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Tweet MS, Pellikka PA, Gulati R, Gochanour BR, Barrett-O'Keefe Z, Raphael CE, Best PJM, Hayes SN. Coronary Artery Tortuosity and Spontaneous Coronary Artery Dissection: Association With Echocardiography and Global Longitudinal Strain, Fibromuscular Dysplasia, and Outcomes. J Am Soc Echocardiogr 2024; 37:518-529. [PMID: 38467311 DOI: 10.1016/j.echo.2024.02.013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/09/2023] [Revised: 02/13/2024] [Accepted: 02/18/2024] [Indexed: 03/13/2024]
Abstract
BACKGROUND The etiology and significance of coronary artery tortuosity (TCA) among patients with spontaneous coronary artery dissection (SCAD) are unknown. The aim of this prospective imaging cohort study was to report echocardiographic findings and evaluate whether TCA correlates with cardiac anatomy and function among patients with SCAD. Comorbidities including fibromuscular dysplasia (FMD) and outcomes were also assessed. METHODS TCA was determined on coronary angiography performed during the diagnosis of SCAD, and cardiac structure and function were evaluated using prospective comprehensive echocardiography. RESULTS Among 116 patients with SCAD, the mean age at echocardiography was 50.8 ± 8.8 years, a median of 10.9 months after SCAD. Sixty-two patients (53.4%) had FMD, 41 (35.3%) had histories of hypertension, and 17 (14.8%) were hypertensive during echocardiography. Most patients (n = 78 [69%]) had normal left ventricular geometry with normal median ejection fraction (61%; interquartile range, 56% to 64%) and normal global longitudinal strain (-22.2%; interquartile range, -24.0% to -19.9%). Fifteen patients (13.4%) had diastolic dysfunction that was associated with hypertension at the time of echocardiography. Patients with TCA (n = 96 [82.8%]) were older (mean age, 52.1 ± 8.0 vs 44.7 ± 9.9 years; P < .001) with a higher prevalence of FMD (59.4% vs 25%, P = .007) but a similar prevalence of hypertension (35% vs 35%, P > .99) compared with patients without TCA. Across the age range (31.5 to 66.9 years), each decade of age was associated with an approximately 0.89-unit increase in coronary tortuosity score (P < .0001). Echocardiographic parameters were not significantly different between the two groups. Median follow-up duration was 4.4 years (95% CI, 3.8 to 5.2 years). The Kaplan-Meier 3-year SCAD recurrence rate was 9.4% (95% CI, 3.7% to 14.8%). There were no deaths. CONCLUSIONS The majority of patients with SCAD had normal or near normal echocardiographic results, including global longitudinal strain, with no differences according to TCA. However, patients with SCAD with TCA were older, with a higher prevalence of FMD.
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Affiliation(s)
- Marysia S Tweet
- Department of Cardiovascular Medicine, Mayo Clinic College of Medicine, Rochester, Minnesota.
| | - Patricia A Pellikka
- Department of Cardiovascular Medicine, Mayo Clinic College of Medicine, Rochester, Minnesota
| | - Rajiv Gulati
- Department of Cardiovascular Medicine, Mayo Clinic College of Medicine, Rochester, Minnesota
| | - Benjamin R Gochanour
- Division of Clinical Trials and Biostatistics, Mayo Clinic College of Medicine, Rochester, Minnesota
| | - Zachary Barrett-O'Keefe
- Department of Cardiovascular Medicine, Mayo Clinic College of Medicine, Rochester, Minnesota
| | - Claire E Raphael
- Department of Cardiovascular Medicine, Mayo Clinic College of Medicine, Rochester, Minnesota
| | - Patricia J M Best
- Department of Cardiovascular Medicine, Mayo Clinic College of Medicine, Rochester, Minnesota
| | - Sharonne N Hayes
- Department of Cardiovascular Medicine, Mayo Clinic College of Medicine, Rochester, Minnesota
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Brunton N, Best PJM, Skelding KA, Cendrowski EE. Spontaneous Coronary Artery Dissection (SCAD) from an Interventionalist Perspective. Curr Cardiol Rep 2024; 26:91-96. [PMID: 38236518 PMCID: PMC10991027 DOI: 10.1007/s11886-023-02019-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 12/30/2023] [Indexed: 01/19/2024]
Abstract
PURPOSE OF REVIEW Spontaneous coronary artery dissection (SCAD) is an increasingly recognized cause of acute coronary syndrome (ACS), particularly among women < 50 years of age. Here, we aim to review the pathogenesis of SCAD, discuss SCAD as an initial manifestation of systemic arterial disease, and highlight invasive strategies as well as unique challenges in the care of women with SCAD. RECENT FINDINGS A paradigm shift has occurred in the care of SCAD patients in the past decade as recommendations for conservative management have become widespread. Invasive interventions are reserved for patients with hemodynamic compromise or active ischemia due to increased periprocedural complications and failure rates. Certain patient populations have been identified for larger territory infarcts and proximal disease including patients with known connective tissue disease, premenopausal women, and patients with pregnancy-associated SCAD (P-SCAD). Current recommended management of SCAD is conservative. Despite a growing awareness of SCAD and its known association with systemic arteriopathies in women, evidence-based data remains scarce. Future studies focused on identifying genetic factors, optimal medical therapy after SCAD, and techniques to minimize interventional complications are needed.
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Affiliation(s)
- Nichole Brunton
- Department of Cardiovascular Diseases, Mayo Clinic College of Medicine, 200 1st St SW, Rochester, MN, 55905, USA
| | - Patricia J M Best
- Department of Cardiovascular Diseases, Mayo Clinic College of Medicine, 200 1st St SW, Rochester, MN, 55905, USA.
| | | | - Emily E Cendrowski
- Department of Cardiovascular Diseases, Mayo Clinic College of Medicine, 200 1st St SW, Rochester, MN, 55905, USA
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Tarabochia AD, Tan NY, Lewis BR, Slusser JP, Hayes SN, Best PJM, Gulati R, Deshmukh AJ, Tweet MS. Association of Spontaneous Coronary Artery Dissection With Atrial Arrhythmias. Am J Cardiol 2023; 186:203-208. [PMID: 36328832 PMCID: PMC10403149 DOI: 10.1016/j.amjcard.2022.09.032] [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] [Received: 06/16/2022] [Revised: 09/14/2022] [Accepted: 09/29/2022] [Indexed: 11/01/2022]
Abstract
The co-morbidities and long-term complications of spontaneous coronary artery dissection (SCAD) are incompletely understood. This study investigated the association of atrial arrhythmias (AA), defined as atrial fibrillation and atrial flutter, with SCAD in a patient registry and population-based cohort. This observational study was performed in 2 parts. The first was a retrospective study reviewing patients diagnosed with AA in the Mayo Clinic SCAD Registry. The second was a population-based, case-control study to assess AA in patients with SCAD compared with age- and gender-matched controls. Of 1,214 patients in the Mayo Clinic SCAD Registry, 45 patients (3.7%) with SCAD were identified with an AA. A total of 8 of those patients (17.8%) had a pre-SCAD AA; 20 (44.4%) had a peri-SCAD AA; and 17 (37.8%) had a post-SCAD AA. The univariate analysis did not reveal significant associations with traditional cardiovascular risk factors. In the population-based cohort, 5 patients with SCAD (4%) and 4 controls (1%) developed an AA before the date of SCAD for each patient (odds ratio 4.5, 95% confidence interval [CI] 1.05 to 19.0, p = 0.04). A total of 5 patients with SCAD (4%) and 3 controls (1%) developed an AA in the 10 years after SCAD (hazard ratio 6.3, 95% CI 1.2 to 32.8, p = 0.03). A subgroup of patients with SCAD experienced AA before and after SCAD. Patients with a history of SCAD were more likely to develop AA in the next 10 years than were age- and gender-matched healthy controls.
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Affiliation(s)
- Alex D Tarabochia
- Department of Internal Medicine, Mayo Clinic College of Medicine, Rochester, Minnesota
| | - Nicholas Y Tan
- Department of Cardiovascular Medicine, Mayo Clinic College of Medicine, Rochester, Minnesota
| | - Bradley R Lewis
- Division of Clinical Trials and Biostatistics, Mayo Clinic College of Medicine, Rochester, Minnesota
| | - Joshua P Slusser
- Division of Clinical Trials and Biostatistics, Mayo Clinic College of Medicine, Rochester, Minnesota
| | - Sharonne N Hayes
- Department of Cardiovascular Medicine, Mayo Clinic College of Medicine, Rochester, Minnesota
| | - Patricia J M Best
- Department of Cardiovascular Medicine, Mayo Clinic College of Medicine, Rochester, Minnesota
| | - Rajiv Gulati
- Department of Cardiovascular Medicine, Mayo Clinic College of Medicine, Rochester, Minnesota
| | - Abhishek J Deshmukh
- Department of Cardiovascular Medicine, Mayo Clinic College of Medicine, Rochester, Minnesota
| | - Marysia S Tweet
- Department of Cardiovascular Medicine, Mayo Clinic College of Medicine, Rochester, Minnesota.
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Tweet MS, Young KA, Best PJM, Hyun M, Gulati R, Rose CH, Hayes SN. Association of Pregnancy With Recurrence of Spontaneous Coronary Artery Dissection Among Women With Prior Coronary Artery Dissection. JAMA Netw Open 2020; 3:e2018170. [PMID: 32965500 PMCID: PMC7512056 DOI: 10.1001/jamanetworkopen.2020.18170] [Citation(s) in RCA: 30] [Impact Index Per Article: 7.5] [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: 12/20/2022] Open
Abstract
IMPORTANCE Spontaneous coronary artery dissection (SCAD) is a notable cause of acute coronary syndrome in women of childbearing age. OBJECTIVE To test the hypothesis that pregnancy after SCAD is associated with recurrent SCAD. DESIGN, SETTING, AND PARTICIPANTS Three study designs were implemented: a case series of women with pregnancy after SCAD; a nested case-control study comparing patients with recurrent SCAD to matched controls without recurrent SCAD; and a cohort study. Women with SCAD who were of childbearing potential and enrolled into the Mayo Clinic SCAD Registry from August 30, 2011, to April 4, 2019, were included in the study. Patients with coronary dissections associated with iatrogenesis, trauma, or atherosclerosis were not enrolled. EXPOSURES Pregnancy after SCAD. MAIN OUTCOMES AND MEASURES The primary outcome was SCAD recurrence, defined as an acute coronary syndrome or cardiac arrest due to new SCAD. Other demographic measures collected included age, year of SCAD occurrence, and comorbidities. RESULTS The cohort included 636 women of childbearing potential. Twenty-three of those women had a total of 32 pregnancies after SCAD. The median (interquartile range) age of women with pregnancy after SCAD was 38 years (34-40 years), and 20 (87%) were White. In the nested case-control study, 92 cases of recurrent SCAD were matched to 158 controls. There was no significant difference in exposure to subsequent pregnancies in the women with recurrent SCAD as compared with matched controls (2 of 92 [2%] vs 13 of 158 [8%]; P = .06). In the overall cohort of 636 patients, recurrent SCAD was present in 122 patients with a Kaplan-Meier 5-year SCAD recurrence estimate of 14.8%. The Cox analysis showed no significant association between subsequent pregnancy and SCAD recurrence with a nonsignificant hazard ratio of 0.38 (95% CI, 0.09-1.6) when controlling for age at first SCAD, year of first SCAD, and fibromuscular dysplasia. CONCLUSIONS AND RELEVANCE This study found that most women tolerated pregnancy and lactation after SCAD without evidence for increased risk of SCAD recurrence when compared with women with a history of SCAD who did not experience pregnancy. Although this study is reassuring and indicates complex contributors to SCAD recurrence, the results need to be interpreted prudently because of study selection bias and the small total number of women who became pregnant after SCAD. The notable hemodynamic changes that occur with pregnancy and severe presentation of pregnancy-associated SCAD are reasons for concern when considering pregnancy after SCAD.
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Affiliation(s)
- Marysia S. Tweet
- Department of Cardiovascular Diseases, Mayo Clinic College of Medicine and Science, Rochester, Minnesota
| | - Kathleen A. Young
- Department of Cardiovascular Diseases, Mayo Clinic College of Medicine and Science, Rochester, Minnesota
| | - Patricia J. M. Best
- Department of Cardiovascular Diseases, Mayo Clinic College of Medicine and Science, Rochester, Minnesota
| | - Meredith Hyun
- Department of Biomedical Statistics and Informatics, Mayo Clinic College of Medicine and Science, Rochester, Minnesota
| | - Rajiv Gulati
- Department of Cardiovascular Diseases, Mayo Clinic College of Medicine and Science, Rochester, Minnesota
| | - Carl H. Rose
- Division of Maternal and Fetal Medicine, Department of Obstetrics and Gynecology, Mayo Clinic College of Medicine and Science, Rochester, Minnesota
| | - Sharonne N. Hayes
- Department of Cardiovascular Diseases, Mayo Clinic College of Medicine and Science, Rochester, Minnesota
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Vallabhajosyula S, Vallabhajosyula S, Dunlay SM, Hayes SN, Best PJM, Brenes-Salazar JA, Lerman A, Gersh BJ, Jaffe AS, Bell MR, Holmes DR, Barsness GW. Sex and Gender Disparities in the Management and Outcomes of Acute Myocardial Infarction-Cardiogenic Shock in Older Adults. Mayo Clin Proc 2020; 95:1916-1927. [PMID: 32861335 PMCID: PMC7582223 DOI: 10.1016/j.mayocp.2020.01.043] [Citation(s) in RCA: 27] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/04/2019] [Revised: 01/11/2020] [Accepted: 01/31/2020] [Indexed: 12/23/2022]
Abstract
OBJECTIVE To evaluate outcomes by sex in older adults with cardiogenic shock complicating acute myocardial infarction (AMI-CS). MATERIALS AND METHODS A retrospective cohort of older (≥75 years) AMI-CS admissions during January 1, 2000, to December 31, 2014, was identified using the National Inpatient Sample. Interhospital transfers were excluded. Use of angiography, percutaneous coronary intervention (PCI), mechanical circulatory support (MCS), and noncardiac interventions was identified. The primary outcome was in-hospital mortality stratified by sex, and secondary outcomes included temporal trends of prevalence, in-hospital mortality, use of cardiac and noncardiac interventions, hospitalization costs, and length of stay. RESULTS In this 15-year period, there were 134,501 AMI-CS admissions 75 years or older, of whom 51.5% (n=69,220) were women. Women were on average older, were more often Hispanic or nonwhite race, and had lower comorbidity, acute organ failure, and concomitant cardiac arrest. Compared with older men (n=65,281), older women (n=69,220) had lower use of coronary angiography (55.4% [n=35,905] vs 49.2% [n=33,918]), PCI (36.3% [n=23,501] vs 34.4% [n=23,535]), MCS (34.3% [n=22,391] vs 27.2% [n=18,689]), mechanical ventilation, and hemodialysis (all P<.001). Female sex was an independent predictor of higher in-hospital mortality (adjusted odds ratio, 1.05; 95% CI, 1.02-1.08; P<.001) and more frequent discharges to a skilled nursing facility. In subgroup analyses of ethnicity, presence of cardiac arrest, and those receiving PCI and MCS, female sex remained an independent predictor of increased mortality. CONCLUSION Female sex is an independent predictor of worse in-hospital outcomes in older adults with AMI-CS in the United States.
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Affiliation(s)
- Saraschandra Vallabhajosyula
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, MN; Division of Pulmonary and Critical Care Medicine, Department of Medicine, Mayo Clinic, Rochester, MN; Center for Clinical and Translational Science, Mayo Clinic Graduate School of Biomedical Sciences, Rochester, MN.
| | | | - Shannon M Dunlay
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, MN; Center for Clinical and Translational Science, Mayo Clinic Graduate School of Biomedical Sciences, Rochester, MN
| | - Sharonne N Hayes
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, MN
| | | | - Jorge A Brenes-Salazar
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, MN; Division of Geriatric Medicine and Gerontology, Department of Medicine, Mayo Clinic, Rochester, MN
| | - Amir Lerman
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, MN
| | - Bernard J Gersh
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, MN
| | - Allan S Jaffe
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, MN; Division of Clinical Core Laboratory Services, Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, MN
| | - Malcolm R Bell
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, MN
| | - David R Holmes
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, MN
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Abstract
Pregnancy-associated myocardial infarction is a primary contributor to maternal cardiovascular morbidity and mortality. Specific attention to the cause of myocardial infarction, diagnostic evaluation, treatment strategies, and postevent care is necessary when treating women with pregnancy-associated myocardial infarction. This review summarizes the current knowledge, consensus statements, and essential nuances.
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Affiliation(s)
- Marysia S Tweet
- Department of Cardiovascular Diseases, Mayo Clinic College of Medicine and Science, Rochester, MN (M.S.T., P.J.M.B.)
| | - Jennifer Lewey
- Division of Cardiovascular Medicine, University of Pennsylvania Perelman School of Medicine, Philadelphia (J.L.)
| | - Nathaniel R Smilowitz
- Leon H. Charney Division of Cardiology, Department of Medicine, New York University School of Medicine, New York, NY (N.R.S.)
| | - Carl H Rose
- Department of Obstetrics and Gynecology, Division of Maternal Fetal Medicine, Mayo Clinic College of Medicine, Rochester, MN (C.H.R.)
| | - Patricia J M Best
- Department of Cardiovascular Diseases, Mayo Clinic College of Medicine and Science, Rochester, MN (M.S.T., P.J.M.B.)
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Kok SN, Hayes SN, Cutrer FM, Raphael CE, Gulati R, Best PJM, Tweet MS. Prevalence and Clinical Factors of Migraine in Patients With Spontaneous Coronary Artery Dissection. J Am Heart Assoc 2019; 7:e010140. [PMID: 30561271 PMCID: PMC6405609 DOI: 10.1161/jaha.118.010140] [Citation(s) in RCA: 53] [Impact Index Per Article: 10.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
Background Spontaneous coronary artery dissection (SCAD) is a cause of acute coronary syndrome predominantly in women without usual cardiovascular risk factors. Many have a history of migraine headaches, but this association is poorly understood. This study aimed to determine migraine prevalence among SCAD patients and assess differences in clinical factors based on migraine history. Methods and Results A cohort study was conducted using the Mayo Clinic SCAD "Virtual" Multi-Center Registry composed of patients with SCAD as confirmed on coronary angiography. Participant-provided data and records were reviewed for migraine history, risk factors, SCAD details, therapies, and outcomes. Among 585 patients (96% women), 236 had migraine history; the lifetime and 1-year prevalence of migraine were 40% and 26%, respectively. Migraine was more common in SCAD women than comparable literature-reported female populations (42% versus 24%, P<0.0001; 42% versus 33%, P<0.0001). Among all SCAD patients, those with migraine history were more likely to be female (99.6% versus 94%; P=0.0002); have SCAD at a younger age (45.2±9.0 years versus 47.6±9.9 years; P=0.0027); have depression (27% versus 17%; P=0.025); have recurrent post-SCAD chest pain at 1 month (50% versus 39%; P=0.035); and, among those assessed, have aneurysms, pseudoaneurysms, or dissections (28% versus 18%; P=0.018). There was no difference in recurrent SCAD at 5 years for those with versus without migraine (15% versus 19%; P=0.39). Conclusions Many SCAD patients have a history of migraine. SCAD patients with migraine are younger at the time of SCAD; have more aneurysms, pseudoaneurysms, and dissections among those imaged; and more often report a history of depression and post-SCAD chest pain. Clinical Trial Registration URL: https://www.clinicaltrials.gov . Unique identifiers: NCT01429727, NCT01427179.
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Affiliation(s)
- Susan N Kok
- 1 Division of General Internal Medicine Department of Medicine Mayo Clinic College of Medicine and Science Rochester MN
| | - Sharonne N Hayes
- 2 Department of Cardiovascular Diseases Mayo Clinic College of Medicine and Science Rochester MN
| | - F Michael Cutrer
- 3 Department of Neurology Mayo Clinic College of Medicine and Science Rochester MN
| | - Claire E Raphael
- 4 Dorset Heart Center Royal Bournemouth Hospital Bournemouth United Kingdom
| | - Rajiv Gulati
- 2 Department of Cardiovascular Diseases Mayo Clinic College of Medicine and Science Rochester MN
| | - Patricia J M Best
- 2 Department of Cardiovascular Diseases Mayo Clinic College of Medicine and Science Rochester MN
| | - Marysia S Tweet
- 2 Department of Cardiovascular Diseases Mayo Clinic College of Medicine and Science Rochester MN
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Nan J, Tan N, Schaff H, Bell MR, Pislaru S, Best PJM. A Dangerous Dilemma: Thrombus in Transit During Pregnancy. JACC Case Rep 2019; 1:369-371. [PMID: 34316828 PMCID: PMC8288568 DOI: 10.1016/j.jaccas.2019.08.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/17/2019] [Revised: 08/23/2019] [Accepted: 08/29/2019] [Indexed: 11/15/2022]
Abstract
Pregnancy is associated with venous thromboembolism. Occasionally, thrombus can become entrapped across a patent foramen ovale, with risk of systemic embolism. This report presents a case of a pregnant woman who had thrombus in transit diagnosed by echocardiography, which was successfully removed by surgical thrombectomy. (Level of Difficulty: Intermediate.)
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Affiliation(s)
- John Nan
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester Minnesota
| | - Nicholas Tan
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester Minnesota
| | - Hartzell Schaff
- Department of Cardiovascular Surgery, Mayo Clinic, Rochester, Minnesota
| | - Malcolm R Bell
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester Minnesota
| | - Sorin Pislaru
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester Minnesota
| | - Patricia J M Best
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester Minnesota
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Affiliation(s)
- Jacob C Jentzer
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, MN; Department of Internal Medicine, Division of Pulmonary and Critical Care Medicine, Mayo Clinic, Rochester, MN.
| | | | - Roger D White
- Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, Rochester, MN
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Tweet MS, Hayes SN, Codsi E, Gulati R, Rose CH, Best PJM. Reply: Sex, Gender, and Reproductive History Are Critical Variables for Spontaneous Coronary Artery Dissection Research. J Am Coll Cardiol 2018; 71:471-472. [PMID: 29389371 PMCID: PMC5953428 DOI: 10.1016/j.jacc.2017.10.057] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/28/2017] [Accepted: 10/02/2017] [Indexed: 10/18/2022]
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Tweet MS, Hayes SN, Codsi E, Gulati R, Rose CH, Best PJM. Spontaneous Coronary Artery Dissection Associated With Pregnancy. J Am Coll Cardiol 2017; 70:426-435. [PMID: 28728686 DOI: 10.1016/j.jacc.2017.05.055] [Citation(s) in RCA: 189] [Impact Index Per Article: 27.0] [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: 02/14/2017] [Revised: 05/24/2017] [Accepted: 05/29/2017] [Indexed: 12/12/2022]
Abstract
BACKGROUND Spontaneous coronary artery dissection (SCAD) is the most common cause of pregnancy-associated myocardial infarction and remains poorly characterized. OBJECTIVES This study sought to assess presentation, clinical factors, and outcomes of pregnancy-associated spontaneous coronary artery dissection (P-SCAD) compared with spontaneous coronary artery dissection not associated with pregnancy (NP-SCAD). METHODS A Mayo Clinic registry was established in 2010 to include comprehensive retrospective and prospective SCAD data. Records were reviewed to identify women who were pregnant or ≤12 weeks postpartum at time of SCAD. Complete records were available for 323 women; 54 women met criteria for P-SCAD (4 during pregnancy) and they were compared with 269 women with NP-SCAD. RESULTS Most events occurred within the first month postpartum (35 of 50). Compared with NP-SCAD, P-SCAD patients more frequently presented with ST-segment elevation myocardial infarction (57% vs. 36%; p = 0.009), left main or multivessel SCAD (24% vs. 5%; p < 0.0001; and 33% vs. 14%; p = 0.0027, respectively), and left ventricular function ≤35% (26% vs. 10%; p = 0.0071). Among women with imaging of other vascular territories, P-SCAD was less likely with a diagnosis of fibromuscular dysplasia and extracoronary vascular abnormalities (42% vs. 64%; p = 0.047; and 46% vs. 77%; p = 0.0032, respectively). Compared with U.S. birth data, women with P-SCAD were more often multiparous (p = 0.0167), had a history of infertility therapies (p = 0.0004), and had pre-eclampsia (p = 0.001). On long-term follow-up (median 2.3 years) recurrent SCAD occurred in 51 patients, with no difference in the Kaplan Meier 5-year recurrence rates (10% vs. 23%; p = 0.18). CONCLUSIONS P-SCAD patients had more acute presentations and high-risk features than women with NP-SCAD did. The highest frequency of P-SCAD occurred during the first postpartum month and P-SCAD patients less often had extracoronary vascular abnormalities. Hormonal, hemodynamic variations, and yet-undefined mechanisms might be significant contributors to P-SCAD. (The "Virtual" Multicenter Spontaneous Coronary Artery Dissection [SCAD] Registry [SCAD]; NCT01429727; Genetic Investigations in Spontaneous Coronary Artery Dissection [SCAD]; NCT01427179).
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Affiliation(s)
- Marysia S Tweet
- Department of Cardiovascular Diseases, Mayo Clinic College of Medicine, Rochester, Minnesota.
| | - Sharonne N Hayes
- Department of Cardiovascular Diseases, Mayo Clinic College of Medicine, Rochester, Minnesota
| | - Elisabeth Codsi
- Department of Obstetrics and Gynecology, Division of Maternal and Fetal Medicine, Mayo Clinic College of Medicine, Rochester, Minnesota
| | - Rajiv Gulati
- Department of Cardiovascular Diseases, Mayo Clinic College of Medicine, Rochester, Minnesota
| | - Carl H Rose
- Department of Obstetrics and Gynecology, Division of Maternal and Fetal Medicine, Mayo Clinic College of Medicine, Rochester, Minnesota
| | - Patricia J M Best
- Department of Cardiovascular Diseases, Mayo Clinic College of Medicine, Rochester, Minnesota
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Affiliation(s)
- Patricia J M Best
- From the Department of Cardiovascular Medicine, Mayo Clinic, Rochester, MN (P.J.M.B.); Department of Biochemistry and Molecular Biology, Mayo Clinic, Rochester, MN (N.M.R.); and Most Sacred Heart of Jesus Cardiology and Valvular Institute, Sheboygan, WI (N.M.R.)
| | - Nalini M Rajamannan
- From the Department of Cardiovascular Medicine, Mayo Clinic, Rochester, MN (P.J.M.B.); Department of Biochemistry and Molecular Biology, Mayo Clinic, Rochester, MN (N.M.R.); and Most Sacred Heart of Jesus Cardiology and Valvular Institute, Sheboygan, WI (N.M.R.).
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Hickson LJ, Negrotto SM, Onuigbo M, Scott CG, Rule AD, Norby SM, Albright RC, Casey ET, Dillon JJ, Pellikka PA, Pislaru SV, Best PJM, Villarraga HR, Lin G, Williams AW, Nkomo VT. Echocardiography Criteria for Structural Heart Disease in Patients With End-Stage Renal Disease Initiating Hemodialysis. J Am Coll Cardiol 2016; 67:1173-1182. [PMID: 26965538 DOI: 10.1016/j.jacc.2015.12.052] [Citation(s) in RCA: 58] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/14/2015] [Revised: 12/07/2015] [Accepted: 12/14/2015] [Indexed: 12/12/2022]
Abstract
BACKGROUND Cardiovascular disease among hemodialysis (HD) patients is linked to poor outcomes. The Acute Dialysis Quality Initiative Workgroup proposed echocardiographic (ECHO) criteria for structural heart disease (SHD) in dialysis patients. The association of SHD with important patient outcomes is not well defined. OBJECTIVES This study sought to determine prevalence of ECHO-determined SHD and its association with survival among incident HD patients. METHODS We analyzed patients who began chronic HD from 2001 to 2013 who underwent ECHO ≤1 month prior to or ≤3 months following initiation of HD (n = 654). RESULTS Mean patient age was 66 ± 16 years, and 60% of patients were male. ECHO findings that met 1 or more and ≥3 of the new criteria were discovered in 87% and 54% of patients, respectively. Over a median of 2.4 years, 415 patients died: 108 (26%) died within 6 months. Five-year mortality was 62%. Age- and sex-adjusted structural heart disease variables associated with death were left ventricular ejection fraction (LVEF) ≤45% (hazard ratio [HR]: 1.48; confidence interval [CI]: 1.20 to 1.83) and right ventricular (RV) systolic dysfunction (HR: 1.68; CI: 1.35 to 2.07). An additive of higher death risk included LVEF ≤45% and RV systolic dysfunction rather than neither (HR: 2.04; CI: 1.57 to 2.67; p = 0.53 for test for interaction). Following adjustment for age, sex, race, diabetic kidney disease, and dialysis access, RV dysfunction was independently associated with death (HR: 1.66; CI 1.34 to 2.06; p < 0.001). CONCLUSIONS SHD was common in our HD study population, and RV systolic dysfunction independently predicted mortality.
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Affiliation(s)
- LaTonya J Hickson
- Division of Nephrology and Hypertension, Mayo Clinic, Rochester, Minnesota; Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Mayo Clinic, Rochester, Minnesota.
| | | | - Macaulay Onuigbo
- Division of Nephrology and Hypertension, Mayo Clinic, Rochester, Minnesota
| | - Christopher G Scott
- Division of Biomedical Statistics and Informatics, Mayo Clinic, Rochester, Minnesota
| | - Andrew D Rule
- Division of Nephrology and Hypertension, Mayo Clinic, Rochester, Minnesota
| | - Suzanne M Norby
- Division of Nephrology and Hypertension, Mayo Clinic, Rochester, Minnesota
| | - Robert C Albright
- Division of Nephrology and Hypertension, Mayo Clinic, Rochester, Minnesota
| | - Edward T Casey
- Division of Nephrology and Hypertension, Mayo Clinic, Rochester, Minnesota
| | - John J Dillon
- Division of Nephrology and Hypertension, Mayo Clinic, Rochester, Minnesota
| | | | - Sorin V Pislaru
- Division of Cardiovascular Diseases, Mayo Clinic, Rochester, Minnesota
| | - Patricia J M Best
- Division of Cardiovascular Diseases, Mayo Clinic, Rochester, Minnesota
| | | | - Grace Lin
- Division of Cardiovascular Diseases, Mayo Clinic, Rochester, Minnesota
| | - Amy W Williams
- Division of Nephrology and Hypertension, Mayo Clinic, Rochester, Minnesota
| | - Vuyisile T Nkomo
- Division of Cardiovascular Diseases, Mayo Clinic, Rochester, Minnesota
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Lyle M, Van Woerkom RC, Tweet M, Young PM, Best PJM. Conus artery occlusion causing isolated right ventricular outflow tract infarction: novel application of cardiac magnetic resonance in anterior STEMI. Cardiovasc Diagn Ther 2016; 6:262-6. [PMID: 27280090 DOI: 10.21037/cdt.2015.11.05] [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] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Acute ST elevation in the anterior precordial leads typically suggests an anteroseptal infarction due to left anterior descending coronary artery obstruction, but the differential can be broad. Conus branch artery occlusion is a potentially overlooked cause of anteroseptal ST elevation myocardial infraction. Cardiac magnetic resonance (CMR) imaging is an emerging technology which can differentiate the etiology of anterior ST elevation in patients with no apparent coronary abnormalities on coronary angiography and normal echocardiography.
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Affiliation(s)
- Melissa Lyle
- 1 Department of Internal Medicine, Mayo Clinic Rochester, MN, USA ; 2 Department of Cardiovascular Diseases, Mayo Clinic Scottsdale, AZ, USA ; 3 Department of Cardiovascular Diseases, 4 Department of Diagnostic Radiology, Mayo Clinic Rochester, MN, USA
| | - Ryan C Van Woerkom
- 1 Department of Internal Medicine, Mayo Clinic Rochester, MN, USA ; 2 Department of Cardiovascular Diseases, Mayo Clinic Scottsdale, AZ, USA ; 3 Department of Cardiovascular Diseases, 4 Department of Diagnostic Radiology, Mayo Clinic Rochester, MN, USA
| | - Marysia Tweet
- 1 Department of Internal Medicine, Mayo Clinic Rochester, MN, USA ; 2 Department of Cardiovascular Diseases, Mayo Clinic Scottsdale, AZ, USA ; 3 Department of Cardiovascular Diseases, 4 Department of Diagnostic Radiology, Mayo Clinic Rochester, MN, USA
| | - Phillip M Young
- 1 Department of Internal Medicine, Mayo Clinic Rochester, MN, USA ; 2 Department of Cardiovascular Diseases, Mayo Clinic Scottsdale, AZ, USA ; 3 Department of Cardiovascular Diseases, 4 Department of Diagnostic Radiology, Mayo Clinic Rochester, MN, USA
| | - Patricia J M Best
- 1 Department of Internal Medicine, Mayo Clinic Rochester, MN, USA ; 2 Department of Cardiovascular Diseases, Mayo Clinic Scottsdale, AZ, USA ; 3 Department of Cardiovascular Diseases, 4 Department of Diagnostic Radiology, Mayo Clinic Rochester, MN, USA
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15
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Yoshino S, Cilluffo R, Prasad M, Best PJM, Atkinson EJ, Aoki T, Cunningham JM, de Andrade M, Lerman LO, Lerman A. Sex-Specific Genetic Variants are Associated With Coronary Endothelial Dysfunction. J Am Heart Assoc 2016; 5:e002544. [PMID: 27091178 PMCID: PMC4859270 DOI: 10.1161/jaha.115.002544] [Citation(s) in RCA: 29] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
Background Endothelial dysfunction is an early stage of atherosclerosis. Single‐nucleotide polymorphisms (SNPs) have been associated with vascular dysfunction, cardiac events, and coronary artery remodeling. We aimed to detect SNPs associated with endothelial dysfunction and determine whether these associations are sex specific. Methods and Results Six hundred forty‐three subjects without significant obstructive coronary artery disease underwent invasive coronary endothelial function assessment. We collected data from 1536 SNPs that had previously been associated with vasoreactivity, angiogenesis, inflammation, artery calcification, atherosclerotic risk factors, insulin resistance, hormone levels, blood coagulability, or with coronary heart disease. Coronary vascular reactivity was assessed by the percent change in coronary artery diameter ≤ −20% after an intracoronary bolus injection of acetylcholine on invasive coronary physiology study. SNPs significantly associated with coronary epicardial endothelial dysfunction were ADORA1,KCNQ1, and DNAJC4 in the whole cohort, LPA, MYBPH, ADORA3, and PON1 in women and KIF6 and NFKB1 in men (P<0.01). Conclusions We have identified several significant SNPs that are associated with an increased risk of coronary endothelial dysfunction. These associations appear to be sex specific and may explain gender‐related differences in development of atherosclerosis.
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Affiliation(s)
- Satoshi Yoshino
- Cardiovascular Medicine and Hypertension, Kagoshima University Hospital, Sakuragaoka, Kagoshima, Japan
| | - Rebecca Cilluffo
- Cardiovascular Diseases and Internal Medicine, Mayo Clinic and College of Medicine, Rochester, MN
| | - Megha Prasad
- Cardiovascular Diseases and Internal Medicine, Mayo Clinic and College of Medicine, Rochester, MN
| | - Patricia J M Best
- Cardiovascular Diseases and Internal Medicine, Mayo Clinic and College of Medicine, Rochester, MN
| | - Elizabeth J Atkinson
- Biomedical Statistics and Informatics, Mayo Clinic and College of Medicine, Rochester, MN
| | - Tatsuo Aoki
- Department of Cardiovascular Medicine, Tohoku University Graduate School of Medicine, Aoba-ku, Sendai, Japan
| | - Julie M Cunningham
- Genomics Shared Resource, Mayo Clinic and College of Medicine, Rochester, MN
| | - Mariza de Andrade
- Biomedical Statistics and Informatics, Mayo Clinic and College of Medicine, Rochester, MN
| | - Lilach O Lerman
- Nephrology and Internal Medicine, Mayo Clinic and College of Medicine, Rochester, MN
| | - Amir Lerman
- Cardiovascular Diseases and Internal Medicine, Mayo Clinic and College of Medicine, Rochester, MN
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16
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Scantlebury DC, Rohe DE, Best PJM, Lennon RJ, Lerman A, Prasad A. Stress-coping skills and neuroticism in apical ballooning syndrome (Takotsubo/stress cardiomyopathy). Open Heart 2016; 3:e000312. [PMID: 26870388 PMCID: PMC4746526 DOI: 10.1136/openhrt-2015-000312] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/29/2015] [Revised: 12/24/2015] [Accepted: 01/08/2016] [Indexed: 02/07/2023] Open
Abstract
Introduction Apical ballooning syndrome (ABS) is typically associated with an antecedent stressful situation. Affected patients have been reported to have higher frequencies of premorbid affective disorders. We hypothesised that patients with ABS would have elevated levels of neuroticism (tendency to experience negative affect) and greater vulnerability to stress. Methods In this cross-sectional study, all active participants in the Mayo Clinic ABS prospective follow-up registry were invited to complete the third edition of the NEO Personality Inventory (NEO-PI-3). The NEO-PI-3 is the universally accepted measure of the ‘Five-Factor Model’ of personality. Inventory responses were scored using the NEO-PI-3 computer program and the data were compared with US normative sample used in standardisation of the inventory. Significance was set at 0.0014 to account for multiple comparisons. Results Of 106 registry participants approached, 53 completed the inventory. There was no difference in age, gender, time from ABS diagnosis, type of antecedent stressor (emotional, physical or none) or severity of initial illness between the responders and non-responders. Responders had mean Neuroticism T-scores of 48.0±10.6 (95% CI 45.1 to 50.9); p=0.18, when compared with the normal mean of 50. There was also no significant difference in the facet scale of Vulnerability: 46.9±8.4 (44.6 to 49.2), p=0.038, at α=0.0014. Conclusions Contrary to our hypothesis, patients with ABS do not manifest higher levels of neuroticism and do not have greater vulnerability to stress than the general population. These findings have implications for the clinicians’ perception of, and approach to, patients with ABS.
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Affiliation(s)
- Dawn C Scantlebury
- Division of Cardiovascular Diseases, Department of Internal Medicine , Mayo Clinic , Rochester, Minnesota , USA
| | - Daniel E Rohe
- Department of Psychiatry and Psychology , Mayo Clinic , Rochester, Minnesota , USA
| | - Patricia J M Best
- Division of Cardiovascular Diseases, Department of Internal Medicine , Mayo Clinic , Rochester, Minnesota , USA
| | - Ryan J Lennon
- Department of Health Sciences Research , Mayo Clinic , Rochester, Minnesota , USA
| | - Amir Lerman
- Division of Cardiovascular Diseases, Department of Internal Medicine , Mayo Clinic , Rochester, Minnesota , USA
| | - Abhiram Prasad
- Division of Cardiovascular Diseases, Department of Internal Medicine, Mayo Clinic, Rochester, Minnesota, USA; Cardiovascular and Cell Sciences Institute, St. George's University of London, London, UK
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Tweet MS, Eleid MF, Best PJM, Lennon RJ, Lerman A, Rihal CS, Holmes DR, Hayes SN, Gulati R. Spontaneous coronary artery dissection: revascularization versus conservative therapy. Circ Cardiovasc Interv 2014; 7:777-86. [PMID: 25406203 DOI: 10.1161/circinterventions.114.001659] [Citation(s) in RCA: 406] [Impact Index Per Article: 40.6] [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] [Indexed: 12/24/2022]
Abstract
BACKGROUND Spontaneous coronary artery dissection (SCAD) is a nonatherosclerotic acute coronary syndrome for which optimal management remains undefined. METHODS AND RESULTS We performed a retrospective study of 189 patients presenting with a first SCAD episode. We evaluated outcomes according to initial management: (1) revascularization versus conservative therapy and (2) percutaneous coronary intervention (PCI) versus conservative therapy stratified by vessel flow at presentation. Demographics were similar in revascularization versus conservative (mean age, 44±9 years; women 92% both groups), but vessel occlusion was more frequent in revascularization (44/95 versus 18/94). There was 1 in-hospital death (revascularization) and 1 late death (conservative). Procedural failure rate was 53% in those managed with PCI. In the subgroup of patients presenting with preserved vessel flow, rates of PCI failure were similarly high (50%), and 6 (13%) required emergency coronary artery bypass grafting. In the conservative group, 85 of 94 (90%) had an uneventful in-hospital course, but 9 (10%) experienced early SCAD progression requiring revascularization. Kaplan-Meier estimated 5-year rates of target vessel revascularization and recurrent SCAD were no different in revascularization versus conservative therapy (30% versus 19%; P=0.06 and 23% versus 31%; P=0.7). CONCLUSIONS PCI for SCAD is associated with high rates of technical failure even in those presenting with preserved vessel flow and does not protect against target vessel revascularization or recurrent SCAD. A strategy of conservative management with prolonged observation may be preferable.
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Affiliation(s)
- Marysia S Tweet
- From the Divisions of Cardiovascular Diseases (M.S.T., M.F.E., P.J.M.B., A.L., C.S.R., D.R.H., S.N.H., R.G.) and Biomedical Statistics and Informatics (R.J.L.), Mayo Clinic, Rochester, MN
| | - Mackram F Eleid
- From the Divisions of Cardiovascular Diseases (M.S.T., M.F.E., P.J.M.B., A.L., C.S.R., D.R.H., S.N.H., R.G.) and Biomedical Statistics and Informatics (R.J.L.), Mayo Clinic, Rochester, MN
| | - Patricia J M Best
- From the Divisions of Cardiovascular Diseases (M.S.T., M.F.E., P.J.M.B., A.L., C.S.R., D.R.H., S.N.H., R.G.) and Biomedical Statistics and Informatics (R.J.L.), Mayo Clinic, Rochester, MN
| | - Ryan J Lennon
- From the Divisions of Cardiovascular Diseases (M.S.T., M.F.E., P.J.M.B., A.L., C.S.R., D.R.H., S.N.H., R.G.) and Biomedical Statistics and Informatics (R.J.L.), Mayo Clinic, Rochester, MN
| | - Amir Lerman
- From the Divisions of Cardiovascular Diseases (M.S.T., M.F.E., P.J.M.B., A.L., C.S.R., D.R.H., S.N.H., R.G.) and Biomedical Statistics and Informatics (R.J.L.), Mayo Clinic, Rochester, MN
| | - Charanjit S Rihal
- From the Divisions of Cardiovascular Diseases (M.S.T., M.F.E., P.J.M.B., A.L., C.S.R., D.R.H., S.N.H., R.G.) and Biomedical Statistics and Informatics (R.J.L.), Mayo Clinic, Rochester, MN
| | - David R Holmes
- From the Divisions of Cardiovascular Diseases (M.S.T., M.F.E., P.J.M.B., A.L., C.S.R., D.R.H., S.N.H., R.G.) and Biomedical Statistics and Informatics (R.J.L.), Mayo Clinic, Rochester, MN
| | - Sharonne N Hayes
- From the Divisions of Cardiovascular Diseases (M.S.T., M.F.E., P.J.M.B., A.L., C.S.R., D.R.H., S.N.H., R.G.) and Biomedical Statistics and Informatics (R.J.L.), Mayo Clinic, Rochester, MN
| | - Rajiv Gulati
- From the Divisions of Cardiovascular Diseases (M.S.T., M.F.E., P.J.M.B., A.L., C.S.R., D.R.H., S.N.H., R.G.) and Biomedical Statistics and Informatics (R.J.L.), Mayo Clinic, Rochester, MN.
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18
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Witt CM, Best PJM, Asirvatham SJ, McLeod CJ. Unusual chest pain syndromes caused by implanted cardiac device leads: a case series. J Interv Card Electrophysiol 2013; 39:167-70. [PMID: 24327083 DOI: 10.1007/s10840-013-9846-y] [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] [Received: 07/18/2013] [Accepted: 09/29/2013] [Indexed: 10/25/2022]
Abstract
Chest pain can occur after cardiac device lead placement through various mechanisms. Commonly, this is secondary to perforation. We present four cases of unusual chest pain syndromes secondary to device leads with normal function and position without evidence of typical complications. The possible etiologies and management considerations for these cases are discussed.
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Affiliation(s)
- Chance M Witt
- Department of Internal Medicine, Mayo Clinic, Rochester, MN, USA
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19
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Abdelmoneim SS, Bernier M, Hagen ME, Eifert-Rain S, Bott-Kitslaar D, Wilansky S, Castello R, Bhat G, Pellikka PA, Best PJM, Hayes SN, Mulvagh SL. A multicenter, prospective study to evaluate the use of contrast stress echocardiography in early menopausal women at risk for coronary artery disease: trial design and baseline findings. J Womens Health (Larchmt) 2013; 22:173-83. [PMID: 23398128 DOI: 10.1089/jwh.2012.3714] [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] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
AIMS This multisite prospective trial, Stress Echocardiography in Menopausal Women At Risk for Coronary Artery Disease (SMART), aimed to evaluate the prognostic value of contrast stress echocardiography (CSE), coronary artery calcification (CAC), and cardiac biomarkers for prediction of cardiovascular events after 2 and 5 years in early menopausal women experiencing chest pain symptoms or risk factors. This report describes the study design, population, and initial test results at study entry. METHODS From January 2004 through September 2007, 366 early menopausal women (age 54±5 years, Framingham risk score 6.51%±4.4 %, range 1%-27%) referred for stress echocardiography were prospectively enrolled. Image quality was enhanced with an ultrasound contrast agent. Tests for cardiac biomarkers [high-sensitivity C-reactive protein (hsCRP), atrial natriuretic protein (ANP), brain natriuretic protein (BNP), endothelin (ET-1)] and cardiac computed tomography (CT) for CAC were performed. RESULTS CSE (76% exercise, 24% dobutamine) was abnormal in 42 women (11.5%), and stress electrocardiogram (ECG) was positive in 22 women (6%). Rest BNP correlated weakly with stress wall motion score index (WMSI) (r=0.189, p<0.001). Neither hsCRP, ANP, endothelin, nor CAC correlated with stress WMSI. Predictors of abnormal CSE were body mass index (BMI), diabetes mellitus, family history of premature coronary artery disease (CAD), and positive stress ECG. Twenty-four women underwent clinically indicated coronary angiography (CA); 5 had obstructive (≥50%), 15 had nonobstructive (10%-49%), and 4 had no epicardial CAD. CONCLUSIONS The SMART trial is designed to assess the prognostic value of CSE in early menopausal women. Independent predictors of positive CSE were BMI, diabetes mellitus, family history of premature CAD, and positive stress ECG. CAC scores and biomarkers (with the exception of rest BNP) were not correlated with CSE results. We await the follow-up data.
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Affiliation(s)
- Sahar S Abdelmoneim
- Cardiovascular Ultrasound Imaging and Hemodynamic Laboratory, Division of Cardiovascular Diseases, Mayo Clinic, Rochester, MN 55905, USA
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20
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Scantlebury DC, Prasad A, Rabinstein AA, Best PJM. Prevalence of migraine and Raynaud phenomenon in women with apical ballooning syndrome (Takotsubo or stress cardiomyopathy). Am J Cardiol 2013; 111:1284-8. [PMID: 23415512 DOI: 10.1016/j.amjcard.2013.01.269] [Citation(s) in RCA: 31] [Impact Index Per Article: 2.8] [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: 12/06/2012] [Revised: 01/10/2013] [Accepted: 01/10/2013] [Indexed: 11/16/2022]
Abstract
Apical ballooning syndrome (ABS), migraine, and Raynaud phenomenon are characterized by female predominance, identifiable triggers, and, likely, vascular dysfunction. Estrogen deficiency, such as in menopause, is considered to be a predisposing factor for ABS. We investigated the association of ABS with migraine, Raynaud phenomenon, and hormonal factors. We compared 25 consecutive residents (all women) of Olmsted County, Minnesota, presenting with ABS, to 2 age-matched control groups from the same community: 25 women presenting with ST-segment elevation myocardial infarction (STEMI), matched for the index ABS event date, and 50 women with neither diagnosis. The patients with ABS were more likely to have a migraine history (11 [44%] vs 4 [16%] STEMI controls, p = 0.031, and vs 6 [12%] population controls, p = 0.003), and "possible migraine" (including other headache syndromes suggestive of migraine; 15 [60%] vs 6 [24%] STEMI controls, p = 0.012; and vs 12 [24%] population controls, p = 0.003). Of the patients with ABS, 4 (16%) had Raynaud phenomenon compared to no STEMI controls and 1 (2%) population control (p = 0.038). No differences were present in parity, menopausal status, years since the onset of menopause, and frequency of oophorectomy. Current hormonal replacement therapy use was greater in those with ABS than in the population controls: 4 (16%) versus none (p = 0.002). In conclusion, the association of ABS with migraine and Raynaud phenomenon supports a role of vasomotor dysfunction in the pathogenesis of ABS. The absence of an association with reproductive characteristics and the finding that ABS occurred despite exogenous hormonal use in some patients suggests that estrogen deficiency per se is not the primary factor in the pathophysiology.
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Affiliation(s)
- Dawn C Scantlebury
- Division of Cardiovascular Diseases, Department of Internal Medicine, Mayo Clinic, Rochester, MN, USA
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Abstract
OPINION STATEMENT Contrast-induced acute kidney injury (AKI) is an important complication associated with coronary angiography, percutaneous coronary intervention, and computed tomography studies. The increasing utilization of contrast agents for imaging makes the importance of this complication even greater. Patients can be risk stratified for the risk of contrast-induced AKI by several clinical factors including hypotension, renal function, age, advanced heart failure, anemia, and diabetes mellitus. Contrast volume is also an important and modifiable risk factor for AKI. For the prevention of contrast-induced AKI, multiple approaches have been tried. The most effective prevention strategy is hydration. Normal saline has been the standard, but other options such as sodium bicarbonate may be a reasonable alternative. Further studies will be required to clarify the best preventive strategies.
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Affiliation(s)
- Patricia J M Best
- Division of Cardiovascular Diseases, Mayo Clinic, 200 First Street SW, Rochester, MN, 55905, USA,
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22
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Tweet MS, Hayes SN, Pitta SR, Simari RD, Lerman A, Lennon RJ, Gersh BJ, Khambatta S, Best PJM, Rihal CS, Gulati R. Clinical features, management, and prognosis of spontaneous coronary artery dissection. Circulation 2012; 126:579-88. [PMID: 22800851 DOI: 10.1161/circulationaha.112.105718] [Citation(s) in RCA: 590] [Impact Index Per Article: 49.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
BACKGROUND Spontaneous coronary artery dissection (SCAD) is an acute coronary event of uncertain origin. Clinical features and prognosis remain insufficiently characterized. METHODS AND RESULTS A retrospective single-center cohort study identified 87 patients with angiographically confirmed SCAD. Incidence, clinical characteristics, treatment modalities, in-hospital outcomes, and long-term risk of SCAD recurrence or major adverse cardiac events were evaluated. Mean age was 42.6 years; 82% were female. Extreme exertion at SCAD onset was more frequent in men (7 of 16 versus 2 of 71; P<0.001), and postpartum status was observed in 13 of 71 women (18%). Presentation was ST-elevation myocardial infarction in 49%. Multivessel SCAD was found in 23%. Initial conservative management (31 of 87) and coronary artery bypass grafting (7 of 87) were associated with an uncomplicated in-hospital course, whereas percutaneous coronary intervention was complicated by technical failure in 15 of 43 patients (35%) and 1 death. During a median follow-up of 47 months (interquartile range, 18-106 months), SCAD recurred in 15 patients, all female. Estimated 10-year rate of major adverse cardiac events (death, heart failure, myocardial infarction, and SCAD recurrence) was 47%. Fibromuscular dysplasia of the iliac artery was identified incidentally in 8 of 16 femoral angiograms (50%) undertaken before closure device placement and in the carotid arteries of 2 others with carotid dissection. CONCLUSIONS SCAD affects a young, predominantly female population, frequently presenting as ST-elevation myocardial infarction. Although in-hospital mortality is low regardless of initial treatment, percutaneous coronary intervention is associated with high rates of complication. Risks of SCAD recurrence and major adverse cardiac events in the long term emphasize the need for close follow-up. Fibromuscular dysplasia is a novel association and potentially causative factor.
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Affiliation(s)
- Marysia S Tweet
- Division of Cardiovascular Diseases, Mayo Clinic, Rochester, MN 55905, USA
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Best PJM. Percutaneous coronary revascularization for myocardial infarction in chronic kidney disease: recognizing the risk while seizing the benefits. JACC Cardiovasc Interv 2011; 4:1009-10. [PMID: 21939941 DOI: 10.1016/j.jcin.2011.07.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/18/2011] [Accepted: 07/20/2011] [Indexed: 10/17/2022]
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Miller VM, Best PJM. Implications for reproductive medicine: Sex differences in cardiovascular disease. Sex Reprod Menopause 2011; 9:21-28. [PMID: 21909244 PMCID: PMC3169849] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Grants] [Subscribe] [Scholar Register] [Indexed: 05/31/2023]
Affiliation(s)
- Virginia M Miller
- Departments of Surgery, Physiology and Biomedical Engineering, Mayo Clinic Rochester, Minnesota
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Best PJM, Skelding KA, Mehran R, Chieffo A, Kunadian V, Madan M, Mikhail GW, Mauri F, Takahashi S, Honye J, Hernández-Antolín R, Weiner BH. SCAI consensus document on occupational radiation exposure to the pregnant cardiologist and technical personnel. Heart Lung Circ 2011; 20:83-90. [PMID: 21241961 DOI: 10.1016/j.hlc.2010.11.006] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
Concerns regarding radiation exposure and its effects during pregnancy are often quoted as an important barrier preventing many women from pursuing a career in Interventional Cardiology. Finding the true risk of radiation exposure from performing cardiac catheterisation procedures can be challenging and guidelines for pregnancy exposure have been inadequate. The Women in Innovations group of Cardiologists with endorsement of the Society for Cardiovascular Angiography and Interventions aim to provide guidance in this publication by describing the risk of radiation exposure to pregnant physicians and cardiac catheterisation personnel, to educate on appropriate radiation monitoring and to encourage mechanisms to reduce radiation exposure. Current data do not suggest a significant increased risk to the foetus of pregnant women in the cardiac catheterisation laboratory and thus do not justify precluding pregnant physicians from performing procedures in the cardiac catheterisation laboratory. However, radiation exposure amongst pregnant physicians should be properly monitored and adequate radiation safety measures are still warranted.
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Affiliation(s)
- Patricia J M Best
- Department of Internal Medicine and Cardiovascular Diseases, Mayo Clinic, Rochester, MN, USA.
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Best PJM, Skelding KA, Mehran R, Chieffo A, Kunadian V, Madan M, Mikhail GW, Mauri F, Takahashi S, Honye J, Hernández-Antolín R, Weiner BH. SCAI consensus document on occupational radiation exposure to the pregnant cardiologist and technical personnel. Catheter Cardiovasc Interv 2011; 77:232-41. [DOI: 10.1002/ccd.22877] [Citation(s) in RCA: 49] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/13/2010] [Accepted: 10/14/2010] [Indexed: 11/05/2022]
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From AM, Best PJM, Lennon RJ, Rihal CS, Prasad A. Acute myocardial infarction due to left circumflex artery occlusion and significance of ST-segment elevation. Am J Cardiol 2010; 106:1081-5. [PMID: 20920642 DOI: 10.1016/j.amjcard.2010.06.016] [Citation(s) in RCA: 42] [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: 04/15/2010] [Revised: 06/05/2010] [Accepted: 06/05/2010] [Indexed: 11/30/2022]
Abstract
Acute occlusion of the left circumflex (LC) artery can be difficult to diagnose. The aim of the present study was to assess the incidence of LC occlusion in patients with acute myocardial infarction (AMI) requiring percutaneous coronary intervention (PCI), the frequency of ST-segment versus non-ST-segment elevation presentation among them, and to correlate the electrocardiographic findings with the outcomes. The clinical characteristics and outcomes of consecutive patients from November 2001 through December 2007 with AMI within 7 days before PCI of a single acutely occluded culprit vessel were included in the present analysis. Of the 1,500 patients, the culprit lesion was located in the right coronary artery, left anterior descending artery, or LC artery in 44.7%, 35.8%, and 19.5% of patients, respectively. Of the 1,500 patients, 72% presented with ST-segment elevation AMI, but only 43% were patients with a LC lesion (n = 127). PCI was significantly less likely (80%, 83%, and 70% for right coronary, left anterior descending, and LC artery, respectively; p < 0.001) to be performed within 24 hours for LC occlusions than for occlusions in the other territories. Among those with a non-ST-segment elevation AMI, the highest post-PCI troponin levels were in patients with a LC artery occlusion (median 1.4, 1.3, and 2.5 ng/ml; p < 0.001). No significant difference was found in the in-hospital mortality (4.4%, 7.4%, and 6.5%; p = 0.66) or major adverse cardiovascular event (9.2%, 13.9%, and 11.6%; p = 0.53) rates for right, left anterior descending, and LC occlusions, respectively. In conclusion, our results have demonstrated that in clinical practice, the LC artery is the least frequent culprit vessel among patients treated invasively for AMI. Patients with LC occlusion are less likely to present with ST-segment elevation AMI and have emergency PCI. The study results suggest that detection of these patients has been suboptimal, highlighting the need to improve the diagnostic approach toward the detection of an acutely occluded LC artery.
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Affiliation(s)
- Aaron M From
- Division of Cardiovascular Diseases, Department of Internal Medicine, Rochester, Minnesota, USA
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Berger PB, Best PJM. Does kidney function alter the benefit of reperfusion therapy for ST-segment elevation myocardial infarction? JACC Cardiovasc Interv 2010; 2:34-6. [PMID: 19463395 DOI: 10.1016/j.jcin.2008.09.009] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/09/2008] [Accepted: 09/29/2008] [Indexed: 10/21/2022]
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Abstract
Cardiovascular disease is the leading cause of death in women and more heart disease is present in elderly women than men. Risk factors for heart disease affect men and women differently, with a greater impact of diabetes, hyperlipidemia and smoking in women. Diagnosis of heart disease can be more challenging in women, especially when elderly, as symptoms may be vague. Understanding the appropriate use of diagnostic testing and appropriate treatment is essential, given the high burden of disease in elderly women. This article will discuss the current guidelines for diagnosis and therapy of heart disease in women and will discuss the appropriate role of prevention strategies.
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Affiliation(s)
- Rekha Mankad
- Mayo Clinic, Division of Cardiovascular Diseases, Gonda 5, 200 First Street SW, Rochester, MN 55905, USA.
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Wood A, Markovic SN, Best PJM, Erickson LA. Metastatic malignant melanoma manifesting as an intracardiac mass. Cardiovasc Pathol 2009; 19:153-7. [PMID: 19211272 DOI: 10.1016/j.carpath.2008.12.010] [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] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/29/2008] [Revised: 12/09/2008] [Accepted: 12/19/2008] [Indexed: 11/25/2022] Open
Abstract
INTRODUCTION Antemortem diagnoses of intracardiac metastases are uncommon. Metastatic melanoma shows a propensity for cardiac involvement, but cardiac involvement by melanoma is rarely identified clinically due to a paucity of cardiac symptoms. METHODS The surgical pathology files of Mayo Clinic were searched for cases of metastatic melanoma presenting or manifesting as an intracardiac mass. The lesions were evaluated pathologically for diagnoses. Clinical information was obtained by chart review. RESULTS Seven patients, four female and three male (age 31 to 79 years), were identified. No patient had a history of metastatic melanoma. All patients presented with dyspnea and symptoms of outflow obstruction. Echocardiography or CT revealed an intracardiac mass (four atrial, three ventricular). Six cases involved the right side of the heart and one involved the left ventricle. Five of the seven patients had a history of malignant melanoma, but none had a history of metastases when they presented with cardiac symptoms. In four cases, the history of primary melanoma was remote, occurring 7, 9, 13, and 28 years prior to the discovery of their cardiac mass. One patient had no history of melanoma, and no primary melanoma was ever identified. One patient had a history of a benign melanocytic lesion biopsied 2 years before, but retrospective review showed malignant melanoma. CONCLUSIONS Melanoma is known to have an unpredictable and prolonged course. Neoplastic involvement of the heart should be considered in patients with cardiac symptoms when a documented malignancy exists, no matter how remote.
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Affiliation(s)
- Angela Wood
- Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, MN, USA
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Skelding KA, Best PJM, Bartholomew BA, Lennon RJ, O'Neill WW, Rihal CS. Validation of a predictive risk score for radiocontrast-induced nephropathy following percutaneous coronary intervention. J Invasive Cardiol 2007; 19:229-33. [PMID: 17476039] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 05/15/2023]
Abstract
OBJECTIVE We sought to externally validate the William Beaumont Hospital (WBH) risk score for radiocontrast-induced nephropathy (RCIN) following percutaneous coronary intervention (PCI). Background. RCIN is associated with increased mortality and morbidity following PCI and accounts for increased hospital costs and length of stay. METHODS A total of 4,814 PCI procedures were used for validation of the WBH risk score, using a >1.0 mg/dl increase in serum creatinine (Cr) as the definition of RCIN. Clinical and procedural details were identified within the Mayo Clinic PCI registry. Multiple imputation was used to impute values where missing. Five imputation sets were created and averaged to compute the final estimate. RESULTS Follow-up Cr was available in 3,213 (67%) of procedures and RCIN occurred in 1.9% of cases. Baseline Cr clearance was missing in 13%. All other risk factors used to calculate the risk score were missing in 25% of the procedures. The risk score has the ability to discriminate well between patients at low and high risk of post-PCI RCIN; c-statistic = 0.86. In-hospital mortality occurred in 6.6% (4/61) with RCIN vs. 1.2% (37/3152) without RCIN. The odds ratio for in-hospital mortality is 5.3 (95% CI, 1.9, 15.0; p = 0.002) for those with RCIN vs. those without. CONCLUSIONS The WBH risk score can identify patients at high and low risk of RCIN following PCI. Use of this risk score can identify patients at high risk of RCIN development and direct the use of preventative measures to the highest-risk population, improving patient outcome and prognosis.
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Affiliation(s)
- Kimberly A Skelding
- Division of Cardiology, Geisinger Medical Center, Danville, Pennsylvania, USA.
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Kania-Lachance DM, Best PJM, McDonah MR, Ghosh AK. Evidence-based practice and the nurse practitioner. Nurse Pract 2006; 31:46-54. [PMID: 17028497] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/12/2023]
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Brilakis ES, Best PJM, Elesber AA, Barsness GW, Lennon RJ, Holmes DR, Rihal CS, Garratt KN. Incidence, retrieval methods, and outcomes of stent loss during percutaneous coronary intervention: a large single-center experience. Catheter Cardiovasc Interv 2006; 66:333-40. [PMID: 16142808 DOI: 10.1002/ccd.20449] [Citation(s) in RCA: 116] [Impact Index Per Article: 6.4] [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: 12/22/2022]
Abstract
Our goal was to examine the incidence and consequences of stent loss during percutaneous coronary intervention (PCI) and the retrieval techniques used. We retrospectively reviewed 11,773 consecutive PCI cases involving stents performed at our institution between January 1994 and March 2004 to identify cases of stent loss. Stent loss occurred in 38 of 11,773 PCI procedures involving stents (0.32%; 95% CI = 0.23-0.44%). Mean age of the patients was 67 +/- 11 years and 82% were men. Stent loss occurred more frequently in lesions with calcification and/or significant proximal angulation. In three patients, the stent was crushed and covered with another stent without attempting retrieval. Stent retrieval was attempted in 35 of 38 cases and was successful in 30 (86%). The following retrieval methods were used (more than one method was used in some cases): advancing a balloon through the stent, inflating the balloon, and withdrawing the stent (45%); twirling two wires around the stent (5%); loop snare (26%); biliary forceps (12%); Cook retained fragment retriever (10%); and basket retrieval device (2%). Patients in whom stent loss occurred had a higher incidence of bleeding requiring transfusion (24% vs. 7%; P < 0.001) and more often required emergency coronary artery bypass surgery (5% vs. 0.4%; P < 0.001). No patients in whom the stent was crushed or deployed in the coronary artery had any major cardiac complication. Stent loss during PCI occurs infrequently. Lost stents can be successfully retrieved in the majority of cases using a variety of retrieval techniques, yet stent loss is associated with an increased risk of complications. Stent deployment or crushing may be a good alternative to retrieval.
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Affiliation(s)
- Emmanouil S Brilakis
- Division of Cardiovascular Diseases, University of Texas Southwestern Medical Center, Dallas, Texas 75216, USA.
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Berger PB, Best PJM, Topol EJ, White J, DiBattiste PM, Chan AW, Kristensen SD, Herrmann HC, Moliterno DJ. The relation of renal function to ischemic and bleeding outcomes with 2 different glycoprotein IIb/IIIa inhibitors: the do Tirofiban and ReoPro Give Similar Efficacy Outcome (TARGET) trial. Am Heart J 2005; 149:869-75. [PMID: 15894970 DOI: 10.1016/j.ahj.2004.12.002] [Citation(s) in RCA: 37] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/26/2023]
Abstract
BACKGROUND Renal function significantly impacts morbidity and mortality after a percutaneous coronary intervention. Platelet glycoprotein (GP) IIb/IIIa inhibitors reduce ischemic complications during percutaneous coronary intervention; little is known of whether their safety and efficacy are influenced by renal function. In particular, whether outcome differences exist between agents that are renally excreted (tirofiban) or not (abciximab) in patients with mild renal impairment is not known. METHODS The TARGET trial randomized 4623 patients to tirofiban or abciximab. In this analysis, patients were grouped in creatinine clearance quartiles (<70, 70-90, 90-114, >114 mL/min) and analyzed for efficacy and bleeding risk. Univariate and multivariate analyses were performed to identify interactions between GP IIb/IIIa inhibitor used and creatinine clearance with respect to ischemic outcomes and bleeding. RESULTS Using unadjusted logistic regression tests for trend, 30-day death/myocardial infarction/urgent target vessel revascularization was greater in patients with lower creatinine clearances (7.3%, 8.5%, 5.1%, and 5.8%, P = .005), as were both major and minor bleeding. There was no interaction between assigned GP IIb/IIIa inhibitor, creatinine clearance and ischemic outcome, major bleeding or minor bleeding. CONCLUSIONS Both ischemic and bleeding complications are highest in the lowest creatinine clearance quartile of patients treated with GP IIb/IIIa inhibitors. Although tirofiban is renally cleared and abciximab is not, there was no interaction between these GP IIb/IIIa inhibitors and creatinine clearance regarding ischemic or bleeding events.
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Affiliation(s)
- Peter B Berger
- Division of Cardiovascular Medicine, Mayo Clinic, Rochester, Minn 55905, USA.
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Best PJM, Berger PB, Davis BR, Grines CL, Sadeghi HM, Williams BA, Willerson JT, Granett JR, Holmes DR. Impact of mild or moderate chronic kidney disease on the frequency of restenosis: results from the PRESTO trial. J Am Coll Cardiol 2005; 44:1786-91. [PMID: 15519008 DOI: 10.1016/j.jacc.2004.07.052] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.7] [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: 02/20/2004] [Revised: 07/06/2004] [Accepted: 07/12/2004] [Indexed: 10/26/2022]
Abstract
OBJECTIVES The goal of this study was to determine if restenosis is increased in mild and moderate chronic kidney disease (CKD) patients after percutaneous coronary intervention (PCI). BACKGROUND Mortality is increased in CKD after PCI. Restenosis may contribute to increased late mortality. METHODS We analyzed 11,187 patients with a creatinine <1.8 mg/dl from the Prevention of REStenosis with Tranilast and its Outcomes (PRESTO) trial, grouped by estimated creatinine clearance (CrCl) (<60, 60 to 89, >89 ml/min). The Cox proportional hazards models investigated the association between CrCl group and death, myocardial infarction, and target vessel revascularization (TVR). Generalized estimating equation regression models determined the association between CrCl group and lesion-specific restenosis. RESULTS At 30 days, there was no difference in myocardial infarction, death, or TVR between the CrCl groups. At nine months, mortality was higher in the lowest CrCl group (2.2%, 1.2%, 0.8%; p < 0.001), which was no longer significant after adjusting for confounding variables. Myocardial infarction and TVR were not different between the groups. In patients undergoing protocol follow-up angiography, restenosis (>/=50%) was not increased with CKD (32%, 32%, 37%; p = 0.02). CONCLUSIONS Mortality nine months after PCI is mildly increased in mild or moderate CKD patients. However, restenosis is not and does not account for the increased mortality.
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Abstract
We report the case of a 51-year-old male who underwent coronary stent placement for the treatment of an acute myocardial infarction. One week later, he developed symptomatic autoimmune thrombocytopenia likely related to clopidogrel use. This was successfully treated with intravenous methylprednisilone and platelet transfusions.
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Affiliation(s)
- Patricia J M Best
- Division of Cardiovascular Diseases, Department of Internal Medicine, Mayo Clinic, Mayo Foundation, Rochester, Minnesota, USA
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Abstract
Despite the high prevalence and significant morbidity and mortality rates of chronic kidney disease (CKD) related to cardiovascular disease, it remains vastly understudied. Most of the current practice recommendations come from small under-powered prospective studies, retrospective reviews, and assuming patients with CKD will similarly benefit from medications and treatments as patients with normal renal function. In addition, because of the previous lack of a consistent definition of CKD and how to measure renal function, definitions of the degree of renal dysfunction have varied widely and compounded the confusion of these data. Remarkably, despite patients with CKD representing the group at highest risk from cardiovascular complications, even greater than patients with diabetes mellitus, there has been a systematic exclusion of patients with CKD from therapeutic trials. This review outlines our current understanding of CKD as a cardiovascular risk factor, treatment options, and the future directions that are needed to treat cardiovascular disease in patients with CKD.
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Affiliation(s)
- Patricia J M Best
- Division of Cardiovascular Medicine, Mayo Clinic, Rochester, MN 55905, USA.
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Best PJM, Berger PB. Can percutaneous coronary interventions reduce death and myocardial infarction in stable and unstable coronary disease? Catheter Cardiovasc Interv 2004; 61:528-36. [PMID: 15065151 DOI: 10.1002/ccd.20016] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [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: 11/11/2022]
Affiliation(s)
- Patricia J M Best
- Department of Internal Medicine, Mayo Clinic and Mayo Foundation, Rochester, Minnesota 27715, USA
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Best PJM, Berger PB. Perindopril reduced cardiac events in stable coronary artery disease. ACP J Club 2004; 140:31. [PMID: 15122852] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Subscribe] [Scholar Register] [Indexed: 04/29/2023]
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Best PJM, Lennon R, Gersh BJ, Ting HH, Rihal CS, Bell MR, Herzog CA, Holmes DR, Berger PB. Safety of abciximab in patients with chronic renal insufficiency who are undergoing percutaneous coronary interventions. Am Heart J 2003; 146:345-50. [PMID: 12891206 DOI: 10.1016/s0002-8703(03)00231-x] [Citation(s) in RCA: 39] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Patients with chronic renal insufficiency (CRI) have worse outcomes during and after percutaneous coronary interventions (PCI). Abciximab reduces complications, but may cause excessive bleeding in patients with CRI. Therefore, we sought to determine the safety of abciximab in patients with CRI. METHODS Patients (n = 4158) undergoing PCI at the Mayo Clinic since abciximab became available were analyzed according to their estimated creatinine clearance (> or =70, 50-69, or <50 mL/min) or need for dialysis. Major bleeding was defined as a cerebrovascular bleed or a decrease in the hematocrit level >15%. Minor bleeding was defined as a decrease in the hematocrit level of 10% to 15% with an identifiable site of bleeding. RESULTS CRI was associated with increased bleeding in patients who received abciximab and patients who did not. However, there was only a trend toward an interaction between creatinine clearance and major bleeding with abciximab (odds ratio [OR], 1.18; P =.06) and no interaction with minor bleeding (OR, 1.01; P =.94) or any bleeding (OR, 1.10; P =.15). CONCLUSION CRI is associated with an increased risk of bleeding complications after PCI. Although abciximab increases the risk of bleeding in all patients, the increase in relative risk is not significantly greater in patients with CRI. Thus, abciximab may be given safely in patients with CRI who are undergoing PCI.
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Affiliation(s)
- Patricia J M Best
- Division of Cardiovascular Diseases, Department of Internal Medicine, Mayo Clinic and Mayo Foundation, Rochester, Minn 55905, USA
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Bonetti PO, Best PJM, Rodriguez-Porcel M, Holmes DR, Lerman LO, Lerman A. Endothelin type A receptor antagonism restores myocardial perfusion response to adenosine in experimental hypercholesterolemia. Atherosclerosis 2003; 168:367-73. [PMID: 12801621 DOI: 10.1016/s0021-9150(03)00141-2] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.4] [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] [Indexed: 11/30/2022]
Abstract
Experimental hypercholesterolemia is characterized by increased endothelin-1 (ET-1) activity and is associated with an attenuated myocardial perfusion response and an inappropriate increase in coronary microvascular permeability during episodes of increased myocardial demand. This study was designed to determine the effect of chronic selective ET type A (ET(A)) receptor antagonism on coronary vascular response to simulated cardiac stress in experimental hypercholesterolemia. Twenty-one pigs were randomized to three groups: normal diet (N), high-cholesterol diet (HC), and HC diet plus ABT-627, a selective ET(A) receptor antagonist, (HC+ABT-627). After 12 weeks, cardiac electron beam computed tomography (EBCT) was performed before and during intravenous infusion of adenosine, and myocardial perfusion (ml/min per g) and coronary microvascular permeability index (arbitrary units) were calculated. Basal myocardial perfusion was similar in all groups (N: 0.91+/-0.10; HC: 0.95+/-0.08; HC+ABT-627: 1.03+/-0.09; P=0.64). Adenosine infusion led to a significant increase in myocardial perfusion in the N (1.32+/-0.15; P<0.001) but not in the HC (0.95+/-0.07) group. However, in the HC+ABT-627 group, adenosine also significantly increased myocardial perfusion (1.33+/-0.12; P=0.001). Basal permeability index did not differ between the groups (N: 1.56+/-0.13; HC: 1.34+/-0.19; HC+ABT-627: 1.62+/-0.10; P=0.38). Adenosine infusion significantly increased permeability index in HC pigs (2.29+/-0.22; P<0.001) but not in N (1.71+/-0.21) and HC+ABT-627 (1.82+/-0.08) pigs. We conclude that chronic selective ET(A) receptor antagonism preserves myocardial perfusion response and coronary microvascular integrity during episodes of increased myocardial demand in experimental hypercholesterolemia, indicating an important role for the endogenous endothelin system in this disorder.
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Affiliation(s)
- Piero O Bonetti
- Division of Cardiovascular Diseases, Department of Internal Medicine, Mayo Clinic and Foundation, 200 First Street SW, Rochester, MN 55905, USA
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Affiliation(s)
- Patricia J M Best
- Department of Internal Medicine, Mayo Clinic and Mayo Foundation, Rochester, MN 55905, USA
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Krier JD, Rodriguez-Porcel M, Best PJM, Romero JC, Lerman A, Lerman LO. Vascular responses in vivo to 8-epi PGF(2alpha) in normal and hypercholesterolemic pigs. Am J Physiol Regul Integr Comp Physiol 2002; 283:R303-8. [PMID: 12121841 DOI: 10.1152/ajpregu.00602.2001] [Citation(s) in RCA: 19] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
Hypercholesterolemia (HC) is characterized by increased circulating 8-epi-prostaglandin-F(2alpha) (isoprostane), a vasoconstrictor, marker, and mediator of increased oxidative stress, whose vascular effects might be augmented in HC. Anesthetized pigs were studied in vivo with electron beam computed tomography after a 12-wk normal (n = 8) or HC (n = 8) diet. Mean arterial pressure (MAP), single-kidney perfusion, and glomerular filtration rate (GFR) were quantified before and during unilateral intrarenal infusions of U46619 (10 ng x kg(-1) x min(-1)) or isoprostane (1 microg x kg(-1) x min(-1)). Basal renal perfusion and function were similar, and isoprostane infusion elevated its systemic levels similarly in normal and HC (333 +/- 89 vs. 366 +/- 48 pg/ml, respectively, P < 0.01 vs. baseline). Both drugs markedly and comparably decreased cortical perfusion and GFR in both groups, whereas medullary perfusion decreased significantly only in HC. Moreover, MAP increased significantly only in HC (+9 +/- 3 and +11 +/- 3 mmHg, respectively, P<or= 0.05). Hence, in HC, renal functional responses to high-dose isoprostane are largely similar to normal, but the systemic circulation exhibits augmented sensitivity to pathophysiological levels of isoprostane and U46619, which may potentially play a role in development of hypertension and vascular injury associated with increased oxidative stress.
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Affiliation(s)
- James D Krier
- Department of Internal Medicine, Division of Hypertension, Mayo Clinic, Rochester, Minnesota 55905, USA
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Abstract
BACKGROUND Dendroaspis natriuretic peptide (DNP) is the newest member of the natriuretic peptide family and is a circulating peptide in humans. The effects of DNP on the human vasculature are unknown. Since other natriuretic peptides are known to cause vasorelaxation, we determined the response to DNP on human blood vessels in vitro. We also investigated the mechanism of DNP mediated vasorelaxation. METHODS Rings of human internal mammary artery and saphenous vein were suspended in an organ bath. The response to cumulative concentrations of DNP was obtained. Inhibiting agents were used to determine the mechanism of this vasorelaxation. RESULTS DNP caused dose-dependent relaxation, with a greater effect on the internal mammary arteries (relaxation from 10(-7) mol/l DNP: 80.6+/-4.1%) than the saphenous veins (33.4+/-4.1%). At 10(-7) mol/l, DNP resulted in less arterial relaxation compared with atrial and C-type natriuretic peptides and similar relaxation to brain natriuretic peptide. In veins, DNP caused the greatest relaxation of the natriuretic peptides. DNP increased tissue cyclic guanosine monophosphate (cGMP) determined by radioimmunoassay by over 7-fold. Barium chloride and indomethacin attenuated DNP mediated vasorelaxation. However, glibenclamide, charydotoxin, apamin, tetraethyl-ammonium chloride and diisothiocyanato-stilbene-2,2'-disulfonic acid did not. DNP mediated vasorelaxation was mildly attenuated with removal of the endothelium. DNP immunoreactivity was identified in both arteries and veins. CONCLUSIONS The current study demonstrates that DNP is an endogenous human natriuretic peptide that relaxes human arteries more than veins. Furthermore, DNP mediated vasorelaxation involves the inward rectifying potassium channels, prostaglandins, and cGMP. This newest member of the natriuretic peptide family may have an important physiologic role in the human vasculature.
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Affiliation(s)
- Patricia J M Best
- Division of Cardiovascular Diseases, Department of Internal Medicine, Mayo Clinic and Mayo Foundation, 200 First Street SW, Rochester, MN 55905, USA
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Best PJM, Lennon R, Ting HH, Bell MR, Rihal CS, Holmes DR, Berger PB. The impact of renal insufficiency on clinical outcomes in patients undergoing percutaneous coronary interventions. J Am Coll Cardiol 2002; 39:1113-9. [PMID: 11923033 DOI: 10.1016/s0735-1097(02)01745-x] [Citation(s) in RCA: 536] [Impact Index Per Article: 24.4] [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: 11/24/2022]
Abstract
OBJECTIVES We sought to determine the effect of varying degrees of renal insufficiency on death and cardiac events during and after a percutaneous coronary intervention (PCI). BACKGROUND Patients with end-stage renal disease have a high mortality from coronary artery disease. Little is known about the impact of mild and moderate renal insufficiency on clinical outcomes after PCI. METHODS Cardiac mortality and all-cause mortality were determined for 5,327 patients undergoing PCI from January 1, 1994, to August 31, 1999, at the Mayo Clinic, based on the estimated creatinine clearance or whether the patient was on dialysis. RESULTS In-hospital mortality was significantly associated with renal insufficiency (p = 0.001). Even after successful PCI, one-year mortality was 1.5% when the creatinine clearance was > or =70 ml/min (n = 2,558), 3.6% when it was 50 to 69 ml/min (n = 1,458), 7.8% when it was 30 to 49 ml/min (n = 828) and 18.3% when it was < 30 ml/min (n = 141). The 18.3% mortality rate for the group with < 30 ml/min creatinine clearance was similar to the 19.9% mortality rate in patients on dialysis (n = 46). The mortality risk was largely independent of all other factors. CONCLUSIONS Renal insufficiency is a strong predictor of death and subsequent cardiac events in a dose-dependent fashion during and after PCI. Patients with renal insufficiency have more baseline cardiovascular risk factors, but renal insufficiency is associated with an increased risk of death and other adverse cardiovascular events, independent of all other measured variables.
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Affiliation(s)
- Patricia J M Best
- Division of Cardiovascular Diseases, Department of Internal Medicine, Mayo Clinic and Mayo Foundation, Rochester, Minnesota 55905, USA
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Wilson SH, Best PJM, Edwards WD, Holmes DR, Carlson PJ, Celermajer DS, Lerman A. Nuclear factor-kappaB immunoreactivity is present in human coronary plaque and enhanced in patients with unstable angina pectoris. Atherosclerosis 2002; 160:147-53. [PMID: 11755932 DOI: 10.1016/s0021-9150(01)00546-9] [Citation(s) in RCA: 70] [Impact Index Per Article: 3.2] [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] [Indexed: 11/28/2022]
Abstract
BACKGROUND Nuclear factor-kappaB (NF-kappaB) is a transcription factor which plays a coordinating role in inflammation and cellular proliferation and is thought to be involved in the pathogenesis of atherosclerosis. Its role in unstable coronary plaque in humans is unknown. METHODS AND RESULTS Coronary atherectomy plaque was obtained via directional coronary atherectomy from 32 patients [16 with unstable angina pectoris (UAP) and 16 with stable angina pectoris (SAP)]. The predominant pathology in UAP consisted of richly cellular areas with atheromatous gruel or loose intimal proliferative tissue within a myxoid matrix (P<0.05 compared with SAP). By contrast, SAP plaques showed more dense fibrosis (P<0.01 compared with UAP). Sections were then stained with a monoclonal antibody to the activated p65 subunit of NF-kappaB and this staining was present in 31/32 specimens, localized to smooth muscle cells, macrophages and foam cells. Staining was then graded semiquantitatively by three independent observers. Immunostaining grades for activated NF-kappaB were significantly higher in UAP compared with SAP (2.60+/-0.1 vs. 1.98+/-0.18; P<0.01). CONCLUSIONS NF-kappaB immunoreactivity is present in coronary atherosclerotic plaque and is increased among patients with unstable coronary syndromes. These data support a role for NF-kappaB in the pathogenesis of acute coronary syndromes in humans.
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Affiliation(s)
- Stephanie H Wilson
- Division of Cardiovascular Diseases, Mayo Clinic, 200 First St. SW, Rochester, MN 55905, USA
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