clinical Research Institute, Durham, NC, USA
| | - Alanna M. Chamberlain
- Department of Quantitative Health Sciences Research, Mayo Clinic, Rochester, MN, USA
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, MN
| | - Thorsten M. Leucker
- Johns Hopkins Ciccarone Center for the Prevention of Cardiovascular Disease, Baltimore, MD, USA
| | - Wenke Hwang
- Department of Public Health Sciences, Penn State Hershey Medical Center, The Pennsylvania State University, PA, USA
| | - M. Wesley Milks
- Division of Cardiovascular Medicine, Department of Internal Medicine, The Ohio State University Wexner Medical Center, Columbus, OH, USA
| | - Anuradha Paranjape
- Department of Medicine, Temple University Lewis Katz School of Medicine, Philadelphia, PA, USA
| | - Jihad S. Obeid
- Division of Biomedical Informatics, Department of Public Health Sciences, Medical University of South Carolina, Charleston, SC, USA
| | - MacRae F. Linton
- Division of Cardiovascular Medicine, Department of Medicine, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Shia T. Kent
- Center for Observational Research, Amgen Inc., Thousand Oaks, CA, USA
| | - Eric D. Peterson
- Department of Medicine, Division of Cardiology, University of Texas Southwestern Medical Center, Dallas, TX, USA
| | | | - Neha J. Pagidipati
- Division of Cardiology, Department of Medicine, Duke University Medical Center, Durham, NC, USA
- Duke Clinical Research Institute, Durham, NC, USA
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9
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Rao VN, Shah A, McDermott J, Barnes SG, Murray EM, Kelsey MD, Greene SJ, Fudim M, Devore AD, Patel CB, Blazing MA, O’Brien C, Mentz RJ. In-Hospital Virtual Peer-to-Peer Consultation to Increase Guideline-Directed Medical Therapy for Heart Failure: A Pilot Randomized Trial. Circ Heart Fail 2023; 16:e010158. [PMID: 36314130 PMCID: PMC9974597 DOI: 10.1161/circheartfailure.122.010158] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/06/2022] [Accepted: 10/11/2022] [Indexed: 11/16/2022]
Abstract
BACKGROUND Guideline-directed medical therapy (GDMT) for heart failure with reduced ejection fraction (HFrEF) improves clinical outcomes and quality of life. Optimizing GDMT in the hospital is associated with greater long-term use in HFrEF. This study aimed to describe the efficacy of a multidisciplinary virtual HF intervention on GDMT optimization among patients with HFrEF admitted for any cause. METHODS In this pilot randomized, controlled study, consecutive patients with HFrEF admitted to noncardiology medicine services for any cause were identified at a large academic tertiary care hospital between May to September 2021. Major exclusions were end-stage renal disease, hemodynamic instability, concurrent COVID-19 infection, and current enrollment in hospice care. Patients were randomized to a clinician-level virtual peer-to-peer consult intervention providing GDMT recommendations and information on medication costs versus usual care. Primary end points included (1) proportion of patients with new GDMT initiation or use and (2) changes to HF optimal medical therapy scores which included target dosing (range, 0-9). RESULTS Of 242 patients identified, 91 (38%) were eligible and randomized to intervention (N=52) or usual care (N=39). Baseline characteristics were similar between intervention and usual care (mean age 63 versus 67 years, 23% versus 26% female, 46% versus 49% Black, mean ejection fraction 33% versus 31%). GDMT use on admission was also similar. There were greater proportions of patients with GDMT initiation or continuation with the intervention compared with usual care. After adjusting for optimal medical therapy score on admission, changes to optimal medical therapy score at discharge were higher for the intervention group compared with usual care (+0.44 versus -0.31, absolute difference +0.75, adjusted estimate 0.86±0.42; P=0.041). CONCLUSIONS Among eligible patients with HFrEF hospitalized for any cause on noncardiology services, a multidisciplinary pilot virtual HF consultation increased new GDMT initiation and dose optimization at discharge.
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Affiliation(s)
- Vishal N. Rao
- Division of Cardiology, Duke University Medical Center, Durham, NC
- Duke Clinical Research Institute, Durham, NC
| | - Anand Shah
- Department of Medicine, Duke University Medical Center, Durham, NC
| | - Jaime McDermott
- Division of Cardiology, Duke University Medical Center, Durham, NC
| | | | - Evan M. Murray
- Department of Medicine, Duke University Medical Center, Durham, NC
| | - Michelle D. Kelsey
- Division of Cardiology, Duke University Medical Center, Durham, NC
- Duke Clinical Research Institute, Durham, NC
| | - Stephen J. Greene
- Division of Cardiology, Duke University Medical Center, Durham, NC
- Duke Clinical Research Institute, Durham, NC
| | - Marat Fudim
- Division of Cardiology, Duke University Medical Center, Durham, NC
- Duke Clinical Research Institute, Durham, NC
| | - Adam D. Devore
- Division of Cardiology, Duke University Medical Center, Durham, NC
- Duke Clinical Research Institute, Durham, NC
| | - Chetan B. Patel
- Division of Cardiology, Duke University Medical Center, Durham, NC
| | | | - Cara O’Brien
- Department of Medicine, Duke University Medical Center, Durham, NC
| | - Robert J. Mentz
- Division of Cardiology, Duke University Medical Center, Durham, NC
- Duke Clinical Research Institute, Durham, NC
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10
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Nelson AJ, Pagidipati NJ, Kelsey MD, Ardissino M, Aroda VR, Cavender MA, Lopes RD, Al-Khalidi HR, Braceras R, Gaynor T, Kaltenbach LA, Kirk JK, Lingvay I, Magwire ML, O'Brien EC, Pak J, Pop-Busui R, Richardson CR, Levya M, Senyucel C, Webb L, McGuire DK, Green JB, Granger CB. Coordinating Cardiology clinics randomized trial of interventions to improve outcomes (COORDINATE) - Diabetes: rationale and design. Am Heart J 2023; 256:2-12. [PMID: 36279931 DOI: 10.1016/j.ahj.2022.10.079] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/04/2022] [Revised: 10/13/2022] [Accepted: 10/18/2022] [Indexed: 06/16/2023]
Abstract
Several medications that are proven to reduce cardiovascular events exist for individuals with type 2 diabetes mellitus (T2DM) and atherosclerotic cardiovascular disease, however they are substantially underused in clinical practice. Clinician, patient, and system-level barriers all contribute to these gaps in care; yet, there is a paucity of high quality, rigorous studies evaluating the role of interventions to increase utilization. The COORDINATE-Diabetes trial randomized 42 cardiology clinics across the United States to either a multifaceted, site-specific intervention focused on evidence-based care for patients with T2DM or standard of care. The multifaceted intervention comprised the development of an interdisciplinary care pathway for each clinic, audit-and-feedback tools and educational outreach, in addition to patient-facing tools. The primary outcome is the proportion of individuals with T2DM prescribed three key classes of evidence-based medications (high-intensity statin, angiotensin converting enzyme inhibitor or angiotensin receptor blocker, and either a sodium/glucose cotransporter-2 inhibitor (SGLT-2i) inhibitor or glucagon-like peptide 1 receptor agonist (GLP-1RA) and will be assessed at least 6 months after participant enrollment. COORDINATE-Diabetes aims to identify strategies that improve the implementation and adoption of evidence-based therapies.
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Affiliation(s)
| | | | | | | | | | | | | | | | | | - Tanya Gaynor
- Boehringer Ingelheim Pharmaceuticals, Inc. Ridgefield, CT
| | | | - Julienne K Kirk
- Wake Forest University School of Medicine, Winston Salem, NC
| | - Ildiko Lingvay
- University of Texas Southwestern Medical Center, Dallas, TX
| | | | | | - Jonathan Pak
- Boehringer Ingelheim Pharmaceuticals, Inc. Ridgefield, CT
| | | | | | | | | | - Laura Webb
- Duke Clinical Research Institute, Durham, NC
| | - Darren K McGuire
- University of Texas Southwestern Medical Center, Dallas, TX; Parkland Health and Hospital System, Dallas, TX
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11
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Kelsey MD, Newby LK. In ASCVD, moderate-intensity statin + ezetimibe was noninferior to high-intensity statin alone at 3 y. Ann Intern Med 2022; 175:JC126. [PMID: 36315955 DOI: 10.7326/j22-0085] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
Kim BK, Hong SJ, Lee YJ, et al. Long-term efficacy and safety of moderate-intensity statin with ezetimibe combination therapy versus high-intensity statin monotherapy in patients with atherosclerotic cardiovascular disease (RACING): a randomised, open-label, non-inferiority trial. Lancet. 202;400:380-90. 35863366.
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Affiliation(s)
- Michelle D Kelsey
- Duke University and Duke Clinical Research Institute, Durham, North Carolina, USA (M.D.K., L.K.N.)
| | - L Kristin Newby
- Duke University and Duke Clinical Research Institute, Durham, North Carolina, USA (M.D.K., L.K.N.)
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12
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Rao VN, Mentz RJ, Coniglio AC, Kelsey MD, Fudim M, Fonarow GC, Matsouaka RA, DeVore AD, Caughey MC. Neighborhood Socioeconomic Disadvantage and Hospitalized Heart Failure Outcomes in the American Heart Association Get With The Guidelines-Heart Failure Registry. Circ Heart Fail 2022; 15:e009353. [PMID: 36378758 PMCID: PMC9673180 DOI: 10.1161/circheartfailure.121.009353] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/29/2021] [Accepted: 06/13/2022] [Indexed: 11/16/2022]
Abstract
BACKGROUND Neighborhood socioeconomic status (SES) is associated with worse health outcomes, yet its relationship with in-hospital heart failure (HF) outcomes and quality metrics are underexplored. We examined the association between socioeconomic neighborhood disadvantage and in-hospital HF outcomes for patients from diverse neighborhoods in the Get With The Guidelines-Heart Failure registry. METHODS SES-disadvantage scores were derived from geocoded US census data using a validated algorithm, which incorporated household income, home value, rent, education, and employment. We examined the association between SES-disadvantage quintiles with all-cause in-hospital mortality, adjusting for demographics and comorbidities. RESULTS Of 593 053 patients hospitalized for HF between 2017 and 2020, 321 314 (54%) had residential ZIP Codes recorded. Patients from the most compared with least disadvantaged neighborhoods were younger (mean age 67 versus 76 years), more often Black (42% versus 9%) or Hispanic (14% versus 5%), and had higher comorbidity burden. Demographic-adjusted length of stay increased by ≈1.5 hours with each increment in worsening SES-disadvantage quintiles. Adjusted-mortality odds ratios increased with worsening SES-disadvantage quintiles (Ptrend=0.003), and was 28% higher (adjusted OR=1.28 [1.12-1.48]) for the most compared with least disadvantaged neighborhood groups. CONCLUSIONS Patients hospitalized for HF from disadvantaged neighborhoods were younger and more often Black or Hispanic. SES disadvantage was independently associated with higher in-hospital mortality. Further research is needed to characterize care delivery patterns in disadvantaged neighborhoods and to address social determinants of health among patients hospitalized for HF. REGISTRATION: URL: https://www. CLINICALTRIALS gov; Unique identifier: NCT02693509.
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Affiliation(s)
- Vishal N. Rao
- Division of Cardiology, Duke University Medical Center, Durham, North Carolina
- Duke Clinical Research Institute, Duke University School of Medicine, Durham, North Carolina
| | - Robert J. Mentz
- Division of Cardiology, Duke University Medical Center, Durham, North Carolina
- Duke Clinical Research Institute, Duke University School of Medicine, Durham, North Carolina
| | - Amanda C. Coniglio
- Division of Cardiology, Duke University Medical Center, Durham, North Carolina
| | - Michelle D. Kelsey
- Division of Cardiology, Duke University Medical Center, Durham, North Carolina
- Duke Clinical Research Institute, Duke University School of Medicine, Durham, North Carolina
| | - Marat Fudim
- Division of Cardiology, Duke University Medical Center, Durham, North Carolina
- Duke Clinical Research Institute, Duke University School of Medicine, Durham, North Carolina
| | - Gregg C. Fonarow
- Division of Cardiology, Department of Medicine, University of California at Los Angeles, Los Angeles, California
| | - Roland A. Matsouaka
- Duke Clinical Research Institute, Duke University School of Medicine, Durham, North Carolina
| | - Adam D. DeVore
- Division of Cardiology, Duke University Medical Center, Durham, North Carolina
- Duke Clinical Research Institute, Duke University School of Medicine, Durham, North Carolina
| | - Melissa C. Caughey
- Joint Department of Biomedical Engineering, University of North Carolina and North Carolina State University, Chapel Hill, North Carolina
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13
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Drescher CS, Kelsey MD, Yankey GS, Sun AY, Wang A, Sadeghpour A, Glower DD, Vemulapalli S, Kelsey AM. Imaging Considerations and Clinical Implications of Mitral Annular Disjunction. Circ Cardiovasc Imaging 2022; 15:e014243. [PMID: 36126123 DOI: 10.1161/circimaging.122.014243] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
Mitral annular disjunction is increasingly recognized as an important anatomic feature of mitral valve disease. The presence of mitral annular disjunction, defined as separation between the left atrial wall at the point of mitral valve insertion and the left ventricular free wall, has been associated with increased degeneration of the mitral valve and increased incidence of sudden cardiac death. The clinical importance of this entity necessitates standard reporting on cardiovascular imaging reports if patients are to receive adequate risk stratification and management. We provide a narrative review of the literature pertaining to mitral annular disjunction, its clinical implications, and areas needing further research.
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Affiliation(s)
- Caitlin S Drescher
- Division of Cardiology, Duke University, Durham, North Carolina (C.S.D., M.D.K., G.S.Y., A.Y.S., A.W., S.V., A.M.K.)
| | - Michelle D Kelsey
- Division of Cardiology, Duke University, Durham, North Carolina (C.S.D., M.D.K., G.S.Y., A.Y.S., A.W., S.V., A.M.K.)
| | - George S Yankey
- Division of Cardiology, Duke University, Durham, North Carolina (C.S.D., M.D.K., G.S.Y., A.Y.S., A.W., S.V., A.M.K.)
| | - Albert Y Sun
- Division of Cardiology, Duke University, Durham, North Carolina (C.S.D., M.D.K., G.S.Y., A.Y.S., A.W., S.V., A.M.K.)
| | - Andrew Wang
- Division of Cardiology, Duke University, Durham, North Carolina (C.S.D., M.D.K., G.S.Y., A.Y.S., A.W., S.V., A.M.K.)
| | - Anita Sadeghpour
- Medstar Health Research Institute, Washington, D.C. (A.S.).,Duke Cardiovascular MR Center, Durham, NC (A.S.)
| | - Donald D Glower
- Department of Surgery, Duke University, Durham, North Carolina (D.D.G.)
| | - Sreekanth Vemulapalli
- Division of Cardiology, Duke University, Durham, North Carolina (C.S.D., M.D.K., G.S.Y., A.Y.S., A.W., S.V., A.M.K.)
| | - Anita M Kelsey
- Division of Cardiology, Duke University, Durham, North Carolina (C.S.D., M.D.K., G.S.Y., A.Y.S., A.W., S.V., A.M.K.)
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14
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Kelsey MD, Newby LK. Recommendations for use of ezetimibe and/or PCSK9 inhibitors in patients with elevated LDL-C. Ann Intern Med 2022; 175:JC86. [PMID: 35914252 DOI: 10.7326/j22-0060] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
Hao Q, Aertgeerts B, Guyatt G, et al. PCSK9 inhibitors and ezetimibe for the reduction of cardiovascular events: a clinical practice guideline with risk-stratified recommendations. BMJ. 2022;377:e069066. 35508320.
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Affiliation(s)
| | - L Kristin Newby
- Duke University, Durham, North Carolina, USA (M.D.K., L.K.N.)
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15
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Kelsey MD, Nelson AJ, Green JB, Granger CB, Peterson ED, McGuire DK, Pagidipati NJ. Guidelines for Cardiovascular Risk Reduction in Patients With Type 2 Diabetes: JACC Guideline Comparison. J Am Coll Cardiol 2022; 79:1849-1857. [PMID: 35512864 DOI: 10.1016/j.jacc.2022.02.046] [Citation(s) in RCA: 21] [Impact Index Per Article: 10.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/07/2022] [Accepted: 02/22/2022] [Indexed: 12/12/2022]
Abstract
Cardiovascular disease is a leading cause of morbidity and mortality in individuals with type 2 diabetes mellitus. These high-risk patients benefit from aggressive risk factor management, with blood pressure and low-density lipoprotein-cholesterol treatment, glycemic control, kidney protection, and lifestyle intervention. There are several recommendation and guideline documents across cardiology, endocrinology, nephrology, and general medicine professional societies from the United States and Europe with recommendations for cardiovascular risk reduction in patients with type 2 diabetes mellitus. Although there are some noteworthy differences, particularly in risk stratification, low-density lipoprotein-cholesterol and blood pressure treatment targets, and the use of sodium-glucose cotransporter-2 inhibitors and glucagon-like peptide-1 receptor agonists, overall there is considerable alignment across recommendations from different professional societies.
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Affiliation(s)
- Michelle D Kelsey
- Division of Cardiology, Department of Medicine, Duke University Medical Center, Durham, North Carolina, USA; Duke Clinical Research Institute, Durham, North Carolina, USA.
| | - Adam J Nelson
- Duke Clinical Research Institute, Durham, North Carolina, USA. https://twitter.com/ajnelson
| | - Jennifer B Green
- Duke Clinical Research Institute, Durham, North Carolina, USA; Division of Endocrinology, Department of Medicine, Duke University Medical Center, Durham, North Carolina, USA
| | - Christopher B Granger
- Division of Cardiology, Department of Medicine, Duke University Medical Center, Durham, North Carolina, USA; Duke Clinical Research Institute, Durham, North Carolina, USA
| | - Eric D Peterson
- Division of Cardiology, Department of Medicine, University of Texas Southwestern Medical Center, and Parkland Health and Hospital System, Dallas, Texas, USA
| | - Darren K McGuire
- Division of Cardiology, Department of Medicine, University of Texas Southwestern Medical Center, and Parkland Health and Hospital System, Dallas, Texas, USA
| | - Neha J Pagidipati
- Division of Cardiology, Department of Medicine, Duke University Medical Center, Durham, North Carolina, USA; Duke Clinical Research Institute, Durham, North Carolina, USA
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16
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Kelsey MD, Patrick-Lake B, Abdulai R, Broedl UC, Brown A, Cohn E, Curtis LH, Komelasky C, Mbagwu M, Mensah GA, Mentz RJ, Nyaku A, Omokaro SO, Sewards J, Whitlock K, Zhang X, Bloomfield GS. Inclusion and diversity in clinical trials: Actionable steps to drive lasting change. Contemp Clin Trials 2022; 116:106740. [PMID: 35364292 PMCID: PMC9133187 DOI: 10.1016/j.cct.2022.106740] [Citation(s) in RCA: 33] [Impact Index Per Article: 16.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/05/2021] [Revised: 03/21/2022] [Accepted: 03/24/2022] [Indexed: 11/29/2022]
Abstract
BACKGROUND Improving diversity in clinical trials is essential in order to produce generalizable results. Although the importance of representation has become increasingly recognized, identifying strategies to approach this work remains elusive. This article reviews the proceedings of a multi-stakeholder conference about the current state of diversity in clinical trials and outlines actionable steps for improvement. METHODS Conference attendees included representatives from the United States Food and Drug Administration (FDA), National Institutes of Health (NIH), practicing clinical investigators, pharmaceutical and device companies, community-based organizations, data analytics companies, and patient advocacy groups. At this virtual event, attendees were asked to consider key questions around best practices for engagement of underrepresented populations. RESULTS Community engagement is an integral part of recruitment and retention of underrepresented groups. Decentralization of sites and use of digital tools can enhance the accessibility of clinical research. Finally, improving representation among investigators and clinical research staff may translate to diverse clinical trial participants. CONCLUSION Improving diversity in clinical trials is an ethical and scientific imperative, which requires a multifaceted approach.
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Affiliation(s)
- Michelle D Kelsey
- Division of Cardiology, Department of Medicine, Duke University, Durham, NC, USA; Duke Clinical Research Institute, Durham, NC, USA
| | | | | | | | | | | | - Lesley H Curtis
- Duke Clinical Research Institute, Durham, NC, USA; Department of Population Health Sciences, Duke University School of Medicine, Durham, NC, USA
| | | | | | - George A Mensah
- National Heart, Lung, and Blood Institute, National Institutes of Health, Bethesda, MD, USA
| | - Robert J Mentz
- Division of Cardiology, Department of Medicine, Duke University, Durham, NC, USA; Duke Clinical Research Institute, Durham, NC, USA
| | - Amesika Nyaku
- Division of Infectious Diseases, Department of Medicine, Rutgers-New Jersey Medical School, Newark, NJ, USA
| | | | | | | | - Xinzhi Zhang
- National Institute on Minority Health and Health Disparities, National Institutes of Health, Bethesda, MD, USA
| | - Gerald S Bloomfield
- Division of Cardiology, Department of Medicine, Duke University, Durham, NC, USA; Duke Clinical Research Institute, Durham, NC, USA.
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17
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Kelsey MD, Newby LK. In CV disease, GLP-1 RAs and SGLT2 inhibitors reduce CV mortality. Ann Intern Med 2022; 175:JC26. [PMID: 35226528 DOI: 10.7326/j22-0003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
SOURCE CITATION Kanie T, Mizuno A, Takaoka Y, et al. Dipeptidyl peptidase-4 inhibitors, glucagon-like peptide 1 receptor agonists and sodium-glucose co-transporter-2 inhibitors for people with cardiovascular disease: a network meta-analysis. Cochrane Database Syst Rev. 2021;10:CD013650. 34693515.
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Affiliation(s)
| | - L Kristin Newby
- Duke University, Durham, North Carolina, USA (M.D.K., L.K.N.)
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18
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Kelsey MD, Nelson AJ, Green JB, Granger CB, Peterson ED, McGuire DK, Pagidipati NJ. TROPONIN ELEVATION AS A MANIFESTATION OF COVID-19 MYOCARDIAL INFLAMMATION ASSOCIATED WITH INCREASED MORTALITY. J Am Coll Cardiol 2022. [PMID: 35512864 PMCID: PMC8972581 DOI: 10.1016/s0735-1097(22)02840-6] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Affiliation(s)
- Michelle D Kelsey
- Division of Cardiology, Department of Medicine, Duke University Medical Center, Durham, North Carolina, USA; Duke Clinical Research Institute, Durham, North Carolina, USA.
| | - Adam J Nelson
- Duke Clinical Research Institute, Durham, North Carolina, USA. https://twitter.com/ajnelson
| | - Jennifer B Green
- Duke Clinical Research Institute, Durham, North Carolina, USA; Division of Endocrinology, Department of Medicine, Duke University Medical Center, Durham, North Carolina, USA
| | - Christopher B Granger
- Division of Cardiology, Department of Medicine, Duke University Medical Center, Durham, North Carolina, USA; Duke Clinical Research Institute, Durham, North Carolina, USA
| | - Eric D Peterson
- Division of Cardiology, Department of Medicine, University of Texas Southwestern Medical Center, and Parkland Health and Hospital System, Dallas, Texas, USA
| | - Darren K McGuire
- Division of Cardiology, Department of Medicine, University of Texas Southwestern Medical Center, and Parkland Health and Hospital System, Dallas, Texas, USA
| | - Neha J Pagidipati
- Division of Cardiology, Department of Medicine, Duke University Medical Center, Durham, North Carolina, USA; Duke Clinical Research Institute, Durham, North Carolina, USA
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19
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Affiliation(s)
- Vishal N. Rao
- Division of Cardiology, Duke University Medical Center, Durham, NC
| | | | | | | | - Terry A. Fortin
- Division of Cardiology, Duke University Medical Center, Durham, NC
| | - Marat Fudim
- Division of Cardiology, Duke University Medical Center, Durham, NC
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Nelson AJ, O’Brien EC, Kaltenbach LA, Green JB, Lopes RD, Morse CG, Al-Khalidi HR, Aroda VR, Cavender MA, Gaynor T, Kirk JK, Lingvay I, Magwire ML, McGuire DK, Pak J, Pop-Busui R, Richardson CR, Senyucel C, Kelsey MD, Pagidipati NJ, Granger CB. Use of Lipid-, Blood Pressure-, and Glucose-Lowering Pharmacotherapy in Patients With Type 2 Diabetes and Atherosclerotic Cardiovascular Disease. JAMA Netw Open 2022; 5:e2148030. [PMID: 35175345 PMCID: PMC8855234 DOI: 10.1001/jamanetworkopen.2021.48030] [Citation(s) in RCA: 27] [Impact Index Per Article: 13.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/15/2022] Open
Abstract
IMPORTANCE Based on contemporary estimates in the US, evidence-based therapies for cardiovascular risk reduction are generally underused among patients with type 2 diabetes and atherosclerotic cardiovascular disease (ASCVD). OBJECTIVE To determine the use of evidence-based cardiovascular preventive therapies in a broad US population with diabetes and ASCVD. DESIGN, SETTING, AND PARTICIPANTS This multicenter cohort study used health system-level aggregated data within the National Patient-Centered Clinical Research Network, including 12 health systems. Participants included patients with diabetes and established ASCVD (ie, coronary artery disease, cerebrovascular disease, and peripheral artery disease) between January 1 and December 31, 2018. Data were analyzed from September 2020 until January 2021. EXPOSURES One or more health care encounters in 2018. MAIN OUTCOMES AND MEASURES Patient characteristics by prescription of any of the following key evidence-based therapies: high-intensity statin, angiotensin-converting enzyme inhibitor (ACEI) or angiotensin-receptor blocker (ARB) and sodium glucose cotransporter-2 inhibitors (SGLT2I) or glucagon-like peptide-1 receptor agonist (GLP-1RA). RESULTS The overall cohort included 324 706 patients, with a mean (SD) age of 68.1 (12.2) years and 144 169 (44.4%) women and 180 537 (55.6%) men. A total of 59 124 patients (18.2% ) were Black, and 41 470 patients (12.8%) were Latinx. Among 205 885 patients with specialized visit data from the prior year, 17 971 patients (8.7%) visited an endocrinologist, 54 330 patients (26.4%) visited a cardiologist, and 154 078 patients (74.8%) visited a primary care physician. Overall, 190 277 patients (58.6%) were prescribed a statin, but only 88 426 patients (26.8%) were prescribed a high-intensity statin; 147 762 patients (45.5%) were prescribed an ACEI or ARB, 12 724 patients (3.9%) were prescribed a GLP-1RA, and 8989 patients (2.8%) were prescribed an SGLT2I. Overall, 14 918 patients (4.6%) were prescribed all 3 classes of therapies, and 138 173 patients (42.6%) were prescribed none. Patients who were prescribed a high-intensity statin were more likely to be men (59.9% [95% CI, 59.6%-60.3%] of patients vs 55.6% [95% CI, 55.4%-55.8%] of patients), have coronary atherosclerotic disease (79.9% [95% CI, 79.7%-80.2%] of patients vs 73.0% [95% CI, 72.8%-73.3%] of patients) and more likely to have seen a cardiologist (40.0% [95% CI, 39.6%-40.4%] of patients vs 26.4% [95% CI, 26.2%-26.6%] of patients). CONCLUSIONS AND RELEVANCE In this large cohort of US patients with diabetes and ASCVD, fewer than 1 in 20 patients were prescribed all 3 evidence-based therapies, defined as a high-intensity statin, either an ACEI or ARB, and either an SGLT2I and/or a GLP-1RA. These findings suggest that multifaceted interventions are needed to overcome barriers to the implementation of evidence-based therapies and facilitate their optimal use.
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Affiliation(s)
- Adam J. Nelson
- Duke Clinical Research Institute, Durham, North Carolina
| | | | | | | | | | - Caryn G. Morse
- Wake Forest School of Medicine, Winston-Salem, North Carolina
| | | | | | | | - Tanya Gaynor
- Boehringer Ingelheim Pharmaceuticals, Ridgefield, Connecticut
| | | | | | | | - Darren K. McGuire
- University of Texas Southwestern Medical Center, Dallas
- Parkland Health and Hospital System, Dallas, Texas
| | - Jonathan Pak
- Boehringer Ingelheim Pharmaceuticals, Ridgefield, Connecticut
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21
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Kelsey MD, Granger CB. LOW-HARM score predicted mortality in patients hospitalized with COVID-19 in Mexico. Ann Intern Med 2021; 174:JC59. [PMID: 33939489 DOI: 10.7326/acpj202105180-059] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
Soto-Mota A, Marfil-Garza BA, Martinez Rodriguez E, et al. The low-harm score for predicting mortality in patients diagnosed with COVID-19: a multicentric validation study. J Am Coll Emerg Physicians Open. 2020;1:1436-43. 33230506.
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22
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Rao VN, Kelsey MD, Kelsey AM, Russell SD, Mentz RJ, Patel MR, Fudim M. Acute cardiovascular hospitalizations and illness severity before and during the COVID-19 pandemic. Clin Cardiol 2021; 44:656-664. [PMID: 33682157 PMCID: PMC8119829 DOI: 10.1002/clc.23590] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/06/2021] [Revised: 02/25/2021] [Accepted: 03/01/2021] [Indexed: 02/06/2023] Open
Abstract
Background Cardiovascular disease (CVD) hospitalizations declined worldwide during the COVID‐19 pandemic. It is unclear how shelter‐in‐place orders affected acute CVD hospitalizations, illness severity, and outcomes. Hypothesis COVID‐19 pandemic was associated with reduced acute CVD hospitalizations (heart failure [HF], acute coronary syndrome [ACS], and stroke [CVA]), and worse HF illness severity. Methods We compared acute CVD hospitalizations at Duke University Health System before and after North Carolina's shelter‐in‐place order (January 1–March 29 vs. March 30–August 31), and used parallel comparison cohorts from 2019. We explored illness severity among admitted HF patients using ADHERE (“high risk”: >2 points) and GWTG‐HF (“>10%”: >57 points) in‐hospital mortality risk scores, as well as echocardiography‐derived parameters. Results Comparing hospitalizations during January 1–March 29 (N = 1618) vs. March 30–August 31 (N = 2501) in 2020, mean daily CVD hospitalizations decreased (18.2 vs. 16.1 per day, p = .0036), with decreased length of stay (8.4 vs. 7.5 days, p = .0081) and no change in in‐hospital mortality (4.7 vs. 5.3%, p = .41). HF hospitalizations decreased (9.0 vs. 7.7 per day, p = .0019), with higher ADHERE (“high risk”: 2.5 vs. 4.5%; p = .030), but unchanged GWTG‐HF (“>10%”: 5.3 vs. 4.6%; p = .45), risk groups. Mean LVEF was lower (39.0 vs. 37.2%, p = .034), with higher mean LV mass (262.4 vs. 276.6 g, p = .014). Conclusions CVD hospitalizations, HF illness severity, and echocardiography measures did not change between admission periods in 2019. Evaluating short‐term data, the COVID‐19 shelter‐in‐place order was associated with reductions in acute CVD hospitalizations, particularly HF, with no significant increase in in‐hospital mortality and only minor differences in HF illness severity.
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Affiliation(s)
- Vishal N Rao
- Division of Cardiology, Duke University Medical Center, Durham, North Carolina, USA.,Duke Clinical Research Institute, Duke University Medical Center, Durham, North Carolina, USA
| | - Michelle D Kelsey
- Division of Cardiology, Duke University Medical Center, Durham, North Carolina, USA.,Duke Clinical Research Institute, Duke University Medical Center, Durham, North Carolina, USA
| | - Anita M Kelsey
- Division of Cardiology, Duke University Medical Center, Durham, North Carolina, USA
| | - Stuart D Russell
- Division of Cardiology, Duke University Medical Center, Durham, North Carolina, USA
| | - Robert J Mentz
- Division of Cardiology, Duke University Medical Center, Durham, North Carolina, USA.,Duke Clinical Research Institute, Duke University Medical Center, Durham, North Carolina, USA
| | - Manesh R Patel
- Division of Cardiology, Duke University Medical Center, Durham, North Carolina, USA.,Duke Clinical Research Institute, Duke University Medical Center, Durham, North Carolina, USA
| | - Marat Fudim
- Division of Cardiology, Duke University Medical Center, Durham, North Carolina, USA.,Duke Clinical Research Institute, Duke University Medical Center, Durham, North Carolina, USA
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Kelsey MD, Newby LK. In patients at high CV risk receiving simvastatin, the Myopathy Risk Score predicted statin-related myopathy. Ann Intern Med 2020; 173:JC71. [PMID: 33316194 DOI: 10.7326/acpj202012150-071] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
Hopewell JC, Offer A, Haynes R, et al. Independent risk factors for simvastatin-related myopathy and relevance to different types of muscle symptom. Eur Heart J. 2020;41:3336-42. 32702748.
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Affiliation(s)
| | - L Kristin Newby
- Duke University, Durham, North Carolina, USA (M.D.K., L.K.N.)
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24
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Kelsey MD, Newby LK. In older patients with NSTE-ACS, clopidogrel safely reduced bleeding compared with ticagrelor at 1 year. Ann Intern Med 2020; 173:JC28. [PMID: 32926825 DOI: 10.7326/acpj202009150-028] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
Gimbel M, Qaderdan K, Willemsen L, et al. Clopidogrel versus ticagrelor or prasugrel in patients aged 70 years or older with non-ST-elevation acute coronary syndrome (POPular AGE): the randomised, open-label, non-inferiority trial. Lancet. 2020;395:1374-81. 32334703.
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Affiliation(s)
- Michelle D Kelsey
- Division of Cardiology, Duke University, Durham, North Carolina, USA (M.K., L.K.N.)
| | - L Kristin Newby
- Division of Cardiology, Duke University, Durham, North Carolina, USA (M.K., L.K.N.)
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Kelsey MD. Aporia in Medicine. Conn Med 2015; 79:365-366. [PMID: 26263719] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 06/04/2023]
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26
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Mujtaba M, Kelsey MD, Saeed MA. Spontaneous carotid artery dissection: a rare cause of stroke in pregnancy and approach to diagnosis and management. Conn Med 2014; 78:349-352. [PMID: 25672062] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 06/04/2023]
Abstract
Acute onset of neurological symptoms in a pregnant female is a rare medical emergency. We report a case of a 38-year-old female who presented with a stroke secondary to carotid artery dissection. Our case illustrates the need to consider vascular imaging before administering thrombolytic therapy in peripartum females to avoid unnecessary risks to either the mother or the fetus. Management is controversial and is discussed briefly.
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MESH Headings
- Adult
- Carotid Artery, Internal, Dissection/complications
- Carotid Artery, Internal, Dissection/diagnosis
- Carotid Artery, Internal, Dissection/physiopathology
- Carotid Artery, Internal, Dissection/therapy
- Cerebral Angiography/methods
- Enoxaparin/administration & dosage
- Female
- Fetal Monitoring
- Fibrinolytic Agents/administration & dosage
- Humans
- Injections, Intra-Arterial
- Pregnancy
- Stroke/diagnosis
- Stroke/etiology
- Stroke/physiopathology
- Stroke/therapy
- Thrombectomy/methods
- Tissue Plasminogen Activator/administration & dosage
- Tomography, X-Ray Computed
- Treatment Outcome
- Ultrasonography, Doppler, Duplex
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