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On the Structural Transformation of Ni/BaH2 During a N2-H2 Chemical Looping Process for Ammonia Synthesis: A Joint In Situ Inelastic Neutron Scattering and First-Principles Simulation Study. Top Catal 2021. [DOI: 10.1007/s11244-021-01445-w] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
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Abstract
Background Traditional risk factors for heart failure––coronary heart disease, hypertension, diabetes mellitus, obesity, and smoking––only account for about 50% of cases. Thus, the identification of novel risk factors is of significant public health importance. As high birth weight infants are at increased risk for obesity and diabetes mellitus later in life, which are both risk factors for the development of heart failure, we sought to assess the association of high birth weight with incident heart failure in the ARIC (Atherosclerosis Risk in Communities) study. Methods and Results The ARIC study is a biracial prospective community‐based investigation of 15 792 individuals aged 45 to 64 years at baseline. Study participants who were born premature or born a twin were excluded from this analysis, resulting in 9820 participants who provided either their birth weight category (low, medium, high) or exact birth weight. After adjusting for differences in demographics, risk factors, and comorbidities, compared with medium birth weight, those with high birth weight had a significantly increased risk of incident heart failure (hazard ratio, 1.27; 95% CI, 1.05–1.54 [P=0.014]). The hazard for all‐cause mortality for high birth weight compared with medium birth weight was 1.16 (95% CI, 0.99–1.34; P=0.06). There was no association of high birth weight with myocardial infarction (hazard ratio, 1.06; 95% CI, 0.84–1.34 [P=0.6]). Conclusions High birth weight was associated with a significantly increased hazard of incident heart failure independent of traditional risk factors and a trend toward an increased hazard of death. A history of high birth weight should be ascertained in young adults for primordial prevention of heart failure and in older adults for primary prevention.
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Inverse Probability of Treatment Weighting (Propensity Score) using the Military Health System Data Repository and National Death Index. J Vis Exp 2020. [PMID: 31984959 DOI: 10.3791/59825] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/02/2023] Open
Abstract
When randomized controlled trials are not feasible, retrospective studies using big data provide an efficient and cost-effective alternative, though they are at risk for treatment selection bias. Treatment selection bias occurs in a non-randomized study when treatment selection is based on pre-treatment characteristics that are also associated with the outcome. These pre-treatment characteristics, or confounders, can influence evaluation of a treatment's effect on the outcome. Propensity scores minimize this bias by balancing the known confounders between treatment groups. There are a few approaches to performing propensity score analyses, including stratifying by the propensity score, propensity matching, and inverse probability of treatment weighting (IPTW). Described here is the use of IPTW to balance baseline comorbidities in a cohort of patients within the US Military Health System Data Repository (MDR). The MDR is a relatively optimal data source, as it provides a contained cohort in which nearly complete information on inpatient and outpatient services is available for eligible beneficiaries. Outlined below is the use of the MDR supplemented with information from the national death index to provide robust mortality data. Also provided are suggestions for using administrative data. Finally, the protocol shares an SAS code for using IPTW to balance known confounders and plot the cumulative incidence function for the outcome of interest.
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Multimarker Approach to Identify Patients With Higher Mortality and Rehospitalization Rate After Surgical Aortic Valve Replacement for Aortic Stenosis. JACC Cardiovasc Interv 2019; 11:2172-2181. [PMID: 30409274 DOI: 10.1016/j.jcin.2018.07.039] [Citation(s) in RCA: 23] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/11/2018] [Revised: 06/15/2018] [Accepted: 07/23/2018] [Indexed: 02/04/2023]
Abstract
OBJECTIVES This study sought to evaluate whether a multimarker approach might identify patients with higher mortality and hospitalization rates after aortic valve replacement (AVR) for aortic stenosis (AS). BACKGROUND The society valve guidelines include accepted triggers for AVR in patients with severe asymptomatic AS, but circulating biomarkers do not have a clear role. METHOD From a prospective registry of patients undergoing cardiac surgery between 2000 and 2012, 665 treated with surgical AVR (441 isolated) were evaluated. Seven biomarkers were measured on blood samples obtained before AVR. Biomarker levels were adjusted to account for the influence of age, sex, body mass index, and renal function; the median was used to determine an elevated value. Endpoints included all-cause mortality and all-cause and cardiovascular hospitalizations. Mean follow-up was 10.7 years and 299 (45%) died. RESULTS Patients with 0 to 1, 2 to 3, 4 to 6, and 7 biomarkers elevated had 5-year mortality of 10%, 12%, 24%, and 33%, respectively, and 10-year mortality of 24%, 35%, 58%, and 71%, respectively (log-rank p < 0.001). The association between an increasing number of elevated biomarkers and increased all-cause mortality was observed among those with minimal symptoms (New York Heart Association functional class I or II) and those with a low N-terminal pro-B-type natriuretic peptide (p < 0.01 for both). Compared with those with 0 to 1 biomarkers elevated, patients with 4 to 6 or 7 biomarkers elevated had an increased hazard of mortality after adjustment for clinical risk scores (p < 0.01) and a 2- to 3-fold higher rate of all-cause and cardiovascular rehospitalization after AVR. Similar findings were obtained when evaluating cardiovascular mortality. Among patients with no or minimal symptoms, 42% had ≥4 biomarkers elevated. CONCLUSIONS Among patients with severe AS treated with surgical AVR, an increasing number of elevated biomarkers of cardiovascular stress was associated with higher all-cause and cardiovascular mortality and a higher rate of repeat hospitalization. A multimarker approach may be useful in the surveillance of asymptomatic patients with severe AS to optimize surgical timing.
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Impact of Statins on Cardiovascular Outcomes Following Coronary Artery Calcium Scoring. J Am Coll Cardiol 2019; 72:3233-3242. [PMID: 30409567 DOI: 10.1016/j.jacc.2018.09.051] [Citation(s) in RCA: 175] [Impact Index Per Article: 35.0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/08/2018] [Revised: 09/23/2018] [Accepted: 09/25/2018] [Indexed: 02/07/2023]
Abstract
BACKGROUND Compared with traditional risk factors, coronary artery calcium (CAC) scores improve prognostic accuracy for atherosclerotic cardiovascular disease (ASCVD) outcomes. However, the relative impact of statins on ASCVD outcomes stratified by CAC scores is unknown. OBJECTIVES The authors sought to determine whether CAC can identify patients most likely to benefit from statin treatment. METHODS The authors identified consecutive subjects without pre-existing ASCVD or malignancy who underwent CAC scoring from 2002 to 2009 at Walter Reed Army Medical Center. The primary outcome was first major adverse cardiovascular event (MACE), a composite of acute myocardial infarction, stroke, and cardiovascular death. The effect of statin therapy on outcomes was analyzed stratified by CAC presence and severity, after adjusting for baseline comorbidities with inverse probability of treatment weights based on propensity scores. RESULTS A total of 13,644 patients (mean age 50 years; 71% men) were followed for a median of 9.4 years. Comparing patients with and without statin exposure, statin therapy was associated with reduced risk of MACE in patients with CAC (adjusted subhazard ratio: 0.76; 95% confidence interval: 0.60 to 0.95; p = 0.015), but not in patients without CAC (adjusted subhazard ratio: 1.00; 95% confidence interval: 0.79 to 1.27; p = 0.99). The effect of statin use on MACE was significantly related to the severity of CAC (p < 0.0001 for interaction), with the number needed to treat to prevent 1 initial MACE outcome over 10 years ranging from 100 (CAC 1 to 100) to 12 (CAC >100). CONCLUSIONS In a largescale cohort without baseline ASCVD, the presence and severity of CAC identified patients most likely to benefit from statins for the primary prevention of cardiovascular diseases.
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The Gut Microbe Akkermansia Muciniphilia Increases after Radiation Injury and Can be Supplemented By Gavage to Improve Survival in Radiated Mice. Int J Radiat Oncol Biol Phys 2019. [DOI: 10.1016/j.ijrobp.2019.06.313] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
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Abstract
This analysis of data from US Renal Data System examined patient- and center-level variables for patients who did and did not undergo cardiac stress testing to determine which were associated with stress testing 18 months prior to renal transplantation.
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Improved differential diagnosis of intracardiac and extracardiac shunts using acoustic intensity mapping of saline contrast studies. Eur Heart J Cardiovasc Imaging 2019; 21:307-317. [DOI: 10.1093/ehjci/jez129] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/01/2019] [Accepted: 05/15/2019] [Indexed: 11/13/2022] Open
Abstract
Abstract
Aims
The aim of this study was to test the hypothesis that temporal patterns of saline contrast entry into, and exit from the left heart are significantly different in intra- and extra-cardiac shunts and can be used to differentiate the shunt mechanism when Valsalva manoeuvre cannot be performed, or is of uncertain quality. We propose a novel approach of mapping the temporal changes in acoustic intensity (AI) within the left and right heart to identify and define these unique patterns.
Methods and results
We screened cases of right to left shunting on resting agitated saline contrast echocardiograms with clinical criteria that identified the origin of shunting as either a patent foramen ovale or pulmonary arteriovenous malformation. Acoustic time-intensity curves were generated from the right and left heart chambers that reflected the change in saline contrast density over time. Several novel pre-specified parameters were measured from these curves, in addition to the standard heartbeat counting method, to characterize the entrance (wash-in) and exit (wash-out) patterns of saline contrast in the left heart. Statistical analysis showed that AI mapping provided superior differentiation of the two populations than did the traditional beat counting method.
Conclusion
Diagnosis of shunt mechanism from saline contrast studies can be improved over current methods through the use of AI mapping to define the rapidity that peak contrast effect develops, the speed that the contrast effect decays, and the contrast intensity late in the recording.
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Radiation Exposure During Transcatheter Valve Replacement: What Cardiac Surgeons Need to Know. Ann Thorac Surg 2019; 109:118-122. [PMID: 31288016 DOI: 10.1016/j.athoracsur.2019.05.041] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/28/2018] [Revised: 04/10/2019] [Accepted: 05/12/2019] [Indexed: 10/26/2022]
Abstract
BACKGROUND Transcatheter aortic valve replacement (TAVR) and transcatheter mitral valve replacement expose operators to radiation. These procedures differ primarily in whether they are performed via a transfemoral (TF) or an alternative access (AA) approach. This study compared operator radiation exposure during transcatheter valve implantation when performed via a TF vs an AA approach, when performed in a catheterization lab vs a hybrid operating room (OR), and investigated the potential benefit of disposable shielding. METHODS Dosimeters were worn during TAVR-TF (n = 50) and TAVR-AA (n = 31) procedures by operators. All TAVR-AA procedures were performed in a hybrid OR and TF procedures were performed in either catheterization labs (n = 16) or a hybrid OR (n = 34). Disposable radiation shielding pads (RADPAD; Worldwide Innovations and Technologies, Inc, Kansas City) or a placebo were added in a randomized, blinded fashion. RESULTS Team radiation exposure was higher after TAVR-AA vs TAVR-TF (median 15.1 mRad [interquartile range: IQR 8.6, 32.4] vs 5.5 mRad [IQR 2.4, 9.8], P < .001). TAVR-TF procedures required the same amount of fluoroscopy time regardless of where they were performed (20.3 ± 7.4 min in hybrid OR vs 19.0 ± 6.4 min in catheterization lab, P = .55). However, radiation exposure for TAVR-TF remained higher when performed in a hybrid OR (median 9.0 mRad [IQR 4.5, 11.9] vs 2.2 mRad [IQR 1.3, 2.8], P < .001). Radiation exposure was greatest for TAVR-AA (median 15.1 mRad [IQR 8.6, 32.4]). The use of RADPAD did not decrease radiation exposure (median 9.0 mRad [IQR 4.5, 14.7] vs 9.4 mRad [IQR 2.8, 19.5], P = .82). CONCLUSIONS Procedures performed in the hybrid OR were associated with higher operator radiation exposure. In comparison with the TF approach, AA cases had the highest levels of operator radiation. This is particularly important in cases of transcatheter mitral valve replacement that can only be done via an AA approach. The use of disposable radiation shielding in this series did not attenuate operator radiation exposure. Radiation shielding within hybrid ORs should be scrutinized in an effort to remain on par with that found within catheterization labs.
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Comparison of the Kansas City Cardiomyopathy Questionnaire and Minnesota Living With Heart Failure Questionnaire in Predicting Heart Failure Outcomes. Am J Cardiol 2019; 123:807-812. [PMID: 30587373 DOI: 10.1016/j.amjcard.2018.11.037] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/13/2018] [Revised: 11/21/2018] [Accepted: 11/26/2018] [Indexed: 01/06/2023]
Abstract
Patient-reported outcome measures (PROMs) are relevant independent outcomes in heart failure (HF) care and are predictive of subsequent hospitalization and death in HF. The Kansas City Cardiomyopathy Questionnaire (KCCQ) and the Minnesota Living with Heart Failure Questionnaire (MLHFQ) are the 2 most widely adopted PROMs specific to HF. We compared their prognostic abilities in a prospective cohort of HF patients. A prospective cohort of subjects from a single-center registry was analyzed with regard to baseline KCCQ and MLHFQ scores and the outcomes of death, transplant, or left ventricular assist device implantation and hospitalization. A total of 516 subjects with reduced left ventricular ejection fraction (HFrEF) and 151 subjects with preserved left ventricular ejection fraction (HFpEF) were included. Discrimination was assessed using c-statistics based on time-to-event analyses and receiver-operator curves. The additive contribution of MLHFQ was assessed through the change in c-statistic, incremental discrimination index, and category-free net reclassification index. Overall, KCCQ was superior to MLHFQ for predicting death/transplant/ventricular assist device (c-statistic 0.702 [0.666 to 0.738] and 0.658 [0.621 to 0.695] respectively, p value for difference <0.001) and hospitalization (c-statistic 0.640 [0.613 to 0.666] and 0.624 [0.597 to 0.651], respectively, p value for difference 0.022). However, this difference was statistically nonsignificant in the HFpEF group alone. When analyzing the additional prognostic information afforded by adding MLHFQ to KCCQ in the overall, HFrEF, and HFpEF groups there was no significant improvement, although adding KCCQ to MLHFQ did significantly improve risk stratification. Scoring based upon the abbreviated KCCQ-12 did not reduce the prognostic accuracy of KCCQ. In conclusion, KCCQ is more prognostic of death/transplant/left ventricular assist device and hospitalization than MLHFQ in a combined cohort of patients with HFrEF and HFpEF, although the effect in HFpEF was less pronounced. KCCQ should be the preferred PROM for patients with HF if prognostication is a desired goal of using the PROMs.
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Interaction of cardiac implantable electronic device and patent foramen ovale in ischemic stroke: A case-only study. PACING AND CLINICAL ELECTROPHYSIOLOGY: PACE 2019; 42:341-348. [PMID: 30620091 DOI: 10.1111/pace.13599] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/29/2018] [Revised: 10/24/2018] [Accepted: 12/12/2018] [Indexed: 01/03/2023]
Abstract
BACKGROUND Cardiovascular implantable electronic device (CIED) leads are a nidus for right atrial thrombi. Right-to-left thromboembolism across a patent foramen ovale (PFO) is a putative mechanism for ischemic stroke and PFO has been associated with stroke. We used a novel unbiased case-only study design to assess the effect modification of PFO-associated ischemic stroke risk by presence of CIED. We hypothesized that presence of CIED, as a nidus for right atrial thrombus formation, magnifies the PFO-ischemic stroke relationship; therefore, among hospitalized ischemic stroke patients we would find a higher prevalence of CIED in patients with PFO. METHODS We included consecutive first ischemic stroke patients admitted to our hospital from 2006 to 2015, who were enrolled in a prospectively maintained stroke registry. PFO was ascertained from documentation on echocardiography, and presence of CIED at time of stroke was determined from chest radiography reports at or prior to hospitalization. We measured distributions of CIED within PFO and control groups and used Fisher's exact test to evaluate the PFO-CIED association among ischemic stroke patients. RESULTS We included 7089 patients (age: 64.5 ± 14.9 years, 51% female). Echocardiography diagnosed PFO in 760 (10.7%) patients and CIED was reported on chest radiography in 752 (10.6%) patients. Prevalence of CIED was lower in the PFO (61/760, 8.0%) compared to control group (691/6329, 10.9%), P = 0.015. CONCLUSION Among admitted ischemic stroke patients, we did not find a higher prevalence of CIED in patients with PFO compared to controls. Therefore, in the underlying source population, the presence of CIED did not increase the PFO-associated ischemic stroke risk.
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Development of a risk score to identify patients with type 2 diabetes mellitus and multivessel coronary artery disease who can defer bypass surgery. Diagn Progn Res 2019; 3:3. [PMID: 31093573 PMCID: PMC6460751 DOI: 10.1186/s41512-019-0048-7] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/11/2018] [Accepted: 01/09/2019] [Indexed: 01/12/2023] Open
Abstract
BACKGROUND Current American College of Cardiology/American Heart Association (ACC/AHA) guidelines provide a class I recommendation for patients with type 2 diabetes mellitus and multivessel coronary artery disease (CAD) to be treated with coronary artery bypass graft surgery (CABG). However, these patients are heterogeneous in terms of the risks and benefits associated with CABG. We sought to develop a risk score to identify low-risk patients with diabetes and multivessel CAD in whom CABG can be safely deferred. METHODS Patients in the CABG strata randomized to intensive medical therapy (IMT) in the Bypass Angioplasty Revascularization Investigation 2 Diabetes (BARI 2D) trial who experienced death, myocardial infarction (MI), or stroke were compared with those who did not. We developed a risk score for death, MI, or stroke using a Cox proportional hazards model that included the following variables: age, history of heart failure, history of hypercholesterolemia, history of stroke, transient ischemic attack, serum creatinine, insulin use, myocardial jeopardy index, and HbA1c. RESULTS Among patients with a risk score less than the median, those randomized to IMT or prompt CABG experienced similar rates of event-free survival at 5 years (77.8% vs. 83.2%, logrank P = 0.24). Among patients with a risk score greater than the median, those randomized to IMT experienced worse rates of event-free survival at 5 years than those randomized to prompt CABG (60.3% vs 73.2%, logrank P = 0.01). CONCLUSIONS A novel risk score identifies low-risk patients with diabetes and stable, symptomatic multivessel CAD in whom CABG can be safely deferred.
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Association of Alcohol Consumption After Development of Heart Failure With Survival Among Older Adults in the Cardiovascular Health Study. JAMA Netw Open 2018; 1:e186383. [PMID: 30646330 PMCID: PMC6324331 DOI: 10.1001/jamanetworkopen.2018.6383] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/19/2022] Open
Abstract
IMPORTANCE More than 1 million older adults develop heart failure annually. The association of alcohol consumption with survival among these individuals after diagnosis is unknown. OBJECTIVE To determine whether alcohol use is associated with increased survival among older adults with incident heart failure. DESIGN, SETTING, AND PARTICIPANTS This prospective cohort study included 5888 community-dwelling adults aged 65 years or older who were recruited to participate in the Cardiovascular Health Study between June 12, 1989, and June 1993, from 4 US sites. Of the total participants, 393 individuals had a new diagnosis of heart failure within the first 9 years of follow-up through June 2013. The study analysis was performed between January 19, 2016, and September 22, 2016. EXPOSURES Alcohol consumption was divided into 4 categories: abstainers (never drinkers), former drinkers, 7 or fewer alcoholic drinks per week, and more than 7 drinks per week. PRIMARY OUTCOMES AND MEASURES Participant survival after the diagnosis of incident heart failure. RESULTS Among the 393 adults diagnosed with incident heart failure, 213 (54.2%) were female, 339 (86.3%) were white, and the mean (SD) age was 78.7 (6.0) years. Alcohol consumption after diagnosis was reported in 129 (32.8%) of the participants. Across alcohol consumption categories of long-term abstainers, former drinkers, consumers of 1-7 drinks weekly and consumers of more than 7 drinks weekly, the percentage of men (32.1%, 49.0%, 58.0%, and 82.4%, respectively; P < .001 for trend), white individuals (78.0%, 92.7%, 92.0%, and 94.1%, respectively, P <. 001 for trend), and high-income participants (22.0%, 43.8%, 47.3%, and 64.7%, respectively; P < .001 for trend) increased with increasing alcohol consumption. Across the 4 categories, participants who consumed more alcohol had more years of education (mean, 12 years [interquartile range (IQR), 8.0-10.0 years], 12 years [IQR, 11.0-14.0 years], 13 years [IQR, 12.0-15.0 years], and 13 years [IQR, 12.0-14.0 years]; P < .001 for trend). Diabetes was less common across the alcohol consumption categories (32.1%, 26.0%, 22.3%, and 5.9%, respectively; P = .01 for trend). Across alcohol consumption categories, there were fewer never smokers (58.3%, 44.8%, 35.7%, and 29.4%, respectively; P < .001 for trend) and more former smokers (34.5%, 38.5%, 50.0%, and 52.9%, respectively; P = .006 for trend). After controlling for other factors, consumption of 7 or fewer alcoholic drinks per week was associated with additional mean survival of 383 days (95% CI, 17-748 days; P = .04) compared with abstinence from alcohol. Although the robustness was limited by the small number of individuals who consumed more than 7 drinks per week, a significant inverted U-shaped association between alcohol consumption and survival was observed. Multivariable model estimates of mean time from heart failure diagnosis to death were 2640 days (95% CI, 1967-3313 days) for never drinkers, 3046 days (95% CI, 2372-3719 days) for consumers of 0 to 7 drinks per week, and 2806 (95% CI, 1879-3734 days) for consumers of more than 7 drinks per week (P = .02). Consumption of 10 drinks per week was associated with the longest survival, a mean of 3381 days (95% CI, 2806-3956 days) after heart failure diagnosis. CONCLUSIONS AND RELEVANCE These findings suggest that limited alcohol consumption among older adults with incident heart failure is associated with survival benefit compared with long-term abstinence. These findings suggest that older adults who develop heart failure may not need to abstain from moderate levels of alcohol consumption.
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Effect of Race on Outcomes Following Early Coronary Computed Tomographic Angiography or Standard Emergency Department Evaluation for Acute Chest Pain. Ethn Dis 2018; 28:517-524. [PMID: 30405295 DOI: 10.18865/ed.28.4.517] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022] Open
Abstract
Objective To examine racial differences in outcomes with coronary computed tomographic angiography (CCTA) vs standard emergency department (ED) evaluation for chest pain. Design Retrospective analysis of the prospective, randomized, multicenter Rule Out Myocardial Ischemia/Infarction by Computer Assisted Tomography (ROMICAT-II) trial. Setting ED at nine hospitals in the United States. Participants 940 patients who were Caucasian or African American (AA) presenting to the ED with chest pain. Interventions CCTA or standard ED evaluation. Main Outcome Measures Length of stay, hospital admission, direct ED discharge, downstream testing and repeat ED visit or hospitalization for recurrent chest pain at 28 days. Safety end points: missed acute coronary syndrome (ACS) and cumulative radiation exposure during the index visit and follow-up period. Results 659 (66%) patients self-identified as Caucasian and 281 (28%) self-identified as AA. AA were younger and more often female compared with Caucasians, had a higher prevalence of hypertension (64% vs 49%, P<.001) and diabetes (23% vs 14%, P<.001) and a lower prevalence of hyperlipidemia (28% vs 51%, P<.001). ACS was more frequent among Caucasians (10% vs 2%, P<.001). Randomization to CCTA resulted in a reduction in median LOS for Caucasians (7.4 vs 24.7 hours, P<.001) and AA (8.9 vs. 26.3, P<.001; P-interaction=.88). Both AA and Caucasian patients experienced greater radiation exposure and more downstream testing with CCTA compared with standard evaluation. Conclusions Early CCTA reduced median LOS for both AA and Caucasian patients presenting to the ED with chest pain by approximately 17 hours compared with standard evaluation.
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Correlation between Invasive Hemodynamic Measurements and Echocardiographic Markers of LV Diastolic Function in Heart Transplant Recipients. J Card Fail 2018. [DOI: 10.1016/j.cardfail.2018.07.114] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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P2546High birth weight and cardiovascular outcomes in the ARIC cohort study. Eur Heart J 2018. [DOI: 10.1093/eurheartj/ehy565.p2546] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
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Association of Inferior Vena Cava Filter Placement for Venous Thromboembolic Disease and a Contraindication to Anticoagulation With 30-Day Mortality. JAMA Netw Open 2018; 1:e180452. [PMID: 30646021 PMCID: PMC6324296 DOI: 10.1001/jamanetworkopen.2018.0452] [Citation(s) in RCA: 38] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/27/2022] Open
Abstract
IMPORTANCE Despite the absence of data from randomized clinical trials, professional societies recommend inferior vena cava (IVC) filters for patients with venous thromboembolic disease (VTE) and a contraindication to anticoagulation therapy. Prior observational studies of IVC filters have suggested a mortality benefit associated with IVC filter insertion but have often failed to adjust for immortal time bias, which is the time before IVC filter insertion, during which death can only occur in the control group. OBJECTIVE To determine the association of IVC filter placement with 30-day mortality after adjustment for immortal time bias. DESIGN, SETTING, AND PARTICIPANTS This comparative effectiveness, retrospective cohort study used a population-based sample of hospitalized patients with VTE and a contraindication to anticoagulation using the State Inpatient Database and the State Emergency Department Database, part of the Healthcare Cost and Utilization Project of the Agency for Healthcare Research and Quality, from hospitals in California (January 1, 2005, to December 31, 2011), Florida (January 1, 2005, to December 31, 2013), and New York (January 1, 2005, to December 31, 2012). Data analysis was conducted from September 15, 2015, to March 14, 2018. EXPOSURE Inferior vena cava filter placement. MAIN OUTCOMES AND MEASURES Multivariable Cox proportional hazard models were constructed with IVC filters as a time-dependent variable that adjusts for immortal time bias. The Cox model was further adjusted using the propensity score as an adjustment variable. RESULTS Of 126 030 patients with VTE, 61 281 (48.6%) were male and the mean (SD) age was 66.9 (16.6) years. In this cohort, 45 771 (36.3%) were treated with an IVC filter, whereas 80 259 (63.7%) did not receive a filter. In the Cox model with IVC filter status analyzed as a time-dependent variable to account for immortal time bias, IVC filter placement was associated with a significantly increased hazard ratio of 30-day mortality (1.18; 95% CI, 1.13-1.22; P < .001). When the propensity score was included in the Cox model, IVC filter placement remained associated with an increased hazard ratio of 30-day mortality (1.18; 95% CI, 1.13-1.22; P < .001). CONCLUSIONS AND RELEVANCE After adjustment for immortal time bias, IVC filter placement was associated with increased 30-day mortality in patients with VTE and a contraindication to anticoagulation. Randomized clinical trials are needed to determine the efficacy of IVC filter placement in patients with VTE and a contraindication to anticoagulation.
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Paired associative stimulation after spinal cord injury: Who should undergo? Ann Phys Rehabil Med 2018. [DOI: 10.1016/j.rehab.2018.05.558] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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Dynamics in the Plastic Crystalline Phases of Cyclohexanol and Cyclooctanol Studied by Quasielastic Neutron Scattering. J Phys Chem B 2018; 122:6296-6304. [PMID: 29775540 DOI: 10.1021/acs.jpcb.8b03448] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
Plastic crystals are a promising candidate for solid state ionic conductors. In this work, quasielastic neutron scattering is employed to investigate the center of mass diffusive motions in two types of plastic crystalline cyclic alcohols: cyclohexanol and cyclooctanol. Two separate motions are observed which are attributed to long-range translational diffusion (α-process) and cage rattling (fast β-process). Residence times and diffusion coefficients are calculated for both processes, along with the confinement distances for the cage rattling. In addition, a binary mixture of these two materials is measured to understand how the dynamics change when a second type of molecule is added to the matrix. It is observed that, upon the addition of the larger cyclooctanol molecules into the cyclohexanol solution, the cage size decreases, which causes a decrease in the observed diffusion rates for both the α- and fast β-processes.
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Pre-transplant Macrophage Cholesterol Efflux Capacity is Associated With Angiographic Cardiac Allograft Vasculopathy in a Multi-center Observational Study. J Heart Lung Transplant 2018. [DOI: 10.1016/j.healun.2018.01.068] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
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INSURANCE ACCESS IN ADULTS WITH CONGENITAL HEART DISEASE IN THE AFFORDABLE CARE ACT ERA. J Am Coll Cardiol 2018. [DOI: 10.1016/s0735-1097(18)31075-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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CHRONIC INOTROPIC THERAPY IN END-STAGE HEART FAILURE IN THE CURRENT ERA. J Am Coll Cardiol 2018. [DOI: 10.1016/s0735-1097(18)31295-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/17/2022]
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AN INVASIVE STRATEGY IS ASSOCIATED WITH IMPROVED SURVIVAL IN MEDICARE PATIENTS WITH NON-ST ELEVATION MYOCARDIAL INFARCTION. J Am Coll Cardiol 2018. [DOI: 10.1016/s0735-1097(18)30605-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/17/2022]
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Insurance access in adults with congenital heart disease in the Affordable Care Act era. CONGENIT HEART DIS 2018; 13:384-391. [DOI: 10.1111/chd.12582] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/28/2017] [Revised: 12/11/2017] [Accepted: 01/03/2018] [Indexed: 11/30/2022]
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Heterogeneity of systolic dysfunction in patients with severe aortic stenosis and preserved ejection fraction. J Card Surg 2018; 32:454-461. [PMID: 28833636 DOI: 10.1111/jocs.13183] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Abstract
BACKGROUND AND AIM Left ventricular (LV) systolic strain has been shown to be an early marker of LV dysfunction in patients with severe aortic stenosis (AS) despite preserved ejection fraction (EF). Echocardiography has provided useful data on regional LV strain patterns, but is not as sensitive as magnetic resonance imaging (MRI). No prior studies have used MRI-based strain analysis to characterize regional three-dimensional strain in patients with severe AS. METHODS Twelve patients with severe AS and preserved EF underwent MRI-based multiparametric strain analysis. Circumferential and longitudinal strain values were calculated at individual points throughout the LV and analyzed in 12 discrete regions. Strain values were compared to a database of normal controls. RESULTS Compared to control patients, circumferential strain in AS patients was significantly reduced at the base (P = 0.002), mid (P = 0.042), and inferior walls (P < 0.001). Longitudinal strain was significantly reduced at the base (P < 0.001), mid (P < 0.001), anterior (P < 0.001), and septal (P < 0.001) walls. Among patients with AS, there was heterogeneity in the location and severity of abnormalities in circumferential and longitudinal strains despite the presence of a preserved EF and lack of prior myocardial infarction. CONCLUSIONS LV systolic strain is significantly impaired in patients with AS and preserved EF compared to healthy volunteers. Abnormalities in circumferential and longitudinal strains were heterogeneously distributed across the LV of patients with AS, allowing us to identify sentinel regions that may reflect the earliest signs of developing LV dysfunction.
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Bariatric Surgery-Induced Cardiac and Lipidomic Changes in Obesity-Related Heart Failure with Preserved Ejection Fraction. Obesity (Silver Spring) 2018; 26:284-290. [PMID: 29243396 PMCID: PMC5783730 DOI: 10.1002/oby.22038] [Citation(s) in RCA: 43] [Impact Index Per Article: 7.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/06/2017] [Revised: 08/24/2017] [Accepted: 09/04/2017] [Indexed: 12/11/2022]
Abstract
OBJECTIVE To determine the effects of gastric bypass on myocardial lipid deposition and function and the plasma lipidome in women with obesity and heart failure with preserved ejection fraction (HFpEF). METHODS A primary cohort (N = 12) with HFpEF and obesity underwent echocardiography and magnetic resonance spectroscopy both before and 3 months and 6 months after bariatric surgery. Plasma lipidomic analysis was performed before surgery and 3 months after surgery in the primary cohort and were confirmed in a validation cohort (N = 22). RESULTS After surgery-induced weight loss, Minnesota Living with Heart Failure questionnaire scores, cardiac mass, and liver fat decreased (P < 0.02, P < 0.001, and P = 0.007, respectively); echo-derived e' increased (P = 0.03), but cardiac fat was unchanged. Although weight loss was associated with decreases in many plasma ceramide and sphingolipid species, plasma lipid and cardiac function changes did not correlate. CONCLUSIONS Surgery-induced weight loss in women with HFpEF and obesity was associated with improved symptoms, reverse cardiac remodeling, and improved relaxation. Although weight loss was associated with plasma sphingolipidome changes, cardiac function improvement was not associated with lipidomic or myocardial triglyceride changes. The results of this study suggest that gastric bypass ameliorates obesity-related HFpEF and that cardiac fat deposition and lipidomic changes may not be critical to its pathogenesis.
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Noninvasive Cardiac Testing vs Clinical Evaluation Alone in Acute Chest Pain: A Secondary Analysis of the ROMICAT-II Randomized Clinical Trial. JAMA Intern Med 2018; 178:212-219. [PMID: 29138794 PMCID: PMC5838790 DOI: 10.1001/jamainternmed.2017.7360] [Citation(s) in RCA: 41] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/15/2023]
Abstract
IMPORTANCE The incremental benefit of noninvasive testing in addition to clinical evaluation (history, physical examination, an electrocardiogram [ECG], and biomarker assessment) vs clinical evaluation alone for patients who present to the emergency department (ED) with acute chest pain is unknown. OBJECTIVE To examine differences in outcomes with clinical evaluation and noninvasive testing (coronary computed tomographic angiography [CCTA] or stress testing) vs clinical evaluation alone. DESIGN, SETTING, AND PARTICIPANTS This study was a retrospective analysis of data from the randomized multicenter Rule Out Myocardial Ischemia/Infarction by Computer Assisted Tomography (ROMICAT-II) trial. Data for 1000 patients who presented with chest pain to the EDs at 9 hospitals in the United States were evaluated. INTERVENTIONS Clinical evaluation plus noninvasive testing (CCTA or stress test) vs clinical evaluation alone. MAIN OUTCOMES AND MEASURES Primary outcome was length of stay (LOS). Secondary outcomes included hospital admission, direct ED discharge, downstream testing, rates of invasive coronary angiography, revascularization, major adverse cardiac events (MACE), repeated ED visit or hospitalization for recurrent chest pain at 28 days, and cost. Safety end points were missed acute coronary syndrome (ACS) and cumulative radiation exposure during the index visit and follow-up period. RESULTS Of the 1000 patients randomized, 118 patients (12%) (mean [SD] age, 53.2 [7.8]; 49 [42%] were female) did not undergo noninvasive testing, whereas 882 (88%) (mean [SD] age, 54.4 [8.14] years; 419 [48%] were female) received CCTA or stress testing. There was no difference in baseline characteristics or clinical presentation between groups. Patients who underwent clinical evaluation alone experienced a shorter LOS (20.3 vs 27.9 hours; P < .001), lower rates of diagnostic testing (P < .001) and angiography (2% vs 11%; P < .001), lower median costs ($2261.50 vs $2584.30; P = .009), and less cumulative radiation exposure (0 vs 9.9 mSv; P < .001) during the 28-day study period. Lack of testing was associated with a lower rate of diagnosis of ACS (0% vs 9%; P < .001) and less coronary angiography and percutaneous coronary intervention (PCI) during the index visit (0% vs 10%; P < .001, and 0% vs 4%; P = .02, respectively). There was no difference in rates of PCI (2% vs 5%; P = .15), coronary artery bypass surgery (0% vs 1%; P = .61), return ED visits (5.8% vs 2.8%; P = .08), or MACE (2% vs 1%; P = .24) in the 28-day follow-up period. CONCLUSIONS AND RELEVANCE In patients presenting to the ED with acute chest pain, negative biomarkers, and a nonischemic ECG result, noninvasive testing with CCTA or stress testing leads to longer LOS, more downstream testing, more radiation exposure, and greater cost without an improvement in clinical outcomes. TRIAL REGISTRATION clinicaltrials.gov Identifier: NCT01084239.
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Coronary Artery Calcium and Long-Term Risk of Death, Myocardial Infarction, and Stroke: The Walter Reed Cohort Study. JACC Cardiovasc Imaging 2017; 11:1799-1806. [PMID: 29153576 DOI: 10.1016/j.jcmg.2017.09.003] [Citation(s) in RCA: 65] [Impact Index Per Article: 9.3] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/27/2017] [Revised: 09/05/2017] [Accepted: 09/07/2017] [Indexed: 02/06/2023]
Abstract
OBJECTIVES This study aimed to assess the long-term risk of death and atherosclerotic cardiovascular disease (ASCVD) outcomes, including stroke, in a real-world cohort that underwent coronary artery calcium (CAC) scoring. BACKGROUND Large-scale, long-term studies assessing the independent relationship of CAC for prediction of ASCVD events, to include stroke, in young, low-risk patients are uncommon outside of the clinical trial setting. METHODS A total of 23,637 consecutive subjects without ASCVD who underwent CAC scoring from 1997 to 2009 were studied. Subjects were assessed for myocardial infarction (MI), stroke, major adverse cardiovascular events (MACE) (e.g., MI, stroke, or cardiovascular death), and all-cause mortality. Outcomes were extracted from the Military Data Repository and the National Death Index and assessed using Cox proportional hazards models, controlling for baseline risk factors, atrial fibrillation, and competing mortality. RESULTS Patients (mean age 50.0 ± 8.5 years) were followed over a median of 11.4 years. The relative adjusted subhazard ratio (aSHR) for CAC 1 to 100, 101 to 400, and >400 was 2.2, 3.8, and 5.9 for MI; 1.2, 1.4, and 1.9 for stroke; 1.4, 2.0, and 2.8 for MACE; and 1.2, 1.5 and 2.1 for death (p < 0.0001). The addition of CAC score to risk factors significantly improved the prognostic accuracy for all outcomes by the likelihood ratio test. Area under the curve increased from 0.658 to 0.738 for MI, 0.703 to 0.704 for stroke, 0.685 to 0.705 for MACE, and 0.759 to 0.767 for mortality. Among subjects without traditional risk factors (n = 6,208; mean age 43.8 ± 4.4 years), the presence of any CAC (>0; n = 848) was associated with an increased risk of MACE (aSHR: 1.67; 95% confidence interval: 1.16 to 2.39). CONCLUSIONS CAC scoring significantly improved long-term prognostic accuracy for MACE events and mortality, irrespective of age and risk factors. These results support CAC screening for improving individual ASCVD risk assessment and prevention in low-risk, young adults.
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Comparison of Rate of Utilization of Medicare Services in Private Versus Academic Cardiology Practice. Am J Cardiol 2017; 120:1899-1902. [PMID: 28939195 DOI: 10.1016/j.amjcard.2017.07.105] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/13/2017] [Revised: 07/14/2017] [Accepted: 07/20/2017] [Indexed: 10/19/2022]
Abstract
Cardiovascular services are the third largest source of Medicare spending. We examined the rate of cardiovascular service utilization in the community of Glendale, CA, compared with the nearest academic medical center, the University of Southern California. Publicly available utilization data released by Medicare for the years 2012 and 2013 were used to identify all inpatient and outpatient cardiology services provided in each practice setting. The analysis included 19 private and 17 academic cardiologists. In unadjusted analysis, academic physicians performed half as many services per Medicare beneficiary per year as those in private practice: 2.3 versus 4.8, p <0.001. Other factors associated with higher utilization included male physician, international (vs US) medical school graduate, interventional (vs general) cardiologist, and more years in practice. Factors independently associated with higher utilization rates by multivariable analysis included private practice setting (odds ratio [OR] 1.84, 95% confidence interval [CI] 1.30 to 2.61, p <0.001), male physician (OR 1.64, 95% CI 1.00 to 2.67, p = 0.049), and international medical school graduate (OR 1.37, 95% CI 1.07 to 1.78, p = 0.014). In conclusion, in this analysis of 2 cardiology practice settings in southern California, medical service utilization per Medicare beneficiary was nearly 2-fold higher in private practice than in the academic setting, suggesting that there may be opportunity for substantially reducing costs of cardiology care in the community setting.
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Increased Hazard of Myocardial Infarction With Insulin-Provision Therapy in Actively Smoking Patients With Diabetes Mellitus and Stable Ischemic Heart Disease: The BARI 2D (Bypass Angioplasty Revascularization Investigation 2 Diabetes) Trial. J Am Heart Assoc 2017; 6:JAHA.117.005946. [PMID: 28903941 PMCID: PMC5634262 DOI: 10.1161/jaha.117.005946] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/22/2023]
Abstract
Background In the BARI 2D (Bypass Angioplasty Revascularization Investigation 2 Diabetes) trial, randomization of diabetic patients with stable ischemic heart disease to insulin provision (IP) therapy, as opposed to insulin sensitization (IS) therapy, resulted in biochemical evidence of impaired fibrinolysis but no increase in adverse clinical outcomes. We hypothesized that the prothrombotic effect of IP therapy in combination with the hypercoagulable state induced by active smoking would result in an increased risk of myocardial infarction (MI). Methods and Results We analyzed BARI 2D patients who were active smokers randomized to IP or IS therapy. The primary end point was fatal or nonfatal MI. PAI‐1 (plasminogen activator inhibitor 1) activity was analyzed at 1, 3, and 5 years. Of 295 active smokers, MI occurred in 15.4% randomized to IP and in 6.8% randomized to IS over the 5.3 years (P=0.023). IP therapy was associated with a 3.2‐fold increase in the hazard of MI compared with IS therapy (hazard ratio: 3.23; 95% confidence interval, 1.43–7.28; P=0.005). Baseline PAI‐1 activity (19.0 versus 17.5 Au/mL, P=0.70) was similar in actively smoking patients randomized to IP or IS therapy. However, IP therapy resulted in significantly increased PAI‐1 activity at 1 year (23.0 versus 16.0 Au/mL, P=0.001), 3 years (24.0 versus 18.0 Au/mL, P=0.049), and 5 years (29.0 versus 15.0 Au/mL, P=0.004) compared with IS therapy. Conclusions Among diabetic patients with stable ischemic heart disease who were actively smoking, IP therapy was independently associated with a significantly increased hazard of MI. This finding may be explained by higher PAI‐1 activity in active smokers treated with IP therapy. Clinical Trial Registration URL: http://www.clinicaltrials.gov. Unique identifier: NCT00006305.
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Effect of New Oral Anticoagulants on Prescribing Practices for Atrial Fibrillation in Older Adults. J Am Geriatr Soc 2017; 65:2405-2412. [PMID: 28832920 DOI: 10.1111/jgs.15058] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/26/2023]
Abstract
OBJECTIVES To determine the effect of new oral anticoagulants (NOACs) on prescribing practices in older adults with atrial fibrillation (AF). DESIGN Retrospective observational cohort study. SETTING Academic medical center in St. Louis, Missouri. PARTICIPANTS Individuals aged 75 and older with AF admitted to the hospital from October 2010 through September 2015 (N = 6,568, 50% female, 15% non-white). MEASUREMENTS Information on NOACs and warfarin prescribed at discharge was obtained from hospital discharge summaries, and linear regression was used to examine quarterly trends in their use. Multivariable logistic regression was used to assess independent predictors of anticoagulant use. RESULTS NOAC use increased over time (correlation coefficient (r) = 0.87, P < .001), warfarin use did not change (r = -0.16, P = .50), and overall anticoagulant use (NOACs and warfarin) increased (r = 0.68, P = .001). NOAC use increased over time in all age groups (75-79, 80-84, 85-89) except aged 90 and older, but increasing age attenuated the rate of NOAC uptake. There was no consistent relationship between age and warfarin or overall anticoagulant use, except that individuals aged 90 and older had consistently lower use. Overall, fewer than 45% of participants were prescribed an anticoagulant. In multivariable analysis, younger age, white race, female sex, higher hemoglobin, higher creatinine clearance, being on a medical service, hypertension, stroke or transient ischemic attack, no history of intracranial hemorrhage, and a modified HAS-BLED score of less than 3 increased the likelihood of receiving NOACs. CONCLUSION Prescription of anticoagulants for AF increased in older adults primarily because of an increase in the use of NOACs. Nonetheless, fewer than 45% of participants were prescribed an anticoagulant. Additional research is needed to optimize prescribing practices for older adults with AF.
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Abnormal Global Longitudinal Strain Predicts Future Deterioration of Left Ventricular Function in Heart Failure Patients With a Recovered Left Ventricular Ejection Fraction. Circ Heart Fail 2017; 10:CIRCHEARTFAILURE.116.003788. [PMID: 28559418 DOI: 10.1161/circheartfailure.116.003788] [Citation(s) in RCA: 56] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/13/2016] [Accepted: 04/24/2017] [Indexed: 11/16/2022]
Abstract
BACKGROUND Patients with recovery of left ventricular ejection fraction (LVEF) remain at risk for future deterioration of LVEF. However, there are no tools to risk stratify these patients. We hypothesized that global longitudinal strain (GLS) could predict sustained recovery within this population. METHODS AND RESULTS We retrospectively identified 96 patients with a reduced LVEF <50% (screening echocardiogram), whose LVEF had increased by at least 10% and normalized (>50%) on evidence-based medical therapies (baseline echocardiogram). We examined absolute GLS on the baseline echocardiogram in relation to changes in LVEF on a follow-up echocardiogram. Patients with recovered LVEF had a wide range of GLS. The GLS on the baseline study correlated with the LVEF at the time of follow-up (r=0.33; P<0.001). The likelihood of having an LVEF >50% on follow-up increased by 24% for each point increase in absolute GLS on the baseline study (odds ratio, 1.24; P=0.001). An abnormal GLS (≤16%) at baseline had a sensitivity of 88%, a specificity of 46%, and an accuracy of 0.67 (P<0.001) as a predictor of a decrease in LVEF >5% during follow-up. A normal GLS (>16%) on the baseline study had a sensitivity of 47%, a specificity of 83%, and an accuracy of 0.65 (P=0.002) for predicting a stable LVEF (-5% to 5%) on follow-up. CONCLUSIONS In patients with a recovered LVEF, an abnormal GLS predicts the likelihood of having a decreased LVEF during follow-up, whereas a normal GLS predicts the likelihood of stable LVEF during recovery.
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Impact of Preeclampsia on Clinical and Functional Outcomes in Women With Peripartum Cardiomyopathy. Circ Heart Fail 2017; 10:CIRCHEARTFAILURE.116.003797. [PMID: 28572214 DOI: 10.1161/circheartfailure.116.003797] [Citation(s) in RCA: 36] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/16/2016] [Accepted: 04/24/2017] [Indexed: 12/15/2022]
Abstract
BACKGROUND Preeclampsia is a risk factor for the development of peripartum cardiomyopathy (PPCM), but it is unknown whether preeclampsia impacts clinical or left ventricular (LV) functional outcomes. This study sought to assess clinical and functional outcomes in women with PPCM complicated by preeclampsia. METHODS AND RESULTS This retrospective cohort study included women diagnosed with PPCM delivering at Barnes-Jewish Hospital between 2004 to 2014. The primary outcome was one-year event-free survival rate for the combined end point of death and hospital readmission. The secondary outcome was recovery of LV ejection fraction. Seventeen of 39 women (44%) with PPCM had preeclampsia. The groups had similar mean LV ejection fraction at diagnosis (29.6 with versus 27.3 without preeclampsia; P=0.5). Women with preeclampsia had smaller mean LV end-diastolic diameters (5.2 versus 6.0 cm; P=0.001), greater relative wall thickness (0.41 versus 0.35 mm Hg; P=0.009), and lower incidence of eccentric remodeling (12% versus 48%; P=0.03). Clinical follow-up was available for 32 women; 5 died of cardiovascular complications within 1 year of diagnosis (4/15 with versus 1/17 without preeclampsia; P=0.16). In time to event analysis, patients with preeclampsia had worse event-free survival during 1-year follow-up (P=0.047). Echocardiographic follow-up was available in 10 survivors with and 16 without preeclampsia. LV ejection fraction recovered in 80% of survivors with versus 25% without preeclampsia (P=0.014). CONCLUSIONS PPCM with concomitant preeclampsia is associated with increased morbidity and mortality and different patterns of LV remodeling and recovery of LV function when compared with patients with PPCM that is not complicated by preeclampsia.
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Left Ventricular Assist Device-Related Infections are Not Associated with Higher One-Year Mortality after Heart Transplant. J Card Fail 2017. [DOI: 10.1016/j.cardfail.2017.07.367] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Sex affects myocardial blood flow and fatty acid substrate metabolism in humans with nonischemic heart failure. J Nucl Cardiol 2017; 24:1226-1235. [PMID: 27048307 PMCID: PMC5517366 DOI: 10.1007/s12350-016-0467-6] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/27/2015] [Accepted: 02/25/2016] [Indexed: 01/08/2023]
Abstract
BACKGROUND In animal models of heart failure (HF), myocardial metabolism shifts from high-energy fatty acid (FA) metabolism toward glucose. However, FA (vs glucose) metabolism generates more ATP/mole; thus, FA metabolism may be especially advantageous in HF. Sex modulates myocardial blood flow (MBF) and substrate metabolism in normal humans. Whether sex affects MBF and metabolism in patients with HF is unknown. METHODS AND RESULTS We studied 19 well-matched men and women with nonischemic HF (EF ≤ 35%). MBF and myocardial substrate metabolism were quantified using positron emission tomography. Women had higher MBF (mL/g/minute), FA uptake (mL/g/minute), and FA utilization (nmol/g/minute) (P < 0.005, P < 0.005, P < 0.05, respectively) and trended toward having higher FA oxidation than men (P = 0.09). These findings were independent of age, obesity, and insulin resistance. There were no sex-related differences in fasting myocardial glucose uptake or metabolism. Higher MBF was related to improved event-free survival (HR 0.31, P = 0.02). CONCLUSIONS In nonischemic HF, women have higher MBF and FA uptake and metabolism than men, irrespective of age, obesity, or insulin resistance. Moreover, higher MBF portends a better prognosis. These sex-related differences should be taken into account in the development and targeting of novel agents aimed at modulating MBF and metabolism in HF.
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Improving Prediction of Postoperative Myocardial Infarction With High-Sensitivity Cardiac Troponin T and NT-proBNP. Anesth Analg 2017; 124:398-405. [PMID: 28002165 DOI: 10.1213/ane.0000000000001736] [Citation(s) in RCA: 42] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
BACKGROUND This study sought to determine whether preoperatively measured high-sensitivity cardiac troponin T (hs-cTnT) and N-terminal pro-brain natriuretic peptide (NT-proBNP) improve cardiac risk prediction in patients undergoing major noncardiac surgery compared with the standard risk indices. METHODS In this ancillary study to the Vitamins in Nitrous Oxide trial, patients were included who had preoperative hs-cTnT and NT-proBNP measured (n = 572). Study outcome was the incidence of postoperative myocardial infarction (MI) within the first 3 postoperative days. hs-cTnT was considered elevated if >14 ng/L and NT-proBNP if >300 ng/L. Additional cutoff values were investigated on the basis of receiver operating characteristic statistics. Biomarker risk prediction was compared with Lee's Revised Cardiac Risk Index (RCRI) with the use of standard methods and net reclassification index. RESULTS The addition of hs-cTnT (>14 ng/L) and NT-proBNP (>300 ng/L) to RCRI significantly improved the prediction of postoperative MI (event rate 30/572 [5.2%], Area under the receiver operating characteristic curve increased from 0.590 to 0.716 with a 0.66 net reclassification index [95% confidence interval 0.32-0.99], P < .001). The use of 108 ng/L as a cutoff for NT-proBNP improved sensitivity compared with 300 ng/L (0.87 vs 0.53). Sensitivity, specificity, positive, and negative predictive value for hs-cTnT were 0.70, 0.60, 0.09, and 0.97 and for NT-proBNP were 0.53, 0.68, 0.08, and 0.96. CONCLUSIONS The addition of cardiac biomarkers hs-cTnT and NT-proBNP to RCRI improves the prediction of adverse cardiac events in the immediate postoperative period after major noncardiac surgery. The high negative predictive value of preoperative hs-cTnT and NT-proBNP suggest usefulness as a "rule-out" test to confirm low risk of postoperative MI.
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Relationship Between Anticoagulation Intensity and Thrombotic or Bleeding Outcomes Among Outpatients With Continuous-Flow Left Ventricular Assist Devices. Circ Heart Fail 2017; 9:CIRCHEARTFAILURE.115.002680. [PMID: 27154497 DOI: 10.1161/circheartfailure.115.002680] [Citation(s) in RCA: 72] [Impact Index Per Article: 10.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/18/2015] [Accepted: 03/29/2016] [Indexed: 11/16/2022]
Abstract
BACKGROUND We evaluated thrombotic and bleeding outcomes in patients with continuous-flow left ventricular assist devices (CF-LVADs), stratified by anticoagulation intensity. Previous studies of outpatients with CF-LVADs have suggested that target international normalized ratio (INR) values <2.5 (range, 2-3) may be used. However, recent studies reported an increase in pump thrombosis among CF-LVADs, especially within the first 6 months of implant. METHODS AND RESULTS We retrospectively reviewed 249 outpatients at our center who received a CF-LVAD between January 2005 and August 2013. Using Poisson models, we analyzed their 10 927 INRs to determine INR-specific rates of thrombotic (ischemic stroke and suspected pump thrombosis) and hemorrhagic (gastrointestinal bleeding and hemorrhagic stroke) events occurring outside of the hospital. In multivariate analyses, we adjusted for age, sex, atrial fibrillation, coronary disease, and LVAD type as time-dependent Cox proportional hazard models. During a mean follow-up of 17.6±13.6 months, thrombotic events occurred in 46 outpatients. The highest event rate (0.40 thrombotic events per patient-year) was in the INR range of <1.5, but INR values of 1.5 to 1.99 also had high rates (0.16 thrombotic events per patient-year). INR was inversely associated with thrombotic events (hazard ratio, 0.40; 95% confidence interval, 0.22-0.72; P=0.002). The optimal INR based on weighted mortality of thrombotic and bleeding events was 2.6. CONCLUSIONS INR is inversely related to thrombotic events occurring outside of the hospital among patients supported with CF-LVADs. INR values <2.0 increase the rate of thrombotic events occurring outside of the hospital among patients supported with CF-LVADs.
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Epidemiology, pathophysiology and clinical outcomes for heart failure patients with a mid-range ejection fraction. Eur J Heart Fail 2017; 19:1597-1605. [PMID: 29024350 DOI: 10.1002/ejhf.879] [Citation(s) in RCA: 98] [Impact Index Per Article: 14.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/17/2016] [Revised: 04/04/2017] [Accepted: 04/05/2017] [Indexed: 12/28/2022] Open
Abstract
AIMS Heart failure (HF) patients with a mid-range ejection fraction (HFmrEF) are not well characterized. Accordingly, we examined the epidemiology, pathophysiology and clinical outcomes of HF patients with a left ventricular ejection fraction (LVEF) of 40-50%. METHODS AND RESULTS We identified 168 patients with an LVEF between 40-50% at enrollment into a HF registry, and determined whether LVEF was improved, worsened, or the same compared to a prior LVEF. Three subgroups of HFmrEF patients were identified: HFmrEF improved (prior LVEF <40%); HFmrEF deteriorated (prior LVEF >50%); HFmrEF unchanged (prior LVEF 40-50%). The majority of patients (73%) were HFmrEF improved, 17% were HFmrEF deteriorated, and 10% were HFmrEF unchanged. The demographics of the HFmrEF cohort were heterogeneous, with more coronary artery disease in the HFmrEF improved group and more hypertension and diastolic dysfunction in the HFmrEF deteriorated group. HFmrEF improved patients had significantly (P<0.001) better clinical outcomes relative to matched patients with HF and reduced ejection fraction, and significantly (P<0.01) improved clinical outcomes relative to HFmrEF deteriorated patients, whereas clinical outcomes of the HFmrEF deteriorated subgroup of patients were not significantly different from matched HF patients with preserved ejection fraction. CONCLUSIONS Patients with a mid-range LVEF are heterogeneous. Obtaining historical information with regard to prior LVEF allows one to identify a distinct pathophysiological substrate and clinical course for HFmrEF patients. Viewed together, these results suggest that in the modern era of HF therapeutics, the use of LVEF to categorize the pathophysiology of HF may be misleading, and argue for establishing a new taxonomy for classifying HF patients.
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Evaluation of attenuation correction in cardiac PET using PET/MR. J Nucl Cardiol 2017; 24:839-846. [PMID: 26499770 PMCID: PMC6360086 DOI: 10.1007/s12350-015-0197-1] [Citation(s) in RCA: 31] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2015] [Revised: 05/16/2015] [Indexed: 10/22/2022]
Abstract
BACKGROUND Simultaneous acquisition Positron emission tomography/magnetic resonance (PET/MR) is a new technology that has potential as a tool both in research and clinical diagnosis. However, cardiac PET acquisition has not yet been validated using MR imaging for attenuation correction (AC). The goal of this study is to evaluate the feasibility of PET imaging using a standard 2-point Dixon volume interpolated breathhold examination (VIBE) MR sequence for AC. METHODS AND RESULTS Evaluation was performed in both phantom and patient data. A chest phantom containing heart, lungs, and a lesion insert was scanned by both PET/MR and PET/CT. In addition, 30 patients underwent whole-body 18F-fluorodeoxyglucose PET/CT followed by simultaneous cardiac PET/MR. Phantom study showed 3% reduction of activity values in the myocardium due to the non-inclusion of the phased array coil in the AC. In patient scans, average standardized uptake values (SUVs) obtained by PET/CT and PET/MR showed no significant difference (n = 30, 4.6 ± 3.5 vs 4.7 ± 2.8, P = 0.47). There was excellent per patient correlation between the values acquired by PET/CT and PET/MR (R 2 = 0.97). CONCLUSIONS Myocardial SUVs PET imaging using MR for AC shows excellent correlation with myocardial SUVs obtained by standard PET/CT imaging. The 2-point Dixon VIBE MR technique can be used for AC in simultaneous PET/MR data acquisition.
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The long-term risk of smoking in diabetic patients with stable ischemic heart disease treated with intensive medical therapy and lifestyle modification. Eur J Prev Cardiol 2017; 24:1506-1514. [PMID: 28517955 DOI: 10.1177/2047487317711046] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Introduction The long-term risk of smoking in diabetic patients with stable ischemic heart disease (SIHD) is unknown. We sought to analyze the impact of smoking on outcomes of diabetic patients with SIHD when other cardiovascular risk factors are being aggressively treated. Methods The Bypass Angioplasty Revascularization Investigation 2 Diabetes (BARI 2D) trial randomized 2368 diabetics with SIHD to intensive medical therapy (IMT) with prompt revascularization or IMT alone. Smoking status was obtained at baseline, 6 months, and 1, 2, 3, 4 and 5 years. The primary endpoint of interest was all-cause mortality. Results Of 2360 patients, 33.1% of patients never smoked, 54.4% were former smokers, and 12.5% were current smokers. The rate of all-cause mortality was greater for current (2.5 deaths/100 patient-years) and former smokers (3.1 deaths/100 patient-years) than never smokers (2.1 deaths/100 patient-years) (P = 0.007). Cardiac death, cardiovascular death, fatal or nonfatal myocardial infarction, and fatal or nonfatal stroke were not increased in current or former smokers compared with never smokers. Compared with never smokers, current smokers experienced a 49% increased hazard of death (Hazard Ratio (HR) 1.49, 95% Confidence Interval (CI): 0.97-2.29, P = 0.07) whereas former smokers had a 37% increased hazard of death (HR 1.37, 95% CI: 1.04-2.79, P = 0.02) when considering smoking status as a time-dependent variable and adjusting for factors that differed by smoking status. Conclusions Current and former smoking are associated with increased all-cause mortality in diabetics with SIHD but not with increased cardiovascular morbidity or mortality.
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PAQ®, ein einfaches Insulinabgabegerät für Basis-Bolus-Therapie, erhöht die Zeit im Blutzuckerzielbereich signifikant. DIABETOL STOFFWECHS 2017. [DOI: 10.1055/s-0037-1601735] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
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The Impact of LVAD Duration on Short-Term Outcomes After Heart Transplantation. J Heart Lung Transplant 2017. [DOI: 10.1016/j.healun.2017.01.1230] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022] Open
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The Variance and Interplay Between Estimated Glomerular Filtration Rate Calculators and the Risk of Adverse Renal Outcomes After Heart Transplantation. J Heart Lung Transplant 2017. [DOI: 10.1016/j.healun.2017.01.608] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
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Clinical predictors of length of stay in adults with congenital heart disease. Heart 2017; 103:1258-1263. [PMID: 28237970 DOI: 10.1136/heartjnl-2016-310841] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/01/2016] [Revised: 01/05/2017] [Accepted: 02/02/2017] [Indexed: 11/04/2022] Open
Abstract
OBJECTIVE Length of stay (LOS) is a major driver of inpatient care costs. To date, few studies have investigated risk factors associated with increased LOS in patients with adult congenital heart disease (ACHD). In the present work, we sought to address this knowledge gap. METHODS We conducted an analysis of the State Inpatient Databases from Arkansas, California, Florida, Hawaii, Nebraska and New York. We analysed data on admissions in patients with ACHD and constructed a series of hierarchical regression models to identify the clinical factors having the greatest effects on LOS. RESULTS We identified 99 103 inpatient hospitalisations meeting criteria for inclusion. Diagnoses associated with the longest LOS were septicaemia (LOS=14.2 days in patients atrial septal defect, and 11.7 days among all other ACHD) and pericarditis, endocarditis and myocarditis (LOS=13.6 days and 10.0 days, respectively). When separated by underlying anatomy, the variables most consistently associated with longer LOS were bacterial infection, complications of surgeries or medical care, acute renal disease and anaemia. CONCLUSIONS In the present study, we identified risk factors associated with longer LOS in ACHD. These data may be used to identify at-risk patients for targeted intervention to decrease LOS and thereby cost.
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Use of Biomarkers to Predict Readmission for Congestive Heart Failure. Am J Cardiol 2017; 119:445-451. [PMID: 27939586 DOI: 10.1016/j.amjcard.2016.10.022] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/08/2016] [Revised: 10/06/2016] [Accepted: 10/06/2016] [Indexed: 10/20/2022]
Abstract
Acute decompensated heart failure (ADHF) is a major reason for repeated hospitalizations. Identifying those patients with ADHF at risk for readmission is critical so that preventive interventions can be implemented. Biomarkers such as B-type natriuretic peptide (BNP), high-sensitivity troponin I, and galectin-3 (Gal-3) assessed at discharge may be useful, although their role in predicting short-term readmission is not well defined in the literature. We enrolled and had follow-up data for 101 participants admitted to our facility from April 2013 to March 2015 with a primary diagnosis of ADHF. Gal-3, high-sensitivity troponin I, and BNP were obtained within 48 hours before hospital discharge after management of ADHF. Gal-3 was assessed using 2 commercially available assays. We compared subjects who were and were not readmitted. Discharge BNP was found to be a significant predictor of 30- and 60-day readmission (area under the curve [AUC] 0.69 [p = 0.046], AUC 0.7 [p = 0.005], respectively). The addition of Gal-3 to discharge BNP provided significantly improved prediction of 60-day readmission. Gal-3 alone was found to be a significant predictor of 60-day readmission in patients with preserved ejection fraction (AUC 0.85, p <0.001). The net reclassification improvement was 55.2 (p = 0.037). Using multivariate analysis, for every 100 pg/L BNP increase, the probability of readmission increased by approximately 10%, and for every 1-ng/ml Gal-3 increase, the probability further increased 8%. A statistically significant net reclassification improvement was not found on examination of 30-day readmission. In conclusion, measurement of both Gal-3 and BNP at hospital discharge provides significant prediction of hospital readmission within 60 days. When combined, the prediction of readmission is significantly improved.
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Short-Term Costs and Hospitalization Rates in Patients With Adult Congenital Heart Disease After Pulmonic Valve Replacement. Am J Cardiol 2016; 118:1552-1557. [PMID: 27634029 DOI: 10.1016/j.amjcard.2016.08.018] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/28/2016] [Revised: 08/02/2016] [Accepted: 08/02/2016] [Indexed: 11/26/2022]
Abstract
In the adult congenital heart disease (ACHD) population, pulmonary valve replacement (PVR) is a common intervention, its benefit, however, has been incompletely investigated. This study investigates short- and intermediate-term outcomes after PVR in ACHD. Using State Inpatient Databases from the Healthcare Cost and Utilization Project, we investigated both hospitalization rate and financial burden accrued over the 12-month period after PVR compared with the 12 months before. Among 202 patients who underwent PVR, per patient-year hospitalization rates doubled in the year after PVR compared with the year before (0.16 vs 0.36, p = 0.006). With the exception of postprocedural complications, the most common reasons for hospitalization were unchanged after surgery: 22% of patients were admitted with equal or greater frequency after PVR. These patients experienced higher inpatient costs both at index admission and in the year after PVR (p = 0.004 and p <0.001, respectively). Univariate predictors of increased hospitalizations after PVR were age ≥50 years (p = 0.016), transposition of the great arteries, or conotruncal abnormalities (p <0.001), lipid disorders (p = 0.025), hypertension (p = 0.033), and number of chronic conditions ≥4 (p = 0.004). Multivariate analysis identified transposition of the great arteries or conotruncal abnormalities as an independent risk factor for increased hospitalization and cost post-PVR (p ≤0.001). In conclusion, short-term costs and hospitalization rates increase after PVR in a small group of patients with ACHD.
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Use of adenosine diphosphate receptor inhibitor prior to left ventricular assist device implantation is not associated with increased bleeding. J Artif Organs 2016; 20:42-49. [PMID: 27830349 DOI: 10.1007/s10047-016-0932-7] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2016] [Accepted: 10/24/2016] [Indexed: 10/20/2022]
Abstract
Current guidelines recommend adenosine diphosphate receptor inhibitors (ADPRi) be discontinued 5-7 days prior to cardiac surgery due to increased bleeding events, rates of re-exploration, and transfusions. However, the risks of left ventricular assist device (LVAD) implantation in patients taking an ADPRi have not previously been studied. We retrospectively identified 134 eligible patients with ischemic cardiomyopathy that underwent LVAD implantation between July 2009 and August 2013. The cohorts received an ADPRi ≤5 days of surgery (n = 25) versus >5 days prior or not at all (n = 109). Subgroup analyses adjusted for differences in frequency of redo sternotomy between cohorts, excluded patients that received an ADPRi >1 year prior to surgery, and excluded patients with a redo sternotomy. The ADPRi and control groups did not have significant differences in the primary outcomes, intraoperative PRBC units transfused (3.0 vs. 4.0, p = 0.12) or chest tube output within 24 h of surgery (1.66 L vs. 1.80 L, p = 0.61). After adjusting for differences in frequency of redo sternotomy (ADPRi vs. control, 12 vs. 52%, p ≤ 0.001), no significant difference in PRBC units transfused (3.1 vs. 3.5, p = 0.59) or chest tube output (2.04 L vs. 2.04 L, p = 0.98) was seen. No significant difference in 30-day mortality (8.0 vs. 11.0%, p = 0.63), 90-day mortality (16.4 vs. 23.3%, p = 0.42), or length of stay (29.0 vs. 28.0, p = 0.61) was seen. In this single-center experience, use of an ADPRi ≤5 days prior to LVAD implantation was not associated with increased bleeding, length of stay, or mortality.
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Usefulness of Psoas Muscle Area Determined by Computed Tomography to Predict Mortality or Prolonged Length of Hospital Stay in Patients Undergoing Left Ventricular Assist Device Implantation. Am J Cardiol 2016; 118:1363-1367. [PMID: 27622708 DOI: 10.1016/j.amjcard.2016.07.061] [Citation(s) in RCA: 56] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/15/2016] [Revised: 07/28/2016] [Accepted: 07/28/2016] [Indexed: 01/06/2023]
Abstract
The purpose of this study is to examine the association of sarcopenia as measured by psoas muscle area and outcomes in patients undergoing left ventricular assist device (LVAD) implantation. We retrospectively examined 333 consecutive patients who underwent implantation of a HeartMate II LVAD at our institution from June 2008 to August 2013. Patients were included if they had a perioperative computed tomography that spanned the L3-L4 vertebrae. Sarcopenia was defined as having the lowest tertile psoas muscle area by gender. The primary end point was the composite of inpatient death or prolonged length of stay of >30 days. One hundred patients met inclusion criteria. The psoas muscle area cut-off values for the lowest tertiles were 12.0 cm2 for men and 6.5 cm2 for women, resulting in 32 sarcopenic patients (32%). The primary outcome of inpatient death or prolonged length of stay occurred in 81% of patients in the sarcopenic versus 60% in the nonsarcopenic group (p = 0.043). There was a trend toward prolonged length of stay in sarcopenic patients but no difference in overall mortality. This demonstrates that sarcopenia as measured by psoas muscle area is associated with increased composite length of stay and mortality after LVAD implantation and may serve as correlate for frailty.
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Effect of adding nanometre-sized heterogeneities on the structural dynamics and the excess wing of a molecular glass former. Sci Rep 2016; 6:35034. [PMID: 27725747 PMCID: PMC5057163 DOI: 10.1038/srep35034] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/16/2016] [Accepted: 09/21/2016] [Indexed: 11/17/2022] Open
Abstract
We present the relaxation dynamics of glass-forming glycerol mixed with 1.1 nm sized polyhedral oligomeric silsesquioxane (POSS) molecules using dielectric spectroscopy (DS) and two different neutron scattering (NS) techniques. Both, the reorientational dynamics as measured by DS and the density fluctuations detected by NS reveal a broadening of the α relaxation when POSS molecules are added. Moreover, we find a significant slowing down of the α-relaxation time. These effects are in accord with the heterogeneity scenario considered for the dynamics of glasses and supercooled liquids. The addition of POSS also affects the excess wing in glycerol arising from a secondary relaxation process, which seems to exhibit a dramatic increase in relative strength compared to the α relaxation.
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