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Zinoviev R, Hasan RK, Gammie JS, Resar JR, Czarny MJ. Economic Burden of Inpatient Care for Mitral Regurgitation in Maryland. J Am Heart Assoc 2024; 13:e029875. [PMID: 38214264 PMCID: PMC10926798 DOI: 10.1161/jaha.123.029875] [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: 02/17/2023] [Accepted: 10/16/2023] [Indexed: 01/13/2024]
Abstract
BACKGROUND Mitral regurgitation (MR) is the most common valvular disease in the United States and increases the risk of death and hospitalization. The economic burden of MR in the United States is not known. METHODS AND RESULTS We analyzed inpatient hospitalization data from the 1 221 173 Maryland residents who had any in-state admissions from October 1, 2015, to September 30, 2019. We assessed the total charges for patients without MR and for patients with MR who underwent medical management, transcatheter mitral valve repair or replacement, or surgical mitral valve repair or replacement. During the study period, 26 076 inpatients had a diagnosis of MR. Compared with patients without MR, these patients had more comorbidities and higher inpatient mortality. Patients with medically managed MR incurred average total charges of $23 575 per year; MR was associated with $10 559 more in charges per year and an incremental 3.1 more inpatient days per year as compared with patients without MR. Both surgical mitral valve repair or replacement and transcatheter mitral valve repair or replacement were associated with higher charges as compared with medical management during the year of intervention ($47 943 for surgical mitral valve repair or replacement and $63 108 for transcatheter mitral valve repair or replacement). Annual charges for both groups were significantly lower as compared with medical management in the second and third years postintervention. CONCLUSIONS MR is associated with higher mortality and inpatient charges. Patients who undergo surgical or transcatheter intervention incur lower charges compared with medically managed MR patients in the years after the procedure.
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Affiliation(s)
| | - Rani K. Hasan
- Division of Cardiology, Johns Hopkins University School of MedicineBaltimoreMD
| | - James S. Gammie
- Division of Cardiac SurgeryJohns Hopkins University School of MedicineBaltimoreMD
| | - Jon R. Resar
- Division of Cardiology, Johns Hopkins University School of MedicineBaltimoreMD
| | - Matthew J. Czarny
- Division of Cardiology, Johns Hopkins University School of MedicineBaltimoreMD
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2
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Denis RL, Hasan RK, Post WS, Resar JR, Zimmerman SL, Czarny MJ. Racial Differences in Aortic Valve Calcium Volume Among Patients With Severe Aortic Stenosis Who Underwent Transcatheter Aortic Valve Replacement. Am J Cardiol 2023; 208:116-117. [PMID: 37832207 PMCID: PMC10842499 DOI: 10.1016/j.amjcard.2023.09.018] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/04/2023] [Accepted: 09/06/2023] [Indexed: 10/15/2023]
Abstract
“No difference observed in aortic valve calcium volume in patients with severe AS undergoing TAVR.”
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Affiliation(s)
- Rimsky L Denis
- Division of Cardiology, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Rani K Hasan
- Division of Cardiology, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Wendy S Post
- Division of Cardiology, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Jon R Resar
- Division of Cardiology, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Stefan L Zimmerman
- Department of Radiology, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Matthew J Czarny
- Division of Cardiology, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland.
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3
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Rahman F, Mehta HH, Resar JR, Hasan RK, Marconi W, Aziz H, Czarny MJ. Outcomes among patients undergoing transcatheter aortic valve replacement with very low baseline gradients. Front Cardiovasc Med 2023; 10:1194360. [PMID: 37600049 PMCID: PMC10436597 DOI: 10.3389/fcvm.2023.1194360] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/27/2023] [Accepted: 07/24/2023] [Indexed: 08/22/2023] Open
Abstract
Background While there is evidence that patients with low-flow, low-gradient aortic stenosis (AS) benefit from transcatheter aortic valve replacement (TAVR), data are lacking regarding outcomes of patients with a very low gradient (VLG). Methods In this retrospective, single-center study of patients with severe AS who underwent TAVR, three groups were defined using baseline mean aortic valve gradient: VLG (≤25 mmHg), low gradient (LG, 26-39 mmHg), and high gradient (HG, ≥40 mmHg). The primary outcome was the composite of Kansas City Cardiomyopathy Questionnaire (KCCQ)-12 of <45, decrease in KCCQ-12 of ≥10 compared with baseline, or death at 1 year. Results One-thousand six patients were included: 571 HG, 353 LG, and 82 VLG. The median age was 82.1 years [interquartile range (IQR) 76.3-86.9]; VLG patients had more baseline comorbidities compared with the other groups. The primary outcome was highest at 1 year in the VLG group (VLG, 46.7%; LG, 29.9%; HG, 23.1%; p = 0.002), with no difference between groups after adjustment for baseline characteristics. At baseline, <30% of VLG patients had an excellent or good (50-100) KCCQ-12, whereas more than 75% and 50% had an excellent or good KCCQ-12 at 30-day and 1-year follow-up, respectively. Conclusion Although patients with VLG undergoing TAVR have a higher rate of poor outcomes at 1 year compared with patients with LG and HG severe AS, this difference is largely attributable to baseline comorbidities. Patients with severe AS undergoing TAVR have significant improvement in health status outcomes regardless of resting mean gradient.
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Affiliation(s)
- Faisal Rahman
- Division of Cardiology, Johns Hopkins Hospital, Baltimore, MD, United States
| | - Hetal H. Mehta
- Division of Cardiology, Doylestown Health, Doylestown, PA, United States
| | - Jon R. Resar
- Division of Cardiology, Johns Hopkins Hospital, Baltimore, MD, United States
| | - Rani K. Hasan
- Division of Cardiology, Johns Hopkins Hospital, Baltimore, MD, United States
| | - Wendy Marconi
- Division of Cardiology, Johns Hopkins Hospital, Baltimore, MD, United States
| | - Hamza Aziz
- Division of Cardiac Surgery, Johns Hopkins Hospital, Baltimore, MD, United States
| | - Matthew J. Czarny
- Division of Cardiology, Johns Hopkins Hospital, Baltimore, MD, United States
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Yesantharao PS, Etchill EW, Zhou AL, Ong CS, Metkus TS, Canner JK, Alejo DE, Aliu O, Czarny MJ, Hasan RK, Resar JR, Schena S. The impact of a statewide payment reform on transcatheter aortic valve replacement (TAVR) utilization and readmissions. Catheter Cardiovasc Interv 2023; 101:1193-1202. [PMID: 37102376 DOI: 10.1002/ccd.30670] [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: 11/24/2022] [Revised: 02/07/2023] [Accepted: 04/15/2023] [Indexed: 04/28/2023]
Abstract
BACKGROUND Transcatheter aortic valve replacement (TAVR) is an increasingly used but relatively expensive procedure with substantial associated readmission rates. It is unknown how cost-constrictive payment reform measures, such as Maryland's All Payer Model, impact TAVR utilization given its relative expense. This study investigated the impact of Maryland's All Payer Model on TAVR utilization and readmissions among Maryland Medicare beneficiaries. METHODS This was a quasi-experimental investigation of Maryland Medicare patients undergoing TAVR between 2012 and 2018. New Jersey data were used for comparison. Longitudinal interrupted time series analyses were used to study TAVR utilization and difference-in-differences analyses were used to investigate post-TAVR readmissions. RESULTS During the first year of payment reform (2014), TAVR utilization among Maryland Medicare beneficiaries dropped by 8% (95% confidence interval [CI]: -9.2% to -7.1%; p < 0.001), with no concomitant change in TAVR utilization in New Jersey (0.2%, 95% CI: 0%-1%, p = 0.09). Longitudinally, however, the All Payer Model did not impact TAVR utilization in Maryland compared to New Jersey. Difference-in-differences analyses demonstrated that implementation of the All Payer Model was not associated with significantly greater declines in 30-day post-TAVR readmissions in Maryland versus New Jersey (-2.1%; 95% CI: -5.2% to 0.9%; p =0.1). CONCLUSIONS Maryland's All Payer Model resulted in an immediate decline in TAVR utilization, likely a result of hospitals adjusting to global budgeting. However, beyond this transition period, this cost-constrictive reform measure did not limit Maryland TAVR utilization. In addition, the All Payer Model did not reduce post-TAVR 30-day readmissions. These findings may help inform expansion of globally budgeted healthcare payment structures.
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Affiliation(s)
- Pooja S Yesantharao
- Division of Cardiac Surgery, Johns Hopkins Hospital, Baltimore, Maryland, USA
| | - Eric W Etchill
- Division of Cardiac Surgery, Johns Hopkins Hospital, Baltimore, Maryland, USA
| | - Alice L Zhou
- Division of Cardiac Surgery, Johns Hopkins Hospital, Baltimore, Maryland, USA
| | - Chin Siang Ong
- Division of Cardiac Surgery, Johns Hopkins Hospital, Baltimore, Maryland, USA
- Division of Cardiology, Johns Hopkins Hospital, Baltimore, Maryland, USA
| | - Thomas S Metkus
- Division of Cardiac Surgery, Johns Hopkins Hospital, Baltimore, Maryland, USA
- Division of Cardiology, Johns Hopkins Hospital, Baltimore, Maryland, USA
| | - Joseph K Canner
- Department of Surgery, Johns Hopkins Hospital, Baltimore, Maryland, USA
| | - Diane E Alejo
- Division of Cardiac Surgery, Johns Hopkins Hospital, Baltimore, Maryland, USA
| | - Oluseyi Aliu
- Department of Surgery, Johns Hopkins Hospital, Baltimore, Maryland, USA
| | - Matthew J Czarny
- Division of Cardiology, Johns Hopkins Hospital, Baltimore, Maryland, USA
| | - Rani K Hasan
- Division of Cardiology, Johns Hopkins Hospital, Baltimore, Maryland, USA
| | - Jon R Resar
- Division of Cardiology, Johns Hopkins Hospital, Baltimore, Maryland, USA
| | - Stefano Schena
- Division of Cardiac Surgery, Johns Hopkins Hospital, Baltimore, Maryland, USA
- Medical College of Wisconsin, Milwaukee, Wisconsin, 53226, USA
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Damluji AA, Ijaz N, Chung SE, Xue QL, Hasan RK, Batchelor WB, Orkaby AR, Kochar A, Nanna MG, Roth DL, Walston JD, Resar JR, Gerstenblith G. Hierarchical Development of Physical Frailty and Cognitive Impairment and Their Association With Incident Cardiovascular Disease. JACC Adv 2023; 2:100318. [PMID: 37538136 PMCID: PMC10399211 DOI: 10.1016/j.jacadv.2023.100318] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 08/05/2023]
Abstract
BACKGROUND Frailty and cognitive impairment (CI) are geriatric conditions that lead to poor health outcomes among older adults with cardiovascular disease. The association between their temporal patterns of development and cardiovascular risk is unknown. OBJECTIVES This study aims to examine the 5-year cardiovascular outcomes by the pattern of development of frailty and CI in older adults without a history of coronary artery disease. METHODS We used the National Health and Aging Trends Study, linked to Medicare data. Frailty was measured using the physical frailty phenotype. CI was measured using the AD8 Dementia Screening Interview, measured cognitive performance, or self-report by patient or caregiver for a diagnosis given by a physician. The primary outcome was incident major adverse cardiovascular event at 5 years. RESULTS Of a total 2,189 study participants aged 65 and older, 38.5% were male. In this study population, 154 (7%) participants developed frailty first, 829 (38%) developed CI first, and 195 (9%) participants developed both simultaneously (frail-CI group). Those who developed frailty and CI simultaneously were older, more likely to be female, and had multiple chronic conditions. The frail-CI group had the highest risk of major adverse cardiovascular event (hazard ratio [HR]: 1.81; 95% CI: 1.47-2.23) followed by frail first (HR: 1.46; 95% CI: 1.17-1.81) and CI first (HR: 1.31; 95% CI: 1.15-1.50). Frailty first was associated with the greater risk of stroke (HR: 1.49; 95% CI: 1.06-2.09) compared to the intact group. CONCLUSIONS The simultaneous development of frailty and CI is associated with an increased risk of adverse cardiovascular outcomes including death compared with the development of each syndrome alone. Diagnostics to detect frailty and CI are critical in assessment of cardiovascular risk in the older population.
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Affiliation(s)
- Abdulla A. Damluji
- The Inova Center of Outcomes Research, Inova Heart and Vascular Institute, Falls Church, Virginia, USA
- Johns Hopkins Older Americans Independence Center and the Center on Aging and Health
- Division of Cardiology, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Naila Ijaz
- The Inova Center of Outcomes Research, Inova Heart and Vascular Institute, Falls Church, Virginia, USA
| | - Shang-En Chung
- Division of Geriatrics and Gerontology, Department of Medicine, Johns Hopkins School of Medicine, Baltimore, Maryland, USA
| | - Qian-Li Xue
- Johns Hopkins Older Americans Independence Center and the Center on Aging and Health
- Division of Geriatrics and Gerontology, Department of Medicine, Johns Hopkins School of Medicine, Baltimore, Maryland, USA
| | - Rani K. Hasan
- Division of Cardiology, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Wayne B. Batchelor
- The Inova Center of Outcomes Research, Inova Heart and Vascular Institute, Falls Church, Virginia, USA
| | - Ariela R. Orkaby
- Section of Cardiovascular Medicine, Yale University School of Medicine, New Haven, Connecticut, USA
| | - Ajar Kochar
- The Brigham and Women’s Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Michael G. Nanna
- Section of Cardiovascular Medicine, Yale University School of Medicine, New Haven, Connecticut, USA
| | - David L. Roth
- Johns Hopkins Older Americans Independence Center and the Center on Aging and Health
| | - Jeremy D. Walston
- Division of Geriatrics and Gerontology, Department of Medicine, Johns Hopkins School of Medicine, Baltimore, Maryland, USA
| | - Jon R. Resar
- Division of Cardiology, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Gary Gerstenblith
- Division of Cardiology, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
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Alfaddagh A, Aljarallah M, Farrag I, Hasan RK, Zubaid M. SHORTER LENGTH OFHOSPITAL STAY DURING COVID-19 LOCKDOWN IS NOT ASSOCIATED WITHWORSE 30-DAY OUTCOMES IN ACS PATIENTS. J Am Coll Cardiol 2023. [PMCID: PMC9982995 DOI: 10.1016/s0735-1097(23)01670-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 03/06/2023]
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Das TM, Shin J, Czarny MJ, Nanavati J, Resar JR, Hasan RK. Radial versus femoral secondary access for transcatheter aortic valve replacement: A systematic review and meta-analysis. Catheter Cardiovasc Interv 2021; 99:1225-1233. [PMID: 34792259 DOI: 10.1002/ccd.30009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/20/2021] [Revised: 09/28/2021] [Accepted: 10/20/2021] [Indexed: 11/11/2022]
Abstract
OBJECTIVES We aimed to evaluate the risk of procedural complications after TAVR using secondary radial access (RA) versus femoral access (FA) through a systematic review and meta-analysis of the published literature. BACKGROUND Transcatheter aortic valve replacement (TAVR) entails both large-bore arterial access for device delivery and secondary arterial access for hemodynamic and imaging assessments. It is unknown whether RA versus FA for this secondary access reduces the risk of procedural complications. METHODS We searched PubMed, Embase, the Cochrane Library, and Web of Science for observational studies comparing TAVR procedural complications in RA versus FA. Event rates were compared via weighted summary odds ratios using the Mantel-Haenszel method. RESULTS Six manuscripts encompassing 6132 patients were included. Meta-analysis showed that RA reduced the risk of major vascular complications (OR 0.58, 95% CI 0.43-0.77, p < 0.001, I2 0%) and major/life-threatening bleeding (OR 0.46, 95% CI 0.36-0.59, p < 0.001, I2 0%) as compared to FA for secondary TAVR access. We also observed a reduction 30-day mortality (OR 0.55, 95% CI 0.38-0.79, p = 0.001, I2 0%), acute kidney injury (OR 0.45, 95% CI 0.34-0.60, p < 0.001, I2 0%), and stroke and transient ischemic attack (OR 0.43, 95% CI 0.27-0.67, p < 0.001, I2 0%). CONCLUSIONS RA reduced the risk of major vascular and bleeding complications when compared to FA for secondary access in TAVR. RA is associated with reduced risk of other adverse outcomes including mortality, but these associations may be related to selection bias and confounding given the observational study designs.
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Affiliation(s)
- Thomas M Das
- Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Joseph Shin
- Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Matthew J Czarny
- Department of Medicine, Division of Cardiology, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Julie Nanavati
- Welch Medical Library, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Jon R Resar
- Department of Medicine, Division of Cardiology, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Rani K Hasan
- Department of Medicine, Division of Cardiology, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
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Damluji AA, Chung SE, Xue QL, Hasan RK, Moscucci M, Forman DE, Bandeen-Roche K, Batchelor W, Walston JD, Resar JR, Gerstenblith G. Frailty and cardiovascular outcomes in the National Health and Aging Trends Study. Eur Heart J 2021; 42:3856-3865. [PMID: 34324648 PMCID: PMC8487013 DOI: 10.1093/eurheartj/ehab468] [Citation(s) in RCA: 66] [Impact Index Per Article: 22.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/08/2021] [Revised: 05/25/2021] [Accepted: 07/04/2021] [Indexed: 11/13/2022] Open
Abstract
AIMS Physical frailty is a commonly encountered geriatric syndrome among older adults without coronary heart disease (CHD). The impact of frailty on the incidence of long-term cardiovascular outcomes is not known.We aimed to evaluate the long-term association of frailty, measured by the Fried frailty phenotype, with all-cause-mortality and MACE among older adults without a history of CHD at baseline in the National Health and Aging Trends Study. METHODS AND RESULTS We used the National Health and Aging Trends Study, a prospective cohort study linked to a Medicare sample. Participants with a prior history of CHD were excluded. Frailty was measured during the baseline visit using the Fried physical frailty phenotype. Cardiovascular outcomes were assessed during a 6-year follow-up.Of the 4656 study participants, 3259 (70%) had no history of CHD 1 year prior to their baseline visit. Compared to those without frailty, subjects with frailty were older (mean age 82.1 vs. 75.1 years, P < 0.001), more likely to be female (68.3% vs. 54.9%, P < 0.001), and belong to an ethnic minority. The prevalence of hypertension, falls, disability, anxiety/depression, and multimorbidity was much higher in the frail and pre-frail than the non-frail participants. In a Cox time-to-event multivariable model and during 6-year follow-up, the incidences of death and of each individual cardiovascular outcomes were all significantly higher in the frail than in the non-frail patients including major adverse cardiovascular event (MACE) [hazard ratio (HR) 1.77, 95% confidence interval (CI) 1.53, 2.06], death (HR 2.70, 95% CI 2.16, 3.38), acute myocardial infarction (HR 1.95, 95% CI 1.31, 2.90), stroke (HR 1.71, 95% CI 1.34, 2.17), peripheral vascular disease (HR 1.80, 95% CI 1.44, 2.27), and coronary artery disease (HR 1.35, 95% CI 1.11, 1.65). CONCLUSION In patients without CHD, frailty is a risk factor for the development of MACEs. Efforts to identify frailty in patients without CHD and interventions to limit or reverse frailty status are needed and, if successful, may limit subsequent adverse cardiovascular events.
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Affiliation(s)
- Abdulla A Damluji
- The Inova Center of Outcomes Research, Inova Heart and Vascular Institute, 3300 Gallows Road, I-465, Falls Church, VA 22042, USA
- Division of Cardiology, Department of Medicine, Johns Hopkins School of Medicine, Baltimore, MD 21205, USA
| | - Shang-En Chung
- Division of Geriatric Medicine and Gerontology, Department of Medicine, Johns Hopkins School of Medicine, Baltimore, MD 21224, USA
| | - Qian-Li Xue
- Division of Geriatric Medicine and Gerontology, Department of Medicine, Johns Hopkins School of Medicine, Baltimore, MD 21224, USA
- Department of Biostatistics, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD 21205, USA
| | - Rani K Hasan
- Division of Cardiology, Department of Medicine, Johns Hopkins School of Medicine, Baltimore, MD 21205, USA
| | - Mauro Moscucci
- Division of Cardiovascular Medicine, Department of Medicine, University of Michigan, Ann Arbor, MI 48109, USA
| | - Daniel E Forman
- Geriatric Cardiology Section, University of Pittsburgh, Pittsburgh, PA, USA
- Geriatric Research, Education, and Clinical Center, VA Pittsburgh Healthcare System, Pittsburgh, PA, USA
| | - Karen Bandeen-Roche
- Department of Biostatistics, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD 21205, USA
| | - Wayne Batchelor
- The Inova Center of Outcomes Research, Inova Heart and Vascular Institute, 3300 Gallows Road, I-465, Falls Church, VA 22042, USA
| | - Jeremy D Walston
- Division of Geriatric Medicine and Gerontology, Department of Medicine, Johns Hopkins School of Medicine, Baltimore, MD 21224, USA
| | - Jon R Resar
- Division of Cardiology, Department of Medicine, Johns Hopkins School of Medicine, Baltimore, MD 21205, USA
| | - Gary Gerstenblith
- Division of Cardiology, Department of Medicine, Johns Hopkins School of Medicine, Baltimore, MD 21205, USA
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Czarny MJ, Hasan RK, Post WS, Chacko M, Schena S, Resar JR. Inequities in Aortic Stenosis and Aortic Valve Replacement Between Black/African-American, White, and Hispanic Residents of Maryland. J Am Heart Assoc 2021; 10:e017487. [PMID: 34261361 PMCID: PMC8483496 DOI: 10.1161/jaha.120.017487] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Abstract
Background Racial and ethnic inequities exist in surgical aortic valve replacement for aortic stenosis (AS), and early studies have suggested similar inequities in transcatheter aortic valve replacement. Methods and Results We performed a retrospective analysis of the Maryland Health Services Cost Review Commission inpatient data set from 2016 to 2018. Black patients had half the incidence of any inpatient AS diagnosis compared with White patients (incidence rate ratio [IRR], 0.50; 95% CI, 0.48–0.52; P<0.001) and Hispanic patients had one fourth the incidence compared with White patients (IRR, 0.25; 95% CI, 0.22–0.29; P<0.001). Conversely, the incidence of any inpatient mitral regurgitation diagnosis did not differ between White and Black patients (IRR, 1.00; 95% CI, 0.97–1.03; P=0.97) but was significantly lower in Hispanic compared with White patients (IRR, 0.36; 95% CI, 0.33–0.40; P<0.001). After multivariable adjustment, Black race was associated with a lower incidence of surgical aortic valve replacement (IRR, 0.67; 95% CI, 0.55–0.82 P<0.001 relative to White race) and transcatheter aortic valve replacement (IRR, 0.77; 95% CI, 0.65–0.90; P=0.002) among those with any inpatient diagnosis of AS. Hispanic patients had a similar rate of surgical aortic valve replacement and transcatheter aortic valve replacement compared with White patients. Conclusions Hospitalization with any diagnosis of AS is less common in Black and Hispanic patients than in White patients. In hospitalized patients with AS, Black race is associated with a lower incidence of both surgical aortic valve replacement and transcatheter aortic valve replacement compared with White patients, whereas Hispanic patients have a similar incidence of both. The reasons for these inequities are likely multifactorial.
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Affiliation(s)
- Matthew J Czarny
- Division of Cardiology School of Medicine Johns Hopkins University Baltimore MD
| | - Rani K Hasan
- Division of Cardiology School of Medicine Johns Hopkins University Baltimore MD
| | - Wendy S Post
- Division of Cardiology School of Medicine Johns Hopkins University Baltimore MD
| | - Matthews Chacko
- Division of Cardiology School of Medicine Johns Hopkins University Baltimore MD
| | - Stefano Schena
- Division of Cardiothoracic Surgery School of Medicine Johns Hopkins University Baltimore MD
| | - Jon R Resar
- Division of Cardiology School of Medicine Johns Hopkins University Baltimore MD
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10
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Damluji AA, Chung SE, Xue QL, Hasan RK, Walston JD, Forman DE, Bandeen-Roche K, Moscucci M, Batchelor W, Resar JR, Gerstenblith G. Physical Frailty Phenotype and the Development of Geriatric Syndromes in Older Adults with Coronary Heart Disease. Am J Med 2021; 134:662-671.e1. [PMID: 33242482 PMCID: PMC8107119 DOI: 10.1016/j.amjmed.2020.09.057] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [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: 09/20/2020] [Revised: 09/30/2020] [Accepted: 09/30/2020] [Indexed: 10/22/2022]
Abstract
BACKGROUND Frailty, a clinical state of vulnerability, is associated with subsequent adverse geriatric syndromes in the general population. We examined the long-term impact of frailty on geriatric outcomes among older patients with coronary heart disease. METHODS We used the National Health and Aging Trends Study, a prospective cohort study linked to a Medicare sample. Coronary heart disease was identified by self-report or International Classification of Diseases (ICD) codes 1-year prior to the baseline visit. Frailty was measured using the Fried physical frailty phenotype. Geriatric outcomes were assessed annually during a 6-year follow-up. RESULTS Of the 4656 participants, 1213 (26%) had a history of coronary heart disease 1-year prior to their baseline visit. Compared to those without frailty, subjects with frailty were older (ages ≥75: 80.9% vs 68.9%, P < 0.001), more likely to be female, and belong to an ethnic minority. The prevalence of hypertension, stroke, falls, disability, anxiety/depression, and multimorbidity were much higher in the frail, than nonfrail, participants. In a discrete time survival model, the incidence of geriatric syndromes during 6-year follow-up including 1) dementia, 2) loss of independence, 3) activities of daily living disability, 4) instrumental activities of daily living disability, and 5) mobility disability were significantly higher in the frail than in the nonfrail older patients with coronary heart disease. CONCLUSION In patients with coronary heart disease, frailty is a risk factor for the accelerated development of geriatric outcomes. Efforts to identify frailty in the context of coronary heart disease are needed, as well as interventions to limit or reverse frailty status for older patients with coronary heart disease.
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Affiliation(s)
- Abdulla A Damluji
- The Inova Center of Outcomes Research, Inova Heart and Vascular Institute, Falls Church, Va; Division of Cardiology, Department of Medicine, Johns Hopkins School of Medicine, Baltimore, Md.
| | - Shang-En Chung
- Division of Geriatric Medicine and Gerontology, Department of Medicine, Johns Hopkins School of Medicine, Baltimore, Md
| | - Qian-Li Xue
- Division of Geriatric Medicine and Gerontology, Department of Medicine, Johns Hopkins School of Medicine, Baltimore, Md; Department of Biostatistics, Johns Hopkins Bloomberg School of Public Health, Baltimore, Md
| | - Rani K Hasan
- Division of Cardiology, Department of Medicine, Johns Hopkins School of Medicine, Baltimore, Md
| | - Jeremy D Walston
- Division of Geriatric Medicine and Gerontology, Department of Medicine, Johns Hopkins School of Medicine, Baltimore, Md
| | - Daniel E Forman
- Geriatric Cardiology Section, University of Pittsburgh, Pittsburgh, Penn; Geriatric Research, Education, and Clinical Center, VA Pittsburgh Healthcare System, Pittsburgh, Penn
| | - Karen Bandeen-Roche
- Department of Biostatistics, Johns Hopkins Bloomberg School of Public Health, Baltimore, Md
| | | | - Wayne Batchelor
- The Inova Center of Outcomes Research, Inova Heart and Vascular Institute, Falls Church, Va
| | - Jon R Resar
- Division of Cardiology, Department of Medicine, Johns Hopkins School of Medicine, Baltimore, Md
| | - Gary Gerstenblith
- Division of Cardiology, Department of Medicine, Johns Hopkins School of Medicine, Baltimore, Md
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Bandeen-Roche K, Gross AL, Varadhan R, Buta B, Carlson MC, Huisingh-Scheetz M, Mcadams-Demarco M, Piggott DA, Brown TT, Hasan RK, Kalyani RR, Seplaki CL, Walston JD, Xue QL. Principles and Issues for Physical Frailty Measurement and Its Clinical Application. J Gerontol A Biol Sci Med Sci 2021; 75:1107-1112. [PMID: 31287490 DOI: 10.1093/gerona/glz158] [Citation(s) in RCA: 19] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2019] [Indexed: 12/28/2022] Open
Abstract
INTRODUCTION "Frailty" has attracted attention for its promise of identifying vulnerable older adults, hence its potential use to better tailor geriatric health care. There remains substantial controversy, however, regarding its nature and ascertainment. Recent years have seen a proliferation of frailty assessment methods. We argue that the development of frailty assessments should be grounded in "validation"-the process of substantiating that a measurement accurately and precisely measures what it intends, identify unresolved measurement issues, and highlight measurement-related considerations for clinical practice. METHODS Principles for validating frailty measures are elucidated. We follow principles-articulated, for example, by Borsboom-in which a construct must be clearly defined and then analyses undertaken to substantiate that a measurement accurately and precisely measures what it intends. Key elements are content validity, criterion validity, and construct validity, with an emphasis on the latter. RESULTS We illustrate the principles for a physical frailty phenotype construct. CONCLUSIONS Unresolved conceptual issues include the roles of intersecting concepts such as cognition, disease severity, and disability in frailty measurement, conceptualization of frailty as a state versus a continuum, and the potential need for dynamic measures and systems concepts in furthering understanding of frailty. Clinical considerations include needs to distinguish interventions designed to address frailty "symptoms" versus underlying physiology, improve "prefrailty" measures intended to screen individuals early in their frailty progression, address feasibility demands, and further visioning followed by rigorous efficacy research to address the landscape of potential uses of frailty assessment in clinical practice.
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Affiliation(s)
- Karen Bandeen-Roche
- Department of Biostatistics, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland.,Department of Medicine, Johns Hopkins School of Medicine, Baltimore, Maryland
| | - Alden L Gross
- Department of Epidemiology, Baltimore, Maryland.,Department of Mental Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland
| | - Ravi Varadhan
- Department of Biostatistics, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland.,Department of Oncology, Johns Hopkins School of Medicine, Baltimore, Maryland
| | - Brian Buta
- Department of Medicine, Johns Hopkins School of Medicine, Baltimore, Maryland
| | - Michelle C Carlson
- Department of Epidemiology, Baltimore, Maryland.,Department of Mental Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland
| | - Megan Huisingh-Scheetz
- Geriatrics and Palliative Medicine, Department of Medicine, University of Chicago Medicine, Illinois
| | | | - Damani A Piggott
- Department of Medicine, Johns Hopkins School of Medicine, Baltimore, Maryland.,Department of Epidemiology, Baltimore, Maryland
| | - Todd T Brown
- Department of Medicine, Johns Hopkins School of Medicine, Baltimore, Maryland
| | - Rani K Hasan
- Department of Medicine, Johns Hopkins School of Medicine, Baltimore, Maryland
| | - Rita R Kalyani
- Department of Medicine, Johns Hopkins School of Medicine, Baltimore, Maryland
| | | | - Jeremy D Walston
- Department of Medicine, Johns Hopkins School of Medicine, Baltimore, Maryland
| | - Qian-Li Xue
- Department of Biostatistics, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland.,Department of Medicine, Johns Hopkins School of Medicine, Baltimore, Maryland.,Department of Epidemiology, Baltimore, Maryland
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12
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Khalili H, Lodhi HA, Luna M, Hasan RK, Banerjee S, Harvey JE, Byrne T, Hanzel GS, Abbas AE, Bhatia N, Shreenivas SS, Mathews A, Bansal P, Morcos R, Maini B. Decline in the Volume of Structural Heart Procedures in the United States Due to the COVID-19 Pandemic. Structural Heart 2021; 5:97-98. [PMID: 35378851 PMCID: PMC8968307 DOI: 10.1080/24748706.2020.1836436] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 08/04/2021] [Accepted: 10/05/2021] [Indexed: 11/16/2022]
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13
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Al-Abdouh A, Barbarawi M, Abusnina W, Amr M, Zhao D, Savji N, Hasan RK, Michos ED. Prasugrel vs Ticagrelor for DAPT in Patients with ACS Undergoing PCI: A Systematic Review and Meta-Analysis of Randomized Controlled Trials. Cardiovascular Revascularization Medicine 2020; 21:1613-1618. [DOI: 10.1016/j.carrev.2020.05.038] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/25/2020] [Revised: 05/24/2020] [Accepted: 05/26/2020] [Indexed: 11/15/2022]
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14
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Metkus TS, Sokoll LJ, Barth AS, Czarny MJ, Hays AG, Lowenstein CJ, Michos ED, Nolley EP, Post WS, Resar JR, Thiemann DR, Trost JC, Hasan RK. Myocardial Injury in Severe COVID-19 Compared With Non-COVID-19 Acute Respiratory Distress Syndrome. Circulation 2020; 143:553-565. [PMID: 33186055 PMCID: PMC7864609 DOI: 10.1161/circulationaha.120.050543] [Citation(s) in RCA: 83] [Impact Index Per Article: 20.8] [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: 12/15/2022]
Abstract
Supplemental Digital Content is available in the text. Background: Knowledge gaps remain in the epidemiology and clinical implications of myocardial injury in coronavirus disease 2019 (COVID-19). We aimed to determine the prevalence and outcomes of myocardial injury in severe COVID-19 compared with acute respiratory distress syndrome (ARDS) unrelated to COVID-19. Methods: We included intubated patients with COVID-19 from 5 hospitals between March 15 and June 11, 2020, with troponin levels assessed. We compared them with patients from a cohort study of myocardial injury in ARDS and performed survival analysis with primary outcome of in-hospital death associated with myocardial injury. In addition, we performed linear regression to identify clinical factors associated with myocardial injury in COVID-19. Results: Of 243 intubated patients with COVID-19, 51% had troponin levels above the upper limit of normal. Chronic kidney disease, lactate, ferritin, and fibrinogen were associated with myocardial injury. Mortality was 22.7% among patients with COVID-19 with troponin under the upper limit of normal and 61.5% for those with troponin levels >10 times the upper limit of normal (P<0.001). The association of myocardial injury with mortality was not statistically significant after adjusting for age, sex, and multisystem organ dysfunction. Compared with patients with ARDS without COVID-19, patients with COVID-19 were older and had higher creatinine levels and less favorable vital signs. After adjustment, COVID-19–related ARDS was associated with lower odds of myocardial injury compared with non–COVID-19–related ARDS (odds ratio, 0.55 [95% CI, 0.36–0.84]; P=0.005). Conclusions: Myocardial injury in severe COVID-19 is a function of baseline comorbidities, advanced age, and multisystem organ dysfunction, similar to traditional ARDS. The adverse prognosis of myocardial injury in COVID-19 relates largely to multisystem organ involvement and critical illness.
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Affiliation(s)
- Thomas S Metkus
- Divisions of Cardiology (T.S.M., A.S.B., M.J.C., A.G.H., C.J.L., E.D.M., W.S.P., J.R.R., D.R.T., J.C.T., R.K.H.), Johns Hopkins University School of Medicine, Baltimore, MD
| | - Lori J Sokoll
- Department of Medicine, and Department of Pathology (L.J.S.), Johns Hopkins University School of Medicine, Baltimore, MD
| | - Andreas S Barth
- Divisions of Cardiology (T.S.M., A.S.B., M.J.C., A.G.H., C.J.L., E.D.M., W.S.P., J.R.R., D.R.T., J.C.T., R.K.H.), Johns Hopkins University School of Medicine, Baltimore, MD
| | - Matthew J Czarny
- Divisions of Cardiology (T.S.M., A.S.B., M.J.C., A.G.H., C.J.L., E.D.M., W.S.P., J.R.R., D.R.T., J.C.T., R.K.H.), Johns Hopkins University School of Medicine, Baltimore, MD
| | - Allison G Hays
- Divisions of Cardiology (T.S.M., A.S.B., M.J.C., A.G.H., C.J.L., E.D.M., W.S.P., J.R.R., D.R.T., J.C.T., R.K.H.), Johns Hopkins University School of Medicine, Baltimore, MD
| | - Charles J Lowenstein
- Divisions of Cardiology (T.S.M., A.S.B., M.J.C., A.G.H., C.J.L., E.D.M., W.S.P., J.R.R., D.R.T., J.C.T., R.K.H.), Johns Hopkins University School of Medicine, Baltimore, MD
| | - Erin D Michos
- Divisions of Cardiology (T.S.M., A.S.B., M.J.C., A.G.H., C.J.L., E.D.M., W.S.P., J.R.R., D.R.T., J.C.T., R.K.H.), Johns Hopkins University School of Medicine, Baltimore, MD
| | - Eric P Nolley
- Pulmonary and Critical Care Medicine (E.P.N.), Johns Hopkins University School of Medicine, Baltimore, MD
| | - Wendy S Post
- Divisions of Cardiology (T.S.M., A.S.B., M.J.C., A.G.H., C.J.L., E.D.M., W.S.P., J.R.R., D.R.T., J.C.T., R.K.H.), Johns Hopkins University School of Medicine, Baltimore, MD
| | - Jon R Resar
- Divisions of Cardiology (T.S.M., A.S.B., M.J.C., A.G.H., C.J.L., E.D.M., W.S.P., J.R.R., D.R.T., J.C.T., R.K.H.), Johns Hopkins University School of Medicine, Baltimore, MD
| | - David R Thiemann
- Divisions of Cardiology (T.S.M., A.S.B., M.J.C., A.G.H., C.J.L., E.D.M., W.S.P., J.R.R., D.R.T., J.C.T., R.K.H.), Johns Hopkins University School of Medicine, Baltimore, MD
| | - Jeffrey C Trost
- Divisions of Cardiology (T.S.M., A.S.B., M.J.C., A.G.H., C.J.L., E.D.M., W.S.P., J.R.R., D.R.T., J.C.T., R.K.H.), Johns Hopkins University School of Medicine, Baltimore, MD
| | - Rani K Hasan
- Divisions of Cardiology (T.S.M., A.S.B., M.J.C., A.G.H., C.J.L., E.D.M., W.S.P., J.R.R., D.R.T., J.C.T., R.K.H.), Johns Hopkins University School of Medicine, Baltimore, MD
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15
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Lin CT, Czarny MJ, Hussien A, Hasan RK, Garibaldi BT, Fishman EK, Resar JR, Zimmerman SL. Fibrotic Lung Disease at CT Predicts Adverse Outcomes in Patients Undergoing Transcatheter Aortic Valve Replacement. Radiol Cardiothorac Imaging 2020; 2:e190093. [PMID: 33778552 DOI: 10.1148/ryct.2020190093] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/16/2019] [Revised: 11/25/2019] [Accepted: 12/18/2019] [Indexed: 11/11/2022]
Abstract
Purpose To evaluate the relationship between CT findings of diffuse lung disease and post-transcatheter aortic valve replacement (TAVR) outcomes. Materials and Methods Retrospective review of pre-TAVR CT scans obtained during 2012-2017 was conducted. Emphysema, reticulation, and honeycombing were separately scored using a five-point scale and applied to 10 images per examination. The fibrosis score was the sum of reticulation and honeycombing scores. Lung diseases were also assessed as dichotomous variables (zero vs nonzero scores). The two outcomes evaluated were death and the composite of death and readmission. Results The study included 373 patients with median age of 84 years (age range, 51-98 years; interquartile range, 79-88 years) and median follow-up of 333 days. Fibrosis and emphysema were present in 66 (17.7%) and 95 (25.5%) patients, respectively. Fibrosis as a dichotomous variable was independently associated with the composite of death and readmission (hazard ratio [HR], 1.54; P = .030). In those without known chronic lung disease (CLD) (HR, 3.09; P = .024) and those without airway obstruction, defined by a ratio of forced expiratory volume in 1 second to the forced vital capacity greater than or equal to 70% (HR, 1.67, P = .039), CT evidence of fibrosis was a powerful predictor of adverse events. Neither emphysema score nor emphysema as a dichotomous variable was an independent predictor of outcome. Conclusion The presence of fibrosis on baseline CT scans was an independent predictor of adverse events after TAVR. In particular, fibrosis had improved predictive value in both patients without known CLD and patients without airway obstruction.Supplemental material is available for this article.© RSNA, 2020.
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Affiliation(s)
- Cheng Ting Lin
- Department of Radiology (C.T.L., A.H., E.K.F., S.L.Z.), Department of Medicine, Cardiology Division (M.J.C., R.K.H., J.R.R.), and Department of Medicine, Pulmonary and Critical Care Division (B.T.G.), Johns Hopkins University School of Medicine, 601 N Caroline St, JHOC 3171B, Baltimore, MD 21287
| | - Matthew J Czarny
- Department of Radiology (C.T.L., A.H., E.K.F., S.L.Z.), Department of Medicine, Cardiology Division (M.J.C., R.K.H., J.R.R.), and Department of Medicine, Pulmonary and Critical Care Division (B.T.G.), Johns Hopkins University School of Medicine, 601 N Caroline St, JHOC 3171B, Baltimore, MD 21287
| | - Amira Hussien
- Department of Radiology (C.T.L., A.H., E.K.F., S.L.Z.), Department of Medicine, Cardiology Division (M.J.C., R.K.H., J.R.R.), and Department of Medicine, Pulmonary and Critical Care Division (B.T.G.), Johns Hopkins University School of Medicine, 601 N Caroline St, JHOC 3171B, Baltimore, MD 21287
| | - Rani K Hasan
- Department of Radiology (C.T.L., A.H., E.K.F., S.L.Z.), Department of Medicine, Cardiology Division (M.J.C., R.K.H., J.R.R.), and Department of Medicine, Pulmonary and Critical Care Division (B.T.G.), Johns Hopkins University School of Medicine, 601 N Caroline St, JHOC 3171B, Baltimore, MD 21287
| | - Brian T Garibaldi
- Department of Radiology (C.T.L., A.H., E.K.F., S.L.Z.), Department of Medicine, Cardiology Division (M.J.C., R.K.H., J.R.R.), and Department of Medicine, Pulmonary and Critical Care Division (B.T.G.), Johns Hopkins University School of Medicine, 601 N Caroline St, JHOC 3171B, Baltimore, MD 21287
| | - Elliot K Fishman
- Department of Radiology (C.T.L., A.H., E.K.F., S.L.Z.), Department of Medicine, Cardiology Division (M.J.C., R.K.H., J.R.R.), and Department of Medicine, Pulmonary and Critical Care Division (B.T.G.), Johns Hopkins University School of Medicine, 601 N Caroline St, JHOC 3171B, Baltimore, MD 21287
| | - Jon R Resar
- Department of Radiology (C.T.L., A.H., E.K.F., S.L.Z.), Department of Medicine, Cardiology Division (M.J.C., R.K.H., J.R.R.), and Department of Medicine, Pulmonary and Critical Care Division (B.T.G.), Johns Hopkins University School of Medicine, 601 N Caroline St, JHOC 3171B, Baltimore, MD 21287
| | - Stefan Loy Zimmerman
- Department of Radiology (C.T.L., A.H., E.K.F., S.L.Z.), Department of Medicine, Cardiology Division (M.J.C., R.K.H., J.R.R.), and Department of Medicine, Pulmonary and Critical Care Division (B.T.G.), Johns Hopkins University School of Medicine, 601 N Caroline St, JHOC 3171B, Baltimore, MD 21287
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16
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Khan SU, Osman M, Khan MU, Khan MS, Zhao D, Mamas MA, Savji N, Al-Abdouh A, Hasan RK, Michos ED. Dual Versus Triple Therapy for Atrial Fibrillation After Percutaneous Coronary Intervention: A Systematic Review and Meta-analysis. Ann Intern Med 2020; 172:474-483. [PMID: 32176890 PMCID: PMC7489449 DOI: 10.7326/m19-3763] [Citation(s) in RCA: 23] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/14/2022] Open
Abstract
BACKGROUND The safety and effectiveness of dual therapy (direct oral anticoagulant [DOAC] plus P2Y12 inhibitor) versus triple therapy (vitamin K antagonist plus aspirin and P2Y12 inhibitor) in patients with nonvalvular atrial fibrillation (AF) after percutaneous coronary intervention (PCI) is unclear. PURPOSE To examine the effects of dual versus triple therapy on bleeding and ischemic outcomes in adults with AF after PCI. DATA SOURCES Searches of PubMed, EMBASE, and the Cochrane Library (inception to 31 December 2019) and ClinicalTrials.gov (7 January 2020) without language restrictions; journal Web sites; and reference lists. STUDY SELECTION Randomized controlled trials that compared the effects of dual versus triple therapy on bleeding, mortality, and ischemic events in adults with AF after PCI. DATA EXTRACTION Two independent investigators abstracted data, assessed the quality of evidence, and rated the certainty of evidence. DATA SYNTHESIS Four trials encompassing 7953 patients were selected. At the median follow-up of 1 year, high-certainty evidence showed that dual therapy was associated with reduced risk for major bleeding compared with triple therapy (risk difference [RD], -0.013 [95% CI, -0.025 to -0.002]). Low-certainty evidence showed inconclusive effects of dual versus triple therapy on risks for all-cause mortality (RD, 0.004 [CI, -0.010 to 0.017]), cardiovascular mortality (RD, 0.001 [CI, -0.011 to 0.013]), myocardial infarction (RD, 0.003 [CI, -0.010 to 0.017]), stent thrombosis (RD, 0.003 [CI, -0.005 to 0.010]), and stroke (RD, -0.003 [CI, -0.010 to 0.005]). The upper bounds of the CIs for these effects were compatible with possible increased risks with dual therapy. LIMITATION Heterogeneity of study designs, dosages of DOACs, and types of P2Y12 inhibitors. CONCLUSION In adults with AF after PCI, dual therapy reduces risk for bleeding compared with triple therapy, whereas its effects on risks for death and ischemic end points are still unclear. PRIMARY FUNDING SOURCE None.
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Affiliation(s)
- Safi U Khan
- West Virginia University, Morgantown, West Virginia (S.U.K., M.O., M.U.K.)
| | - Mohammed Osman
- West Virginia University, Morgantown, West Virginia (S.U.K., M.O., M.U.K.)
| | - Muhammad U Khan
- West Virginia University, Morgantown, West Virginia (S.U.K., M.O., M.U.K.)
| | | | - Di Zhao
- Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland (D.Z.)
| | - Mamas A Mamas
- Keele University, Stoke-on-Trent, United Kingdom, and Thomas Jefferson University, Philadelphia, Pennsylvania (M.A.M.)
| | - Nazir Savji
- Johns Hopkins School of Medicine, Baltimore, Maryland (N.S., R.K.H.)
| | | | - Rani K Hasan
- Johns Hopkins School of Medicine, Baltimore, Maryland (N.S., R.K.H.)
| | - Erin D Michos
- Johns Hopkins Bloomberg School of Public Health and Johns Hopkins School of Medicine, Baltimore, Maryland (E.D.M.)
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Al-Abdouh A, Upadhrasta S, Fashanu O, Elias H, Zhao D, Hasan RK, Michos ED. Transcatheter Aortic Valve Replacement in Low-Risk Patients: A Meta-Analysis of Randomized Controlled Trials. Cardiovascular Revascularization Medicine 2020; 21:461-466. [DOI: 10.1016/j.carrev.2019.08.008] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/26/2019] [Revised: 07/08/2019] [Accepted: 08/12/2019] [Indexed: 12/19/2022]
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18
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Cardoso R, Rivera M, Czarny MJ, Knijnik L, Fernandes A, Blumenthal RS, Hasan RK, Schulman SP. In-Hospital Management and Outcomes of Patients With Acute Myocardial Infarction and Influenza. Am J Cardiol 2020; 125:840-844. [PMID: 31932083 DOI: 10.1016/j.amjcard.2019.12.032] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/11/2019] [Revised: 12/05/2019] [Accepted: 12/09/2019] [Indexed: 11/24/2022]
Abstract
Patients with influenza infection are at increased risk of acute myocardial infarction (AMI). There are limited data on the short-term prognosis and management of patients with AMI and concomitant influenza. We examined the National Inpatient Sample from 2010 to 2014 for adult patients with a diagnosis of AMI. Patients were stratified into those with or without concomitant influenza. In-hospital therapies and outcomes were compared between groups in unadjusted and adjusted analyses. Standardized differences of >10% and p values <0.05 were considered significant. Propensity matching was performed using a caliper radius of 0.01*sigma. Of 4,285,641 patients with a discharge diagnosis of AMI, 12,830 had concomitant influenza. Patients with influenza were older, had a higher burden of co-morbidities, and more often presented with non-ST elevation AMI (90% vs 74%) as compared with those without influenza. Coronary angiography (23% vs 54%) and revascularization (11% vs 41%) were less often pursued in AMI patients with influenza. Patients with AMI and influenza had elevated in-hospital mortality (14%) and multiorgan failure (33%). In a propensity-matched analysis of 23,415 patients, in-hospital mortality (odds ratio [OR] 1.26; p = 0.01), acute kidney injury (OR 1.36; p <0.01), multiorgan failure (OR 1.81; p <0.01), length-of-stay, and hospital costs were significantly higher in those with influenza. In conclusion, patients with AMI and concomitant influenza have an adverse in-hospital prognosis as compared with those without influenza.
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19
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Al-Abdouh A, Savji N, Hasan RK, Bizanti A, Abudaya I, Elias H, Upadhrasta S, Zhao D, Michos E. COMPLETE VS CULPRIT-ONLY REVASCULARIZATION IN ST ELEVATION MYOCARDIAL INFARCTION, A SYSTEMATIC REVIEW AND META-ANALYSIS. J Am Coll Cardiol 2020. [DOI: 10.1016/s0735-1097(20)32085-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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20
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Affiliation(s)
- Charles H Brown
- Department of Anesthesiology and Critical Care Medicine (C.H.B., M.B.B.)
| | - Rani K Hasan
- Department of Internal Medicine, Division of Cardiology (R.K.H.), Johns Hopkins University School of Medicine, Baltimore, MD
| | - Mary Beth Brady
- Department of Anesthesiology and Critical Care Medicine (C.H.B., M.B.B.)
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21
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Krishnan A, Suarez-Pierre A, Zhou X, Lin CT, Fraser CD, Crawford TC, Hsu J, Hasan RK, Resar J, Chacko M, Baumgartner WA, Conte JV, Mandal K. Comparing Frailty Markers in Predicting Poor Outcomes after Transcatheter Aortic Valve Replacement. Innovations (Phila) 2019; 14:43-54. [PMID: 30848712 DOI: 10.1177/1556984519827698] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
INTRODUCTION Frailty is an important component of risk prognostication in transcatheter aortic valve replacement (TAVR). Objective markers of frailty, including sarcopenia, the modified Frailty Index (mFI), and albumin levels, have emerged, but little is known how such markers compare to each other in predicting outcomes after TAVR. We sought to define and compare these markers in predicting long-term outcomes after TAVR. METHODS Patients who underwent TAVR at our institution from 2011 to 2016 were included. Indexed cross-sectional areas of the lumbosacral muscles on preoperative computed tomography scans were used to assess sarcopenia. Optimal cutoffs for sarcopenia were defined using a statistically validated method. mFI was calculated using an 11-point scale of clinical characteristics. The primary outcome was 2-year all-cause mortality. Adjusted survival analysis was used to analyze outcomes. RESULTS A total of 381 patients were included in this study. Sarcopenia of the psoas muscles was associated with an increased risk of mortality on univariate (HR: 2.3, P = 0.01) and multivariate (HR: 2.5, P = 0.01) analysis. Sarcopenia of the paravertebral muscles was associated with increased risk of mortality only on univariate analysis (HR: 2.1, P = 0.03). Increased preoperative albumin levels were associated with decreased risk of mortality on univariate (HR: 0.3, P < 0.01) and multivariate analysis (HR: 0.3, P < 0.01). The (mFI) was not associated with mortality on univariate or multivariate analysis. DISCUSSION Novel cutoffs for sarcopenia of the psoas muscles were determined and associated with decreased survival after TAVR. Sarcopenia and albumin levels may be better tools for risk prediction than mFI in TAVR.
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Affiliation(s)
- Aravind Krishnan
- 1 Division of Cardiac Surgery, Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Alejandro Suarez-Pierre
- 1 Division of Cardiac Surgery, Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Xun Zhou
- 1 Division of Cardiac Surgery, Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Cheng T Lin
- 2 Department of Radiology, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Charles D Fraser
- 1 Division of Cardiac Surgery, Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Todd C Crawford
- 1 Division of Cardiac Surgery, Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Joshua Hsu
- 1 Division of Cardiac Surgery, Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Rani K Hasan
- 3 Department of Medicine, Division of Cardiology, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Jon Resar
- 3 Department of Medicine, Division of Cardiology, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Matthews Chacko
- 3 Department of Medicine, Division of Cardiology, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - William A Baumgartner
- 1 Division of Cardiac Surgery, Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - John V Conte
- 4 Division of Cardiac Surgery, Department of Surgery, Penn State College of Medicine, Hershey, PA, USA
| | - Kaushik Mandal
- 4 Division of Cardiac Surgery, Department of Surgery, Penn State College of Medicine, Hershey, PA, USA
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Ibrahim K, Shah R, Goli RR, Kickler TS, Clarke WA, Hasan RK, Blumenthal RS, Thiemann DR, Resar JR, Schulman SP, McEvoy JW. Fentanyl Delays the Platelet Inhibition Effects of Oral Ticagrelor: Full Report of the PACIFY Randomized Clinical Trial. Thromb Haemost 2018; 118:1409-1418. [PMID: 29972861 PMCID: PMC6202927 DOI: 10.1055/s-0038-1666862] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
Morphine delays oral P2Y
12
platelet inhibitor absorption and is associated with adverse outcomes after myocardial infarction. Consequently, many physicians and first responders are now considering fentanyl as an alternative. We conducted a single-centre trial randomizing cardiac patients undergoing coronary angiography to intravenous fentanyl or not. All participants received local anaesthetic and intravenous midazolam. Those requiring percutaneous coronary intervention (PCI) with stenting received 180 mg oral ticagrelor intra-procedurally. The primary outcome was area under the ticagrelor plasma concentration–time curve (AUC
0–24 hours
). The secondary outcomes were platelet function assessed at 2 hours after loading, measured by P2Y
12
reaction units (PRUs) and light transmission platelet aggregometry. Troponin-I was measured post-PCI using a high-sensitivity troponin-I assay (hs-TnI). All participants completed a survey of pain and anxiety. Of the 212 randomized, 70 patients required coronary stenting and were loaded with ticagrelor. Two participants in the no-fentanyl arm crossed over to receive fentanyl for pain. In as-treated analyses, ticagrelor concentrations were higher in the no-fentanyl arm (AUC
0–24 hours
70% larger,
p
= 0.03). Platelets were more inhibited by 2 hours in the no-fentanyl arm (71 vs. 113 by PRU,
p
= 0.03, and 25% vs. 41% for adenosine diphosphate response by platelet aggregation,
p
< 0.01). Mean hs-TnI was higher with fentanyl at 2 hours post-PCI (11.9 vs. 7.0 ng/L,
p
= 0.04) with a rate of enzymatic myocardial infarction of 11% for fentanyl and 0% for no-fentanyl (
p
= 0.08). No statistical differences in self-reported pain or anxiety were found. In conclusion, fentanyl administration can impair ticagrelor absorption and delay platelet inhibition, resulting in mild excess of myocardial damage. This newly described drug interaction should be recognized by physicians and suggests that the interaction between opioids and oral P2Y
12
platelet inhibitors is a drug class effect associated with all opioids.
Clinical Trial Registration:
https://clinicaltrials.gov/ct2/show/NCT02683707(
NCT02683707).
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Affiliation(s)
- Khalil Ibrahim
- Division of Cardiology, Johns Hopkins University School of Medicine, Baltimore, Maryland, United States
| | - Rohan Shah
- Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland, United States
| | - Rakesh R Goli
- Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland, United States
| | - Thomas S Kickler
- Department of Pathology, Johns Hopkins University School of Medicine, Baltimore, Maryland, United States
| | - William A Clarke
- Department of Pathology, Johns Hopkins University School of Medicine, Baltimore, Maryland, United States
| | - Rani K Hasan
- Division of Cardiology, Johns Hopkins University School of Medicine, Baltimore, Maryland, United States
| | - Roger S Blumenthal
- Division of Cardiology, Johns Hopkins University School of Medicine, Baltimore, Maryland, United States.,Ciccarone Center for the Prevention of Heart Disease, Johns Hopkins University School of Medicine, Baltimore, Maryland, United States
| | - David R Thiemann
- Division of Cardiology, Johns Hopkins University School of Medicine, Baltimore, Maryland, United States
| | - Jon R Resar
- Division of Cardiology, Johns Hopkins University School of Medicine, Baltimore, Maryland, United States
| | - Steven P Schulman
- Division of Cardiology, Johns Hopkins University School of Medicine, Baltimore, Maryland, United States
| | - John W McEvoy
- Division of Cardiology, Johns Hopkins University School of Medicine, Baltimore, Maryland, United States.,Ciccarone Center for the Prevention of Heart Disease, Johns Hopkins University School of Medicine, Baltimore, Maryland, United States
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23
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Damluji AA, Murman M, Byun S, Moscucci M, Resar JR, Hasan RK, Alfonso CE, Carrillo RG, Williams DB, Kwon CC, Cho PW, Dijos M, Peltan J, Heldman AW, Cohen MG, Leroux L. Alternative access for transcatheter aortic valve replacement in older adults: A collaborative study from France and United States. Catheter Cardiovasc Interv 2018; 92:1182-1193. [DOI: 10.1002/ccd.27690] [Citation(s) in RCA: 20] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/26/2018] [Accepted: 05/20/2018] [Indexed: 12/19/2022]
Affiliation(s)
- Abdulla A. Damluji
- Beverly and Jerome Fine Cardiac Valve Center, Sinai Hospital of Baltimore; LifeBridge Health Cardiovascular Institute; Baltimore Maryland
- Division of Cardiology; Johns Hopkins University; Baltimore Maryland
| | - Magdalena Murman
- Multidisciplinary Structural Heart Disease Program, the Elaine and Sydney Sussman Cardiac Catheterization Laboratory; University of Miami-Miller School of Medicine; Miami Florida
| | - Seunghwan Byun
- Beverly and Jerome Fine Cardiac Valve Center, Sinai Hospital of Baltimore; LifeBridge Health Cardiovascular Institute; Baltimore Maryland
| | - Mauro Moscucci
- Beverly and Jerome Fine Cardiac Valve Center, Sinai Hospital of Baltimore; LifeBridge Health Cardiovascular Institute; Baltimore Maryland
| | - Jon R Resar
- Division of Cardiology; Johns Hopkins University; Baltimore Maryland
| | - Rani K. Hasan
- Division of Cardiology; Johns Hopkins University; Baltimore Maryland
| | - Carlos E. Alfonso
- Multidisciplinary Structural Heart Disease Program, the Elaine and Sydney Sussman Cardiac Catheterization Laboratory; University of Miami-Miller School of Medicine; Miami Florida
| | - Roger G. Carrillo
- Multidisciplinary Structural Heart Disease Program, the Elaine and Sydney Sussman Cardiac Catheterization Laboratory; University of Miami-Miller School of Medicine; Miami Florida
| | - Donald B. Williams
- Multidisciplinary Structural Heart Disease Program, the Elaine and Sydney Sussman Cardiac Catheterization Laboratory; University of Miami-Miller School of Medicine; Miami Florida
| | - Christopher C. Kwon
- Beverly and Jerome Fine Cardiac Valve Center, Sinai Hospital of Baltimore; LifeBridge Health Cardiovascular Institute; Baltimore Maryland
- Division of Cardiac Surgery, Sinai Hospital of Baltimore; LifeBridge Health Cardiovascular Institute; Baltimore Maryland
| | - Peter W. Cho
- Beverly and Jerome Fine Cardiac Valve Center, Sinai Hospital of Baltimore; LifeBridge Health Cardiovascular Institute; Baltimore Maryland
- Division of Cardiac Surgery, Sinai Hospital of Baltimore; LifeBridge Health Cardiovascular Institute; Baltimore Maryland
| | | | | | - Alan W. Heldman
- Multidisciplinary Structural Heart Disease Program, the Elaine and Sydney Sussman Cardiac Catheterization Laboratory; University of Miami-Miller School of Medicine; Miami Florida
| | - Mauricio G. Cohen
- Multidisciplinary Structural Heart Disease Program, the Elaine and Sydney Sussman Cardiac Catheterization Laboratory; University of Miami-Miller School of Medicine; Miami Florida
| | - Lionel Leroux
- Department of Interventional Cardiology, Hôpital Cardiologique du Haut-Lévêque; Université Victor Segalen Bordeaux II; Bordeaux France
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24
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Czarny MJ, Miller JM, Naiman DQ, Hwang CW, Hasan RK, Lemmon CC, Aversano T. Nonprimary PCI at hospitals without cardiac surgery on-site: Consistent outcomes for all? Am Heart J 2018; 197:18-26. [PMID: 29447780 DOI: 10.1016/j.ahj.2017.10.023] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/28/2017] [Accepted: 10/29/2017] [Indexed: 10/18/2022]
Abstract
BACKGROUND The CPORT-E trial showed the noninferiority of nonprimary percutaneous coronary intervention (PCI) at hospitals without cardiac surgery on-site (SoS) compared with hospitals with SoS for 6-week mortality and 9-month major adverse cardiac events (MACE). However, target vessel revascularization (TVR) was increased at non-SoS hospitals. Therefore, we aimed to determine the consistency of the CPORT-E trial findings across the spectrum of enrolled patients. METHODS Post hoc subgroup analyses of 6-week mortality and 9-month MACE, defined as the composite of death, Q-wave myocardial infarction, or TVR, were performed. Patients with and without 9-month TVR and rates of related outcomes were compared. RESULTS There was no interaction between SoS status and clinically relevant subgroups for 6-week mortality or 9-month MACE (P for any interaction=.421 and .062, respectively). In addition to increased 9-month rates of TVR and diagnostic catheterization at hospitals without SoS, non-TVR was also increased (2.7% vs 1.9%, P=.002); there was no difference in myocardial infarction-driven TVR, non-TVR, or diagnostic catheterization. Predictors of 9-month TVR included intra-aortic balloon pump use, any index PCI complication, and 3-vessel PCI, whereas predictors of freedom from TVR included SoS, discharge on a P2Y12 inhibitor, and stent implantation. CONCLUSIONS The noninferiority of nonprimary PCI at non-SoS hospitals was consistent across clinically relevant subgroups. Elective PCI at an SoS hospital conferred a TVR benefit which may be related to a lower rate of referral for diagnostic catheterization for reasons other than myocardial infarction.
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25
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Czarny MJ, Hwang CW, Naiman DQ, Lemmon CC, Hasan RK, Wang T, Aversano T. Heparin versus bivalirudin for non-primary percutaneous coronary intervention: A post-Hoc analysis of the CPORT-E trial. Catheter Cardiovasc Interv 2017; 90:366-377. [PMID: 28160375 DOI: 10.1002/ccd.26953] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/17/2016] [Revised: 12/23/2016] [Accepted: 12/30/2016] [Indexed: 11/05/2022]
Abstract
OBJECTIVES To compare bivalirudin to heparin during non-primary percutaneous coronary intervention (PCI). BACKGROUND The optimal anticoagulant to support PCI remains uncertain. METHODS We performed a propensity score-based analysis comparing clinical outcomes of patients receiving heparin to those receiving bivalirudin during non-primary PCI. RESULTS Of 18,867 patients in the Cardiovascular Patient Outcomes Research Team Non-Primary PCI (CPORT-E) trial, we selected 7,913 patients undergoing non-staged PCI of whom 57.3% received heparin and 42.7% received bivalirudin. In-hospital myocardial infarction occurred in 4.4% of patients receiving bivalirudin and 3.0% of patients receiving heparin (relative risk [RR] 1.5, 95% confidence interval [CI] 1.1-2.1, P = 0.022); this difference persisted at 6 weeks (5.0% vs. 3.6%, RR 1.4, 95% CI 1.0-1.8, P = 0.041). There was no difference in all-cause mortality either in-hospital (0.2% vs. 0.1% for heparin vs. bivalirudin, P = 0.887) or at 6 weeks (0.5% vs. 0.7%, P = 0.567). In-hospital bleeding requiring transfusion occurred in 0.9% of patients receiving bivalirudin and 1.9% of patients receiving heparin (RR 0.4, 95% CI 0.3-0.7, P <0.001), but there was no difference at 6 weeks (2.7% for heparin vs. 1.9% for bivalirudin, RR 0.7, 95% CI 0.5-1.0, P = 0.062). CONCLUSIONS In patients undergoing non-primary PCI at hospitals without on-site cardiac surgery, bivalirudin was associated with a decreased risk of in-hospital bleeding requiring transfusion and an increased risk of in-hospital MI compared to heparin. © 2017 Wiley Periodicals, Inc.
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Affiliation(s)
- Matthew J Czarny
- Department of Medicine, School of Medicine, Johns Hopkins University, Baltimore, Maryland
| | - Chao-Wei Hwang
- Department of Medicine, School of Medicine, Johns Hopkins University, Baltimore, Maryland
| | - Daniel Q Naiman
- Department of Applied Mathematics and Statistics, Johns Hopkins University, Baltimore, Maryland
| | - Cynthia C Lemmon
- Department of Medicine, School of Medicine, Johns Hopkins University, Baltimore, Maryland
| | - Rani K Hasan
- Department of Medicine, School of Medicine, Johns Hopkins University, Baltimore, Maryland
| | - Thomas Wang
- Center for Cardiac and Vascular Research, Washington Adventist Hospital, Takoma Park, Maryland
| | - Thomas Aversano
- Department of Medicine, School of Medicine, Johns Hopkins University, Baltimore, Maryland
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26
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Brener MI, Bush A, Miller JM, Hasan RK. Influence of radial versus femoral access site on coronary angiography and intervention outcomes: A systematic review and meta-analysis. Catheter Cardiovasc Interv 2017; 90:1093-1104. [DOI: 10.1002/ccd.27043] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/10/2017] [Accepted: 02/25/2017] [Indexed: 12/21/2022]
Affiliation(s)
| | - Aaron Bush
- Johns Hopkins University School of Medicine; Baltimore Maryland
| | - Julie M. Miller
- Johns Hopkins University School of Medicine; Baltimore Maryland
| | - Rani K. Hasan
- Johns Hopkins University School of Medicine; Baltimore Maryland
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27
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Razdan S, Strouse JJ, Reddy A, Resar DF, Hasan RK, Resar JR, Naik RP, Urrutia VC, Lanzkron S, Resar LM. Patent foramen ovale in adults with sickle cell disease and stroke. Am J Hematol 2016; 91:E358-60. [PMID: 27253454 DOI: 10.1002/ajh.24440] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/20/2016] [Revised: 05/25/2016] [Accepted: 05/31/2016] [Indexed: 11/05/2022]
Affiliation(s)
- Sheila Razdan
- Hematology Division; the Johns Hopkins University School of Medicine; Baltimore Maryland
- Department of Medicine; the Johns Hopkins University School of Medicine; Baltimore Maryland
| | - John J. Strouse
- Hematology Division; the Johns Hopkins University School of Medicine; Baltimore Maryland
- Department of Medicine; the Johns Hopkins University School of Medicine; Baltimore Maryland
- Department of Pediatrics; the Johns Hopkins University School of Medicine; Baltimore Maryland
| | - Anusha Reddy
- Hematology Division; the Johns Hopkins University School of Medicine; Baltimore Maryland
- Department of Medicine; the Johns Hopkins University School of Medicine; Baltimore Maryland
| | - Danielle F. Resar
- Hematology Division; the Johns Hopkins University School of Medicine; Baltimore Maryland
- Department of Medicine; the Johns Hopkins University School of Medicine; Baltimore Maryland
| | - Rani K. Hasan
- Department of Cardiology; the Johns Hopkins University School of Medicine; Baltimore Maryland
| | - Jon R. Resar
- Department of Cardiology; the Johns Hopkins University School of Medicine; Baltimore Maryland
| | - Rakhi P. Naik
- Hematology Division; the Johns Hopkins University School of Medicine; Baltimore Maryland
- Department of Medicine; the Johns Hopkins University School of Medicine; Baltimore Maryland
| | - Victor C. Urrutia
- Department of Neurology; the Johns Hopkins University School of Medicine; Baltimore Maryland
| | - Sophie Lanzkron
- Hematology Division; the Johns Hopkins University School of Medicine; Baltimore Maryland
- Department of Medicine; the Johns Hopkins University School of Medicine; Baltimore Maryland
| | - Linda M.S. Resar
- Hematology Division; the Johns Hopkins University School of Medicine; Baltimore Maryland
- Department of Medicine; the Johns Hopkins University School of Medicine; Baltimore Maryland
- Department of Pediatrics; the Johns Hopkins University School of Medicine; Baltimore Maryland
- Department of Oncology; the Johns Hopkins University School of Medicine; Baltimore Maryland
- Institute for Cellular Engineering, the Johns Hopkins University School of Medicine; Baltimore Maryland
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28
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Crawford TC, Magruder JT, Grimm JC, Mandal K, Price J, Resar J, Chacko M, Hasan RK, Whitman G, Conte JV. Phase of Care Mortality Analysis: A Unique Method for Comparing Mortality Differences Among Transcatheter Aortic Valve Replacement and Surgical Aortic Valve Replacement Patients. Semin Thorac Cardiovasc Surg 2016; 28:245-252. [PMID: 28043424 DOI: 10.1053/j.semtcvs.2016.06.008] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/10/2016] [Indexed: 11/11/2022]
Abstract
The objective of this study is based on the phase of care mortality analysis (POCMA), an effective tool to evaluate the root cause of in-hospital mortality in cardiac surgery patients. POCMA has not been used to compare operative mortalities among transcatheter aortic valve replacement (TAVR) and surgical aortic valve replacement (SAVR) populations, and may provide insight that could affect patient safety initiatives and improve outcomes in aortic valve surgery. We included patients who underwent TAVR or isolated SAVR between 2011 and March 31, 2015 and did not survive the index hospitalization. A multidisciplinary heart team made POCMA assignments as part of the weekly morbidity and mortality conference, pinpointing the phase of care and subcategory that directly caused or had the greatest effect on each mortality. During the study period, 240 patients underwent TAVR and 530 underwent SAVR. Unadjusted mortality rates were significantly higher in the TAVR group, 5.0% (n = 12) compared with SAVR, 1.9% (n = 10) (P = 0.016). TAVR deaths by phase of care are as follows: 0 for preoperative, 9 (72.8%) for intraoperative, 2 (18.2%) for postoperative intensive care unit, and 1 (9.1%) for postoperative floor. By comparison, 4 (40%) SAVR deaths had a root cause in the preoperative phase, 1 (10%) in the intraoperative phase, and 5 (50%) in the postoperative intensive care unit phase. POCMA is a novel method of categorizing in-hospital mortalities. Our single institution review revealed that patients who underwent TAVR more often expired because of intraoperative technical issues, whereas SAVR deaths were typically the result of patient selection or postoperative complications.
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Affiliation(s)
- Todd C Crawford
- Division of Cardiac Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - J Trent Magruder
- Division of Cardiac Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Joshua C Grimm
- Division of Cardiac Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Kaushik Mandal
- Division of Cardiac Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Joel Price
- Division of Cardiac Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Jon Resar
- Division of Cardiology, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Matthew Chacko
- Division of Cardiology, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Rani K Hasan
- Division of Cardiology, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Glenn Whitman
- Division of Cardiac Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - John V Conte
- Division of Cardiac Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland.
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29
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Martin SS, Hasan RK. Bioresorbable Vascular Scaffolds in Coronary Artery Disease: Weighing the Evidence and Next Steps. Ann Intern Med 2016; 164:775-6. [PMID: 27043657 DOI: 10.7326/m16-0754] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
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30
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Horne A, Reineck EA, Hasan RK, Resar JR, Chacko M. Transcatheter aortic valve replacement: historical perspectives, current evidence, and future directions. Am Heart J 2014; 168:414-23. [PMID: 25262249 DOI: 10.1016/j.ahj.2014.07.017] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.7] [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: 04/16/2014] [Accepted: 07/11/2014] [Indexed: 11/30/2022]
Abstract
Severe aortic stenosis (AS) results in considerable morbidity and mortality without aortic valve replacement and is expected to increase in prevalence with the aging population. Because AS primarily affects the elderly, many patients with comorbidities are poor candidates for surgical aortic valve replacement (SAVR) and may not be referred. Transcatheter aortic valve replacement (TAVR) has emerged as transformative technology for the management of AS over the past decade. Randomized trials have established the safety and efficacy of TAVR with improved mortality and quality of life compared with medical therapy in inoperable patients, while demonstrating noninferiority and even superiority to SAVR among high-risk operative candidates. However, early studies demonstrated an early penalty of stroke and vascular complications with TAVR as well as increased paravalvular leak as compared with SAVR. Two device platforms have been evaluated and approved for use in the United States: the Edwards SAPIEN and the Medtronic CoreValve. Early studies also suggest cost-effectiveness for TAVR. Ongoing studies are evaluating new iterations of the aforementioned TAVR devices, novel device designs, and applications of TAVR in expanded populations of patients including those with lower risk profiles as well as those with comorbidities that were excluded from early clinical trials. Future improvements in TAVR technology will likely reduce periprocedural and long-term complications. Further studies are needed to confirm device durability over long-term follow-up and explore the applicability of TAVR to broader AS patient populations.
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Affiliation(s)
- Aaron Horne
- Department of Medicine, Division of Cardiology, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Elizabeth A Reineck
- Department of Medicine, Division of Cardiology, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Rani K Hasan
- Department of Medicine, Division of Cardiology, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Jon R Resar
- Department of Medicine, Division of Cardiology, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Matthews Chacko
- Department of Medicine, Division of Cardiology, Johns Hopkins University School of Medicine, Baltimore, MD.
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31
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Jariwala U, Hasan RK, Thorn EM, Zakaria S. An unusual case of infective endocarditis involving a right coronary artery to superior vena cava fistula. Catheter Cardiovasc Interv 2014; 85:620-4. [DOI: 10.1002/ccd.25597] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/15/2013] [Revised: 05/17/2014] [Accepted: 07/06/2014] [Indexed: 11/12/2022]
Affiliation(s)
- Ujjval Jariwala
- Johns Hopkins University School of Medicine; Baltimore Maryland
- Greater Baltimore Medical Center; Towson Maryland
| | - Rani K. Hasan
- Johns Hopkins University School of Medicine; Baltimore Maryland
| | - Eric M. Thorn
- Virginia Cardiovascular Associates; Manassas Virginia
| | - Sammy Zakaria
- Johns Hopkins University School of Medicine; Baltimore Maryland
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32
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Chrispin J, Martin SS, Hasan RK, Joshi PH, Minder CM, McEvoy JW, Kohli P, Johnson AE, Wang L, Blaha MJ, Blumenthal RS. Landmark lipid-lowering trials in the primary prevention of cardiovascular disease. Clin Cardiol 2013; 36:516-23. [PMID: 23722477 PMCID: PMC6649586 DOI: 10.1002/clc.22147] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/03/2013] [Accepted: 04/25/2013] [Indexed: 01/20/2023] Open
Abstract
Although atherosclerotic cardiovascular disease (CVD) is the most common cause of morbidity and mortality in the world, the long disease latency affords ample opportunity for preventive care. Indeed, lifelong exposure to atherogenic apoliprotein B-containing lipoproteins has consistently been shown to increase the cumulative risk of suffering a CVD event, including myocardial infarction, stroke, and symptomatic peripheral arterial disease. Over the past 25 years, lipid-lowering therapies have been developed that are proven to not only lower cholesterol, but also to decrease adverse CVD events and CVD mortality. This review will highlight several key clinical trials encompassing several classes of lipid-lowering medications that have provided clinicians with an evidence-based framework for managing their patients' cardiovascular risk.
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Affiliation(s)
- Jonathan Chrispin
- The Johns Hopkins Ciccarone Center for the Prevention of Heart DiseaseJohns Hopkins School of MedicineBaltimoreMaryland
| | - Seth S. Martin
- The Johns Hopkins Ciccarone Center for the Prevention of Heart DiseaseJohns Hopkins School of MedicineBaltimoreMaryland
| | - Rani K. Hasan
- The Johns Hopkins Ciccarone Center for the Prevention of Heart DiseaseJohns Hopkins School of MedicineBaltimoreMaryland
| | - Parag H. Joshi
- The Johns Hopkins Ciccarone Center for the Prevention of Heart DiseaseJohns Hopkins School of MedicineBaltimoreMaryland
| | - C. Michael Minder
- The Johns Hopkins Ciccarone Center for the Prevention of Heart DiseaseJohns Hopkins School of MedicineBaltimoreMaryland
| | - John W. McEvoy
- The Johns Hopkins Ciccarone Center for the Prevention of Heart DiseaseJohns Hopkins School of MedicineBaltimoreMaryland
| | - Payal Kohli
- Cardiology DivisionUniversity of California San FranciscoSan FranciscoCalifornia.
| | - Amber E. Johnson
- The Johns Hopkins Ciccarone Center for the Prevention of Heart DiseaseJohns Hopkins School of MedicineBaltimoreMaryland
| | - Libin Wang
- The Johns Hopkins Ciccarone Center for the Prevention of Heart DiseaseJohns Hopkins School of MedicineBaltimoreMaryland
| | - Michael J. Blaha
- The Johns Hopkins Ciccarone Center for the Prevention of Heart DiseaseJohns Hopkins School of MedicineBaltimoreMaryland
| | - Roger S. Blumenthal
- The Johns Hopkins Ciccarone Center for the Prevention of Heart DiseaseJohns Hopkins School of MedicineBaltimoreMaryland
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33
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Hasan RK, Nassery N, Bennett N, Miller J. RADIAL VERSUS FEMORAL ACCESS FOR CORONARY ANGIOGRAPHY AND/OR PCI: A SYSTEMATIC REVIEW AND META–ANALYSIS. J Am Coll Cardiol 2013. [DOI: 10.1016/s0735-1097(13)61680-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
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34
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Hasan RK, Ginwala NT, Shah RY, Kumbhani DJ, Wilensky RL, Mehta NN. Quantitative angiography in South Asians reveals differences in vessel size and coronary artery disease severity compared to Caucasians. Am J Cardiovasc Dis 2011; 1:31-37. [PMID: 22254183 PMCID: PMC3253512] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Received: 03/28/2011] [Indexed: 05/31/2023]
Abstract
South Asians are one of the highest risk ethnic groups for development of coronary artery disease (CAD) mortality and morbidity. Previous studies have investigated whether South Asians exhibit differences in angiographic coronary artery disease compared to Caucasians, with inconsistent results. We conducted a retrospective observational study comparing South Asians undergoing cardiac catheterization at a tertiary care institution with Caucasians who underwent catheterization at the same time and location to assess whether South Asians demonstrated smaller coronary artery size and/or increased angiographic coronary artery disease. Demographic and laboratory data were retrospectively abstracted. Quantitative coronary angiographic analysis of all three coronary arteries was performed using the edge-detection method. South Asian patients were younger (57 versus 64 years, p=0.004) and showed higher prevalences of diabetes, dyslipidemia, and acute coronary syndrome compared with Caucasians (40% versus 16%, p=0.004; 65% versus 46%, p=0.04; and 37% versus 10%, p<0.001; respectively). South Asians exhibited smaller normalized proximal LAD luminal diameters (1.56 versus 1.72 mm/m(2), p=0.04) when compared to Caucasians. South Asians also displayed more severe CAD as determined by both increased mean percent stenosis in the proximal LAD and RCA segments (22.7% versus 11.1%, p=0.004; and 24.5% versus 13.9%, p=0.0001, respectively) as well as a higher number of patients with multiple diseased vessel segments. South Asians demonstrated more severe CAD compared to Caucasians undergoing cardiac catheterization as evidenced by smaller proximal LAD luminal diameters, higher mean percent stenosis per vessel, and more patients with multivessel disease. Further study is warranted to better define factors important in the development of CAD and inform risk stratification in this high-risk population.
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35
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Harrington C, Horne A, Hasan RK, Blumenthal RS. Statin therapy in primary prevention: new insights regarding women and the elderly. Am J Cardiol 2010; 106:1357-9. [PMID: 21029838 DOI: 10.1016/j.amjcard.2010.06.067] [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: 06/12/2010] [Revised: 06/18/2010] [Accepted: 06/18/2010] [Indexed: 10/19/2022]
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36
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DeMazumder D, Hasan RK, Blumenthal RS, Michos ED, Jones S. Should statin therapy be allocated on the basis of global risk or on the basis of randomized trial evidence? Am J Cardiol 2010; 106:905-9. [PMID: 20816135 DOI: 10.1016/j.amjcard.2010.05.015] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/23/2010] [Revised: 05/26/2010] [Accepted: 05/26/2010] [Indexed: 10/19/2022]
Abstract
Current clinical guidelines recommend the use of a global risk assessment tool, such as those pioneered by the Framingham Heart Study, to determine eligibility for statin therapy in patients with absolute risk levels greater than a certain threshold. In support of this approach, several randomized trials have reported that patients with high absolute risk clearly benefit from statin therapy. Therefore, the guideline recommendations would seem intuitive and effective, albeit on the core assumption that the mortality and morbidity benefits associated with statin therapy would be greatest in those with high predicted absolute risk. However, if this assumption is incorrect, using predicted absolute risk to guide statin therapy could easily result in underuse in some groups and overuse in others. Herein, the authors question the utility of global risk assessment strategies based on the Framingham risk score for guiding statin therapy in light of current data that have become available from more recent and robust prospective randomized clinical trials since the publication of the National Cholesterol Education Program Adult Treatment Panel III guidelines. Moreover, the Adult Treatment Panel III guidelines do not support treatment of some patients who may benefit from statin therapy. In conclusion, the authors propose an alternative approach for incorporating more recent randomized trial data into future statin allocation algorithms and treatment guidelines.
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Steppan J, Ryoo S, Schuleri KH, Gregg C, Hasan RK, White AR, Bugaj LJ, Khan M, Santhanam L, Nyhan D, Shoukas AA, Hare JM, Berkowitz DE. Arginase modulates myocardial contractility by a nitric oxide synthase 1-dependent mechanism. Proc Natl Acad Sci U S A 2006; 103:4759-64. [PMID: 16537391 PMCID: PMC1450243 DOI: 10.1073/pnas.0506589103] [Citation(s) in RCA: 66] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/05/2005] [Indexed: 12/14/2022] Open
Abstract
Cardiac myocytes contain two constitutive NO synthase (NOS) isoforms with distinct spatial locations, which allows for isoform-specific regulation. One regulatory mechanism for NOS is substrate (l-arginine) bioavailability. We tested the hypothesis that arginase (Arg), which metabolizes l-arginine, constrains NOS activity in the cardiac myocyte in an isoform-specific manner. Arg activity was detected in both rat heart homogenates and isolated myocytes. Although both Arg I and II mRNA and protein were present in whole heart, Arg II alone was found in isolated myocytes. Arg inhibition with S-(2-boronoethyl)-l-cysteine (BEC) augmented Ca(2+)-dependent NOS activity and NO production in myocytes, which did not depend on extracellular l-arginine. Arg II coimmunoprecipited with NOS1 but not NOS3. Isolation of myocyte mitochondrial fractions in combination with immuno-electron microscopy demonstrates that Arg II is confined primarily to the mitochondria. Because NOS1 positively modulates myocardial contractility, we determined whether Arg inhibition would increase basal myocardial contractility. Consistent with our hypothesis, Arg inhibition increased basal contractility in isolated myocytes by a NOS-dependent mechanism. Both the Arg inhibitors N-hydroxy-nor-l-arginine and BEC dose-dependently increased basal contractility in rat myocytes, which was inhibited by both nonspecific and NOS1-specific NOS inhibitors N(G)-nitro-l-arginine methyl ester and S-methyl-l-thiocitrulline, respectively. Also, BEC increased contractility in isolated myocytes from WT and NOS3 but not NOS1 knockout mice. We conclude that mitochondrial Arg II negatively regulates NOS1 activity, most likely by limiting substrate availability in its microdomain. These findings have implications for therapy in pathophysiologic states such as aging and heart failure in which myocardial NO signaling is disrupted.
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Affiliation(s)
- Jochen Steppan
- Departments of Anesthesiology and Critical Care Medicine, Medicine, and Biomedical Engineering, and Institute for Cell Engineering, The Johns Hopkins Medical Institutions, Baltimore, MD 21287
| | - Sungwoo Ryoo
- Departments of Anesthesiology and Critical Care Medicine, Medicine, and Biomedical Engineering, and Institute for Cell Engineering, The Johns Hopkins Medical Institutions, Baltimore, MD 21287
| | - Karl H. Schuleri
- Departments of Anesthesiology and Critical Care Medicine, Medicine, and Biomedical Engineering, and Institute for Cell Engineering, The Johns Hopkins Medical Institutions, Baltimore, MD 21287
| | - Chris Gregg
- Departments of Anesthesiology and Critical Care Medicine, Medicine, and Biomedical Engineering, and Institute for Cell Engineering, The Johns Hopkins Medical Institutions, Baltimore, MD 21287
| | - Rani K. Hasan
- Departments of Anesthesiology and Critical Care Medicine, Medicine, and Biomedical Engineering, and Institute for Cell Engineering, The Johns Hopkins Medical Institutions, Baltimore, MD 21287
| | - A. Ron White
- Departments of Anesthesiology and Critical Care Medicine, Medicine, and Biomedical Engineering, and Institute for Cell Engineering, The Johns Hopkins Medical Institutions, Baltimore, MD 21287
| | - Lukasz J. Bugaj
- Departments of Anesthesiology and Critical Care Medicine, Medicine, and Biomedical Engineering, and Institute for Cell Engineering, The Johns Hopkins Medical Institutions, Baltimore, MD 21287
| | - Mehnaz Khan
- Departments of Anesthesiology and Critical Care Medicine, Medicine, and Biomedical Engineering, and Institute for Cell Engineering, The Johns Hopkins Medical Institutions, Baltimore, MD 21287
| | - Lakshmi Santhanam
- Departments of Anesthesiology and Critical Care Medicine, Medicine, and Biomedical Engineering, and Institute for Cell Engineering, The Johns Hopkins Medical Institutions, Baltimore, MD 21287
| | - Daniel Nyhan
- Departments of Anesthesiology and Critical Care Medicine, Medicine, and Biomedical Engineering, and Institute for Cell Engineering, The Johns Hopkins Medical Institutions, Baltimore, MD 21287
| | - Artin A. Shoukas
- Departments of Anesthesiology and Critical Care Medicine, Medicine, and Biomedical Engineering, and Institute for Cell Engineering, The Johns Hopkins Medical Institutions, Baltimore, MD 21287
| | - Joshua M. Hare
- Departments of Anesthesiology and Critical Care Medicine, Medicine, and Biomedical Engineering, and Institute for Cell Engineering, The Johns Hopkins Medical Institutions, Baltimore, MD 21287
| | - Dan E. Berkowitz
- Departments of Anesthesiology and Critical Care Medicine, Medicine, and Biomedical Engineering, and Institute for Cell Engineering, The Johns Hopkins Medical Institutions, Baltimore, MD 21287
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Affiliation(s)
- Rani K Hasan
- Johns Hopkins University School of Medicine, Baltimore, Md, USA
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