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Chedid M, Shroff GR, Iqbal O, Adabag S, Karim RM. Temporary-permanent pacemakers are associated with better clinical and safety outcomes compared to balloon-tipped temporary pacemakers. Pacing Clin Electrophysiol 2024; 47:203-210. [PMID: 38240391 DOI: 10.1111/pace.14918] [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: 11/03/2023] [Revised: 12/18/2023] [Accepted: 12/21/2023] [Indexed: 02/15/2024]
Abstract
BACKGROUND Balloon Tipped Temporary Pacemakers (BTTP) are the most used temporary pacemakers; however, they are associated with a risk of dislodgement and thromboembolism. Recently, Temporary Permanent Pacemakers (TPPM) have been increasingly used. Evidence of outcomes with TPPM compared to BTTP remains scarce. METHODS Retrospective, chart review study evaluating all patients who underwent temporary pacemaker placement between 2014 and 2022 (N = 126) in the cardiac catheterization laboratory (CCL) at a level 1 trauma center. Primary outcome of this study is to evaluate the safety profile of TPPM versus BTTP. Secondary objectives include patient ambulation and healthcare utilization in patients with temporary pacemakers. RESULTS Both groups had similar baseline characteristics distribution including gender, race, and age at temporary pacemaker insertion (p > .05). Subclavian vein was the most common site of access for the TPPM cohort (89.0%) versus the femoral vein in the BTTP group (65.1%). Ambulation was only possible in the TPPM group (55.6%, p < .001). Lead dislodgement, venous thromboembolism, local hematoma, and access site infections were less frequently encountered in the TPPM group (OR = 0.23 [95% CI (0.10-0.67), p < .001]). Within the subgroup of patients with TPPM, 36.6% of the patients were monitored outside the ICU setting. There was no significant difference in the pacemaker-related adverse events among patients with TPPM based on their in-hospital setting. CONCLUSION TPPM is associated with a more favorable safety profile compared to BTTP. They are also associated with earlier patient ambulation and reduced healthcare utilization.
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Affiliation(s)
- Maroun Chedid
- Department of Medicine, Hennepin Healthcare, Minneapolis, Minnesota, USA
| | - Gautam R Shroff
- Division of Cardiology, Hennepin Healthcare, Minneapolis, Minnesota, USA
- Division of Cardiology, University of Minnesota Medical School, Minneapolis, Minnesota, USA
| | - Omer Iqbal
- Division of Cardiology, Hennepin Healthcare, Minneapolis, Minnesota, USA
- Division of Cardiology, University of Minnesota Medical School, Minneapolis, Minnesota, USA
| | - Selçuk Adabag
- Division of Cardiology, University of Minnesota Medical School, Minneapolis, Minnesota, USA
- Veterans Affairs Medical Center, Division of Cardiology, Minneapolis, Minnesota, USA
| | - Rehan M Karim
- Division of Cardiology, Hennepin Healthcare, Minneapolis, Minnesota, USA
- Division of Cardiology, University of Minnesota Medical School, Minneapolis, Minnesota, USA
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Zellmer L, Mallick S, Larsen J, Shroff GR, Pasha M. The Safety Net's Safety Net: Understanding the Crucial Role of Free Clinics in Cardiovascular Care. WMJ 2024; 123:7-8. [PMID: 38436630] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Subscribe] [Scholar Register] [Indexed: 03/05/2024]
Affiliation(s)
- Lucas Zellmer
- Department of Internal Medicine, Hennepin County Medical Center, Minneapolis, Minnesota,
- St. Clare Health Mission, La Crosse, Wisconsin
| | - Sanjoyita Mallick
- Department of Internal Medicine, Hennepin County Medical Center, Minneapolis, Minnesota
| | | | - Gautam R Shroff
- Cardiology Division, Department of Internal Medicine, University of Minnesota, Minneapolis, Minnesota
| | - Maarya Pasha
- Department of Internal Medicine, Hennepin County Medical Center, Minneapolis, Minnesota
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Ogugua FM, Mathew RO, Ternacle J, Rodin H, Pibarot P, Shroff GR. Impact of arteriovenous fistula on flow states in the evaluation of aortic stenosis among ESKD patients on dialysis. Echocardiography 2024; 41:e15728. [PMID: 38113338 DOI: 10.1111/echo.15728] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/29/2023] [Revised: 11/20/2023] [Accepted: 12/10/2023] [Indexed: 12/21/2023] Open
Abstract
INTRODUCTION An arteriovenous fistula (AVF) in patients with end-stage kidney disease (ESKD) can influence flow states. We sought to evaluate if assessment of aortic stenosis (AS) by transthoracic echocardiographic (TTE) differs in the presence of AVF compared to other dialysis accesses in patients on dialysis. METHODS We identified consecutive ESKD patients on dialysis and concomitant AS from a single center between January 2000 and March 2021. We analyzed TTE parameters of AS severity (velocities, gradients, aortic valve area [AVA]) and hemodynamics (cardiac output [CO], valvuloarterial impedance [Zva]) and compared AS parameters in patients with AVF versus other dialysis access. RESULTS The cohort included 94 patients with co-prevalent ESKD and AS; mean age 66 years, 71% male; 43% Black, 24% severe AS. Dialysis access: 53% AVF, 47% others. In the overall cohort, no significant differences were noted between AVF versus non-AVF in AVA/CO/Zva, but with notable subgroup differences. In mild AS, CO was significantly higher in AVF versus non-AVF (6.3 vs. 5.2 L/min; p = .04). In severe AS, Zva was higher in the AVF versus non-AVF (4.6 vs. 3.6 mm Hg/mL/m2 ). With increasing AS severity in the AVF group, CO decreased, coupled with increase in Zva, likely counterbalancing the net hemodynamic impact of the AVF. CONCLUSION Among ESKD patients with AS, TTE parameters of flow states and AS severity differed in those with AVF versus other dialysis accesses and varied with progression in severity of AS. Future longitudinal assessment of hemodynamic parameters in a larger cohort of co-prevalent ESRD and AS would be valuable.
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Affiliation(s)
- Fredrick M Ogugua
- Division of Cardiology, University of Illinois, Chicago, Illinois, USA
| | - Roy O Mathew
- Division of Cardiology, Loma Linda VA Health Care System, Loma Linda, California, USA
| | - Julien Ternacle
- Division of Cardiology, Hôpital Cardiologique Haut-Lévêque, CHU de Bordeaux, Pessac, France
- Division of Cardiology, Québec Heart and Lung Institute, Laval University, Québec City, Québec, Canada
| | - Holly Rodin
- Division of Biostatistics, Hennepin Healthcare, Minneapolis, Minnesota, USA
| | - Philippe Pibarot
- Division of Cardiology, Québec Heart and Lung Institute, Laval University, Québec City, Québec, Canada
| | - Gautam R Shroff
- Division of Biostatistics, Hennepin Healthcare, Minneapolis, Minnesota, USA
- Division of Cardiology, Department of Internal Medicine, Hennepin Healthcare, Minneapolis, Minnesota, USA
- Division of Cardiology, University of Minnesota Medical School, Minneapolis, Minnesota, USA
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Mathew RO, Rangaswami J, Abramov D, Mahalwar G, Vellanki S, Abuazzam F, Fraser GE, Butler FM, Lo KB, Herzog CA, Shroff GR, Sidhu MS, Bangalore S. Proportional troponin changes and risk for outcomes with intervention strategies in non-ST-elevation acute coronary syndrome across kidney function. Catheter Cardiovasc Interv 2023; 102:1162-1176. [PMID: 37870080 DOI: 10.1002/ccd.30863] [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: 06/21/2023] [Revised: 08/17/2023] [Accepted: 10/05/2023] [Indexed: 10/24/2023]
Abstract
AIMS This analysis evaluates whether proportional serial cardiac troponin (cTn) change predicts benefit from an early versus delayed invasive, or conservative treatment strategies across kidney function in non-ST-elevation acute coronary syndrome (NSTE-ACS). METHODS Patients diagnosed with NSTE-ACS in the Veterans Health Administration between 1999 and 2022 were categorized into terciles (<20%, 20 to ≤80%, >80%) of proportional change in serial cTn. Primary outcome included mortality or rehospitalization for myocardial infarction at 6 and 12 months, in survivors of index admission. Adjusted hazard ratio (HR) with 95% confidence Intervals (95% confidence interval [CI]) were calculated for the primary outcome for an early invasive (≤24 h of the index admission), delayed invasive (>24 h of index admission to 90-days postdischarge), or a conservative management. RESULTS Chronic kidney disease (CKD) was more prevalent (45.3%) in the lowest versus 42.2% and 43% in middle and highest terciles, respectively (p < 0.001). Primary outcome is more likely for conservative versus early invasive strategy at 6 (HR: 1.44, 95% CI: 1.37-1.50) and 12 months (HR: 1.44, 95% CI: 1.39-1.50). A >80% proportional change demonstrated HR (95% CI): 0.90 (0.83-0.97) and 0.93 (0.88-1.00; p = 0.041) for primary outcome at 6 and 12 months, respectively, when an early versus delayed invasive strategy was used, across CKD stages. CONCLUSIONS Overall, the invasive strategy was safe and associated with improved outcomes across kidney function in NSTE-ACS. Additionally, >80% proportional change in serial troponin in NSTE-ACS is associated with benefit from an early versus a delayed invasive strategy regardless of kidney function. These findings deserve confirmation in randomized controlled trials.
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Affiliation(s)
- Roy O Mathew
- Division of Nephrology, Department of Medicine, Loma Linda VA Healthcare System, Loma Linda, California, USA
- Division of Nephrology, Department of Medicine, Loma Linda University School of Medicine, Loma Linda, California, USA
| | - Janani Rangaswami
- Division of Nephrology, Department of Medicine, Washington DC VA Medical Center, Washington, District of Columbia, USA
- Department of Medicine, George Washington University School of Medicine, Washington, District of Columbia, USA
| | - Dmitry Abramov
- Division of Cardiology, Department of Medicine, Loma Linda University School of Medicine, Loma Linda, California, USA
| | - Gauranga Mahalwar
- Department of Medicine, Cleveland Clinic Foundation, Cleveland, Ohio, USA
| | - Shaitalya Vellanki
- Department of Medicine, George Washington University School of Medicine, Washington, District of Columbia, USA
| | - Farah Abuazzam
- Division of Nephrology, Department of Medicine, Loma Linda University School of Medicine, Loma Linda, California, USA
| | - Gary E Fraser
- Division of Cardiology, Department of Medicine, Loma Linda University School of Medicine, Loma Linda, California, USA
- Center for Nutrition, Healthy Lifestyle, and Disease Prevention, School of Public Health, Loma Linda University, Loma Linda, California, USA
- Adventist Health Study, Loma Linda University, Loma Linda, California, USA
- Department of Preventive Medicine, School of Medicine, Loma Linda University, Loma Linda, California, USA
| | - Fayth Miles Butler
- Center for Nutrition, Healthy Lifestyle, and Disease Prevention, School of Public Health, Loma Linda University, Loma Linda, California, USA
- Adventist Health Study, Loma Linda University, Loma Linda, California, USA
- Department of Preventive Medicine, School of Medicine, Loma Linda University, Loma Linda, California, USA
| | - Kevin Bryan Lo
- Department of Medicine, Einstein Medical Center, Philadelphia, Pennsylvania, USA
- Department of Medicine, Sydney Kimmel College of Thomas Jefferson University, Philadelphia, Pennsylvania, USA
| | - Charles A Herzog
- Cardiology Division, Department of Internal Medicine, Hennepin Healthcare, University of Minnesota, Minneapolis, Minnesota, USA
| | - Gautam R Shroff
- Cardiology Division, Department of Internal Medicine, Hennepin Healthcare, University of Minnesota, Minneapolis, Minnesota, USA
| | - Mandeep S Sidhu
- Division of Cardiology, Department of Medicine, Albany Medical College, Albany, New York, USA
| | - Sripal Bangalore
- Division of Cardiology, New York University Grossman School of Medicine, New York City, New York, USA
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Choi Y, Jacobs Jr DR, Kramer HJ, Shroff GR, Chang AR, Duprez DA. Racial Differences and Contributory Cardiovascular and Non-Cardiovascular Risk Factors Towards Chronic Kidney Disease Progression. Vasc Health Risk Manag 2023; 19:433-445. [PMID: 37465230 PMCID: PMC10350429 DOI: 10.2147/vhrm.s416395] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/24/2023] [Accepted: 07/04/2023] [Indexed: 07/20/2023] Open
Abstract
Background The prevalence of advanced chronic kidney disease (CKD) is higher in Black than in White Americans. We evaluated CKD progression in Black and White participants and the contribution of biological risk factors. We included the study of lung function (measured by forced vital capacity [FVC]), which is part of the emerging notion of interorgan cross-talk with the kidneys to racial differences in CKD progression. Methods This longitudinal study included 2175 Black and 2207 White adult Coronary Artery Risk Development in Young Adults (CARDIA) participants. Estimated glomerular filtration rate (eGFR) and urinary albumin-to-creatinine ratio (UACR) were measured at study year 10 (age 27-41y) and every five years for 20 years. The outcome was CKD progression through no CKD, low, moderate, high, or very high-risk categories based on eGFR and UACR in combination. The association between race and CKD progression as well as the contribution of risk factors to racial differences were assessed in multivariable-adjusted Cox models. Results Black participants had higher CKD transition probabilities than White participants and more prevalent risk factors during the 20-year period studied. Hazard ratios for CKD transition for Black (vs White participants) were 1.38 from No CKD into ≥ low risk, 2.25 from ≤ low risk into ≥ moderate risk, and 4.49 from ≤ moderate risk into ≥ high risk. Racial differences in CKD progression from No CKD into ≥ low risk were primarily explained by FVC (54.8%), hypertension (30.9%), and obesity (20.8%). In contrast, racial differences were less explained in more severe transitions. Conclusion Black participants had a higher risk of CKD progression, and this discrepancy may be partly explained by FVC and conventional risk factors.
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Affiliation(s)
- Yuni Choi
- Division of Epidemiology and Community Health, School of Public Health, University of Minnesota, Minneapolis, MN, USA
| | - David R Jacobs Jr
- Division of Epidemiology and Community Health, School of Public Health, University of Minnesota, Minneapolis, MN, USA
| | - Holly J Kramer
- Departments of Public Health Sciences and Medicine, Loyola University Chicago, Maywood, IL, USA
| | - Gautam R Shroff
- Division of Cardiology and Department of Medicine, Hennepin Healthcare, University of Minnesota Medical School, Minneapolis, MN, USA
| | - Alexander R Chang
- Departments of Population of Health Sciences and Nephrology, Geisinger, Danville, PA, USA
| | - Daniel A Duprez
- Cardiovascular Division, Department of Medicine, University of Minnesota, Minneapolis, MN, USA
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Zellmer L, Punjabi G, Shroff GR. Recognizing blind spots on echocardiography: Incremental benefit of cardiac CT in investigating the source of systemic embolism. Radiol Case Rep 2023; 18:2376-2377. [PMID: 37179803 PMCID: PMC10172622 DOI: 10.1016/j.radcr.2023.04.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2023] [Revised: 02/15/2023] [Accepted: 04/02/2023] [Indexed: 05/15/2023] Open
Abstract
Transesophageal echocardiography is the gold-standard for evaluating potential central sources of thromboembolism. Despite its routine use and excellent safety profile, limitations exist in the ability to effectively assess the aortic arch and proximal descending aorta with this imaging modality. We herein present a case of a 59 year-old patient presenting with renal and splenic infarcts, without obvious cardioembolic source on echocardiography, who was found to have a large, mobile aortic thrombus on gated cardiac computed tomography.
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Affiliation(s)
- Lucas Zellmer
- Department of Internal Medicine, Hennepin Healthcare, 730 S 8th St., Minneapolis, MN 55415, USA
- Corresponding author.
| | - Gopal Punjabi
- Department of Radiology, Hennepin Healthcare, 730 S 8th St., Minneapolis, MN 55415, USA
| | - Gautam R. Shroff
- Division of Cardiology, Department of Internal Medicine, University of Minnesota, 420 Delaware St. SE, Minneapolis, MN 55455, USA
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Shroff GR, Garcia S, Schmidt C, Okeson B, Tannenbaum E, Pacheco R, Smith TD, Garberich R, Sharkey S, Aguirre F, Tannenbaum M, Shivapour D, Coulson T, Henry TD. Renal impairment and mortality in patients with STEMI and cardiogenic shock/cardiac arrest. Catheter Cardiovasc Interv 2023. [PMID: 37381622 DOI: 10.1002/ccd.30753] [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] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/28/2022] [Revised: 05/14/2023] [Accepted: 06/11/2023] [Indexed: 06/30/2023]
Abstract
OBJECTIVES We sought to study the association of renal impairment (RI) with mortality in ST-segment elevation myocardial infarction (STEMI) complicated by cardiogenic shock and/or cardiac arrest (CS/CA). METHODS Patients with RI (estimated glomerular filtration rate <60 mL/min/1.73 m2 ) were identified from the Midwest STEMI consortium, a prospective registry of four large regional programs comprising consecutive patients over 17 years. Primary outcome was in-hospital and 1-year mortality stratified by RI status and presence of CS/CA among patients with STEMI referred for coronary angiography. RESULTS In a cohort of 13,463 STEMI patients, 13% (n = 1754) had CS/CA, 30% (n = 4085) had RI. Overall, in-hospital mortality was 5% (12% RI vs. 2% no-RI, p < 0.001) and 1-year mortality 9% (21% RI vs. 4% no-RI, p < 0.001). Among uncomplicated STEMI, in-hospital mortality was 2% (4% RI vs. 1% no-RI, p < 0.001) and 1-year mortality 6% (13% RI vs. 3% no-RI, p < 0.001). In STEMI with CS/CA, in-hospital mortality was 29% (43% RI vs. 15% no-RI, p < 0.001) and 1-year mortality 33% (50% RI vs. 16% no-RI, p < 0.001). Using Cox proportional hazards, RI was an independent predictor of in-hospital mortality in STEMI with CS/CA (odds ratio [OR]: 3.86; confidence interval [CI]: 2.6, 5.8). CONCLUSIONS The association of RI with in-hospital and 1-year mortality is disproportionately greater in those with CS/CA compared to uncomplicated STEMI presentations. Factors predisposing RI patients to higher risk STEMI presentations and pathways to promote earlier recognition in the chain of survival need further investigation.
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Affiliation(s)
- Gautam R Shroff
- Hennepin Healthcare and University of Minnesota Medical School, Minneapolis, Minnesota, USA
| | - Santiago Garcia
- Minneapolis Heart Institute Foundation at Abbott Northwestern Hospital, Minneapolis, Minnesota, USA
| | - Christian Schmidt
- Minneapolis Heart Institute Foundation at Abbott Northwestern Hospital, Minneapolis, Minnesota, USA
| | - Brynn Okeson
- Minneapolis Heart Institute Foundation at Abbott Northwestern Hospital, Minneapolis, Minnesota, USA
| | | | | | - Timothy D Smith
- The Carl and Edyth Lindner Center for Research and Education at The Christ Hospital, Cincinnati, Ohio, USA
| | - Ross Garberich
- Minneapolis Heart Institute Foundation at Abbott Northwestern Hospital, Minneapolis, Minnesota, USA
| | - Scott Sharkey
- Minneapolis Heart Institute Foundation at Abbott Northwestern Hospital, Minneapolis, Minnesota, USA
| | | | | | | | | | - Timothy D Henry
- The Carl and Edyth Lindner Center for Research and Education at The Christ Hospital, Cincinnati, Ohio, USA
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Mallick S, Shroff GR, Linzer M. Aspirin for primary prevention of cardiovascular disease: What do the current USPSTF guidelines say? Cleve Clin J Med 2023; 90:287-291. [PMID: 37127334 DOI: 10.3949/ccjm.90a.22087] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/03/2023]
Abstract
The 2022 US Preventive Services Task Force (USPSTF) recommendation notes that the decision to initiate daily aspirin therapy for primary prevention of cardiovascular disease (CVD) should be made on a case-by-case basis for adults ages 40 to 59 with a 10% or greater 10-year CVD risk. The recommendation applies to those without signs or symptoms of clinically evident CVD who are not at an increased risk of bleeding. Clinicians are encouraged to use their judgment in weighing the risks and benefits of aspirin therapy, while taking patient preference into account for patients ages 40 to 60.
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Affiliation(s)
| | - Gautam R Shroff
- Department of Medicine, Hennepin Healthcare, Minneapolis, MN; University of Minnesota, Minneapolis, MN
| | - Mark Linzer
- Department of Medicine, Hennepin Healthcare, Minneapolis, MN; University of Minnesota, Minneapolis, MN
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Choi Y, Jacobs DR, Kramer HJ, Shroff GR, Chang AR, Duprez DA. Nontraditional Risk Factors for Progression Through Chronic Kidney Disease Risk Categories: The Coronary Artery Risk Development in Young Adults Study. Am J Med 2023; 136:380-389.e10. [PMID: 36565799 PMCID: PMC10038875 DOI: 10.1016/j.amjmed.2022.12.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/11/2022] [Revised: 11/29/2022] [Accepted: 12/05/2022] [Indexed: 12/24/2022]
Abstract
BACKGROUND There may be nontraditional pathways of chronic kidney disease (CKD) progression that are complementary to classical pathways. Therefore, we aimed to examine nontraditional risk factors for incident CKD and its progression. METHODS We used the generally healthy population (n = 4382) starting at age 27-41 years in the Coronary Artery Risk Development in Young Adults (CARDIA) cohort, which is an observational longitudinal study. Nontraditional risk factors included forced vital capacity, inflammation, serum urate, and serum carotenoids. CKD risk category was classified using the estimated glomerular filtration rate (eGFR) and urinary albumin-to-creatinine ratio (UACR) measured in 1995-1996 and repeated every 5 years for 20 years: No CKD, low risk, moderate risk, high risk, and very high risk. RESULTS At baseline, 84.8% had no CKD (eGFR ≥60 mL/min/1.73 m2 and UACR <10 mg/g), 10.3% were in the low risk (eGFR ≥60 and UACR 10-29), and 4.9% had CKD (eGFR <60 and/or UACR ≥ 30). Nontraditional risk factors were significantly associated with the progression of CKD to higher categories. Hazard ratios per standard deviation of the predictor for incident CKD and its progression from the No CKD and low and moderate risk into CKD were inverse for forced vital capacity and serum carotenoids and positive for serum urate, GlycA, and C-reactive protein, the first 3 even after adjustment for conventional risk factors. CONCLUSION Several nontraditional markers were significantly associated with an increased risk of progression to higher CKD categories in generally healthy young to middle-aged adults.
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Affiliation(s)
- Yuni Choi
- Division of Epidemiology and Community Health, School of Public Health, University of Minnesota, Minneapolis
| | - David R Jacobs
- Division of Epidemiology and Community Health, School of Public Health, University of Minnesota, Minneapolis
| | - Holly J Kramer
- Departments of Public Health Sciences and Medicine, Loyola University Chicago, Maywood, Ill
| | - Gautam R Shroff
- Division of Cardiology and Department of Medicine, Hennepin Healthcare, University of Minnesota Medical School, Minneapolis
| | - Alexander R Chang
- Department of Population of Health Sciences, Kidney Health Research Institute, Department of Nephrology, Geisinger Medical Center, Danville, Penn
| | - Daniel A Duprez
- Cardiovascular Division, Department of Medicine, University of Minnesota, Minneapolis.
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Choi Y, Jacobs DR, Shroff GR, Kramer H, Chang AR, Duprez DA. Progression of Chronic Kidney Disease Risk Categories and Risk of Cardiovascular Disease and Total Mortality: Coronary Artery Risk Development in Young Adults Cohort. J Am Heart Assoc 2022; 11:e026685. [PMID: 36314497 PMCID: PMC9673645 DOI: 10.1161/jaha.122.026685] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [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: 12/24/2022]
Abstract
Background Previous studies of worsening chronic kidney disease (CKD) based on declining estimated glomerular filtration rate (eGFR) or increasing urine albumin-creatinine ratio (UACR) are limited to later middle-age and older adults. We examined associations of CKD progression and incident cardiovascular disease (CVD) and mortality in younger adults. Methods and Results We studied 4382 adults in CARDIA (Coronary Artery Risk Development in Young Adults) initially aged 27 to 41 years and prospectively over 20 years. Five-year transition probabilities across CKD risk categories were based on eGFR and UACR measured at each exam. Proportional hazards models predicted incident CVD and all-cause mortality by time-varying CKD risk category, adjusting for demographics and CVD risk factors. Progression of CKD risk categories over 20 years occurred in 28.7% (1256/4382) of participants, driven by increases in UACR, but including 5.8% (n=255) with eGFR<60 mL/min per 1.73 m2 or UACR ≥300 mg/g. Compared with eGFR ≥60 and UACR <10, demographic and smoking-adjusted hazard ratios for CVD were 1.62 (95% CI, 1.21-2.18) for low CKD risk (eGFR ≥60 with UACR 10-29) and 13.65 (95% CI, 7.52-24.79) for very high CKD risk (eGFR <30 or eGFR 30-44 with UACR 30-299; or eGFR 30-59 with UACR ≥300). Corresponding hazard ratios for all-cause mortality were 1.42 (95% CI, 1.08-1.88) and 14.75 (95% CI, 9.97-21.82). Although CVD associations were attenuated after adjustment for mediating CVD risk factors, all-cause mortality associations remained statistically significant. Conclusions Among young to middle-aged adults, progression to higher CKD risk category was common. Routine monitoring eGFR and UACR holds promise for prevention of CVD and total mortality.
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Affiliation(s)
- Yuni Choi
- Division of Epidemiology and Community HealthSchool of Public HealthUniversity of MinnesotaMinneapolisMN
| | - David R. Jacobs
- Division of Epidemiology and Community HealthSchool of Public HealthUniversity of MinnesotaMinneapolisMN
| | - Gautam R. Shroff
- Division of Cardiology and Department of Medicine, Hennepin HealthcareUniversity of Minnesota Medical SchoolMinneapolisMN
| | - Holly Kramer
- Departments of Public Health Sciences and MedicineLoyola University ChicagoMaywoodIL
| | - Alexander R. Chang
- Division of Nephrology, Geisinger Health ClinicKidney Health Research InstituteDanvillePA
| | - Daniel A. Duprez
- Cardiovascular Division, Department of MedicineUniversity of MinnesotaMinneapolisMN
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Sharma A, Miranda DF, Rodin H, Bart BA, Smith SW, Shroff GR. Interobserver Variability Among Experienced Electrocardiogram Readers To Diagnose Acute Thrombotic Coronary Occlusion In Patients with Out of Hospital Cardiac Arrest: Impact of Metabolic Milieu and Angiographic Culprit. Resuscitation 2022; 172:24-31. [PMID: 35041876 DOI: 10.1016/j.resuscitation.2022.01.005] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/05/2021] [Revised: 12/18/2021] [Accepted: 01/06/2022] [Indexed: 12/21/2022]
Abstract
OBJECTIVES We sought to evaluate interobserver concordance among experienced electrocardiogram (ECG) readers in predicting acute thrombotic coronary occlusion (ATCO) in the context of abnormal metabolic milieu (AMM) following resuscitated out of hospital cardiac arrest (OHCA). METHODS OHCA patients with initial shockable rhythm who underwent invasive coronary angiography (ICA) were included. AMM was defined as one of: pH < 7.1, lactate > 2 mmol/L, serum potassium < 2.8 or > 6.0 mEq/L. The initial ECG following ROSC but prior to ICA was adjudicated by 2 experienced readers using classic ST elevation myocardial infarction [STEMI] and expanded criteria and their combination to predict ATCO on ICA. RESULTS 152 consecutive patients (mean age 58 years, 76% male) met inclusion criteria. AMM was present in 77%; and 42% had ATCO on ICA. Sensitivity, specificity, PPV, NPV using classic STEMI criteria were 50%, 98%, 94%, 72% (c-statistic 0.74); whereas for combined (STEMI + expanded) criteria they were 69%, 88%, 81%, 79% respectively (c-statistic 0.79). Inter-observer agreement (kappa) was 0.7 for classic STEMI criteria, and 0.66 for combined criteria. Agreement between readers was consistently higher when ATCO was absent and with NMM (kappa 0.78), but lower in AMM (kappa 0.6). CONCLUSIONS Despite experienced ECG readers, there was only modest overall concordance in predicting ATCO in the context of resuscitated OHCA. Significant interobserver variations were noted dependent on metabolic milieu and angiographic ATCO. These observations fundamentally question the role of the 12-lead ECG as primary triaging tool for early angiography among patients with OHCA.
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Affiliation(s)
- Amit Sharma
- Regions Hospital, St. Paul, MN, United States
| | - David F Miranda
- CentraCare Heart and Vascular Center, St. Cloud, United States
| | - Holly Rodin
- Analytic Center of Excellence, Hennepin Healthcare System, HCMC, Minneapolis, MN, United States.
| | - Bradley A Bart
- Division of Cardiology, Department of Medicine, Veterans Affairs Medical Center and University of Minnesota Medical School, Minneapolis, MN, United States.
| | - Stephen W Smith
- Emergency Department, Hennepin Healthcare System, HCMC and University of Minnesota Medical School, Minneapolis, MN, United States.
| | - Gautam R Shroff
- Division of Cardiology, Department of Medicine, Hennepin Healthcare System, HCMC and University of Minnesota Medical School, Minneapolis, MN, United States.
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Shroff GR, Carlson MD, Mathew RO. Coronary Artery Disease in Chronic Kidney Disease: Need for a Heart-Kidney Team-Based Approach. Eur Cardiol 2021; 16:e48. [PMID: 34950244 PMCID: PMC8674634 DOI: 10.15420/ecr.2021.30] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/26/2021] [Accepted: 10/19/2021] [Indexed: 01/10/2023] Open
Abstract
Chronic kidney disease and coronary artery disease are co-prevalent conditions with unique epidemiological and pathophysiological features, that culminate in high rates of major adverse cardiovascular outcomes, including all-cause mortality. This review outlines a summary of the literature, and nuances pertaining to non-invasive risk assessment of this population, medical management options for coronary heart disease and coronary revascularisation. A collaborative heart-kidney team-based approach is imperative for critical management decisions for this patient population, especially coronary revascularisation; this review outlines specific periprocedural considerations pertaining to coronary revascularisation, and provides a proposed algorithm for approaching revascularisation choices in patients with end-stage kidney disease based on available literature.
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Affiliation(s)
- Gautam R Shroff
- Division of Cardiology, Department of Medicine, Hennepin Healthcare & University of Minnesota Medical School Minneapolis, MN, US
| | - Michelle D Carlson
- Division of Cardiology, Department of Medicine, Hennepin Healthcare & University of Minnesota Medical School Minneapolis, MN, US
| | - Roy O Mathew
- Division of Nephrology, Department of Medicine, Columbia VA Health Care System Columbia, SC, US
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13
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Johannsen RA, Kaltenborn ZP, Shroff GR. Saving time saves lives! A time focused evaluation of a single-view echocardiographic screening protocol for subclinical rheumatic heart disease. Int J Cardiol 2021; 351:111-114. [PMID: 34942302 DOI: 10.1016/j.ijcard.2021.12.031] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [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: 08/24/2021] [Revised: 12/10/2021] [Accepted: 12/17/2021] [Indexed: 11/05/2022]
Abstract
BACKGROUND Rheumatic heart disease affects 33 million people in low and middle income countries and is the leading cause of cardiovascular death among children and young adults. Evidence increasingly supports that simplified screening protocols can identify at risk children with good accuracy. One of the more proximal and pragmatic hurdles that has not been completely explored is the time required for executing the screening exam. METHODS We conducted an observational study comparing three different echocardiographic strategies in four separate school-based screening programs in Kenya and Cameroon. RESULTS In a sample of 911 children, we found that a single-view screening strategy can be obtained in an average time of 1.2 min/child, the two-view in an average of 2.1 min/child, and multi-view in an average of 5 min/child. CONCLUSIONS Our study demonstrates that there are significant differences in the time required to execute different screening protocols and is an essential consideration in the feasibility of large scale populations based rheumatic heart disease screening programs.
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Affiliation(s)
- Ronald A Johannsen
- Division of Cardiology, Department of Internal Medicine, Hennepin County Medical Center, 716 S 7th St, Minneapolis, MN 55415, United States of America
| | - Zachary P Kaltenborn
- Division of General Internal Medicine and Hospital Pediatrics, Department of Internal Medicine and Pediatrics, University of Minnesota Medical School, Division Mailbox - MMC 741, 420 Delaware Street SE, Minneapolis, MN 55455, United States of America.
| | - Gautam R Shroff
- Division of Cardiology, Department of Internal Medicine, Hennepin County Medical Center, 716 S 7th St, Minneapolis, MN 55415, United States of America; Department of Medicine, University of Minnesota Medical School, 420 Delaware Street SE, Minneapolis, MN 55455, United States of America
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14
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Meyers HP, Bracey A, Lee D, Lichtenheld A, Li WJ, Singer DD, Rollins Z, Kane JA, Dodd KW, Meyers KE, Shroff GR, Singer AJ, Smith SW. Ischemic ST-Segment Depression Maximal in V1-V4 (Versus V5-V6) of Any Amplitude Is Specific for Occlusion Myocardial Infarction (Versus Nonocclusive Ischemia). J Am Heart Assoc 2021; 10:e022866. [PMID: 34775811 PMCID: PMC9075358 DOI: 10.1161/jaha.121.022866] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background Occlusion myocardial infarctions (OMIs) of the posterolateral walls are commonly missed by ST-segment-elevation myocardial infarction (STEMI) criteria, with >50% of patients with circumflex occlusion not receiving emergent reperfusion and experiencing increased mortality. ST-segment depression maximal in leads V1-V4 (STDmaxV1-4) has been suggested as an indicator of posterior OMI. Methods and Results We retrospectively reviewed a high-risk population with acute coronary syndrome. OMI was defined from prior studies as a culprit lesion with TIMI (Thrombolysis in Myocardial Infarction) 0 to 2 flow or TIMI 3 flow plus peak troponin T >1.0 ng/mL or troponin I >10 ng/mL. STEMI was defined by the Fourth Universal Definition of Myocardial Infarction. ECGs were interpreted blinded to outcomes. Among 808 patients, there were 265 OMIs, 108 (41%) meeting STEMI criteria. A total of 118 (15%) patients had "suspected ischemic" STDmaxV1-4, of whom 106 (90%) had an acute culprit lesion, 99 (84%) had OMI, and 95 (81%) underwent percutaneous coronary intervention. Suspected ischemic STDmaxV1-4 had 97% specificity and 37% sensitivity for OMI. Of the 99 OMIs detected by STDmaxV1-4, 34% had <1 mm ST-segment depression, and only 47 (47%) had accompanying STEMI criteria, of which 17 (36%) were identified a median 1.00 hour earlier by STDmaxV1-4 than STEMI criteria. Despite similar infarct size, TIMI flow, and coronary interventions, patients with STEMI(-) OMI and STDmaxV1-4 were less likely than STEMI(+) patients to undergo catheterization within 90 minutes (46% versus 68%; P=0.028). Conclusions Among patients with high-risk acute coronary syndrome, the specificity of ischemic STDmaxV1-4 was 97% for OMI and 96% for OMI requiring emergent percutaneous coronary intervention. STEMI criteria missed half of OMIs detected by STDmaxV1-4. Ischemic STDmaxV1-V4 in acute coronary syndrome should be considered OMI until proven otherwise.
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Affiliation(s)
- H Pendell Meyers
- Department of Emergency Medicine Carolinas Medical Center Charlotte NC
| | - Alexander Bracey
- Department of Emergency Medicine Albany Medical Center Albany NY
| | - Daniel Lee
- Department of Emergency Medicine Hennepin County Medical Center Minneapolis MN
| | - Andrew Lichtenheld
- Department of Emergency Medicine Hennepin County Medical Center Minneapolis MN
| | - Wei J Li
- Department of Emergency Medicine Stony Brook University Hospital Stony Brook NY
| | - Daniel D Singer
- Department of Emergency Medicine Stony Brook University Hospital Stony Brook NY
| | - Zach Rollins
- William Beaumont School of Medicine Oakland University Rochester MI
| | - Jesse A Kane
- Department of Cardiology Stony Brook University Hospital Stony Brook NY
| | - Kenneth W Dodd
- Department of Emergency Medicine Advocate Christ Medical Center Oak Lawn IL
| | - Kristen E Meyers
- Department of Emergency Medicine Stony Brook University Hospital Stony Brook NY
| | - Gautam R Shroff
- Division of Cardiology Department of Medicine Hennepin County Medical Center University of Minnesota Medical School Minneapolis MN
| | - Adam J Singer
- Department of Emergency Medicine Stony Brook University Hospital Stony Brook NY
| | - Stephen W Smith
- Department of Emergency Medicine Hennepin County Medical Center Minneapolis MN.,Department of Emergency Medicine University of Minnesota Medical Center Minneapolis MN
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Zellmer L, Buda KG, Fine DG, Punjabi G, Shroff GR. A diagnostic conundrum: Role of multimodality imaging in evaluating a rare intracardiac mass. Eur Heart J Cardiovasc Imaging 2021; 23:e127. [PMID: 34632480 DOI: 10.1093/ehjci/jeab207] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [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: 09/15/2021] [Accepted: 09/21/2021] [Indexed: 11/14/2022] Open
Affiliation(s)
- Lucas Zellmer
- Department of Internal Medicine, Hennepin Healthcare, 730 S 8th St, Minneapolis, MN 55415, USA
| | - Kevin G Buda
- Department of Internal Medicine, Hennepin Healthcare, 730 S 8th St, Minneapolis, MN 55415, USA
| | - David G Fine
- Cardiology Division, Department of Internal Medicine, Hennepin Healthcare, 730 S 8th St, Minneapolis, MN 55415, USA
| | - Gopal Punjabi
- Department of Radiology, Hennepin Healthcare, 730 S 8th St, Minneapolis, MN 55415, USA
| | - Gautam R Shroff
- Cardiology Division, Department of Internal Medicine, Hennepin Healthcare, 730 S 8th St, Minneapolis, MN 55415, USA
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Garcia S, Cubeddu RJ, Hahn RT, Ternacle J, Kapadia SR, Kodali SK, Thourani VH, Jaber WA, Asher CR, Elmariah S, Makkar R, Webb JG, Herrmann HC, Lu M, Devireddy CM, Malaisrie SC, Smith CR, Mack MJ, Sorajja P, Cavalcante JL, Goessl M, Shroff GR, Leon MB, Pibarot P. 5-Year Outcomes Comparing Surgical Versus Transcatheter Aortic Valve Replacement in Patients With Chronic Kidney Disease. JACC Cardiovasc Interv 2021; 14:1995-2005. [PMID: 34556273 DOI: 10.1016/j.jcin.2021.07.004] [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] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/06/2021] [Revised: 06/14/2021] [Accepted: 07/06/2021] [Indexed: 11/16/2022]
Abstract
OBJECTIVES The aim of this study was to compare 5-year cardiovascular, renal, and bioprosthetic valve durability outcomes in patients with severe aortic stenosis (AS) and chronic kidney disease (CKD) undergoing transcatheter aortic valve replacement (TAVR) or surgical aortic valve replacement (SAVR). BACKGROUND Patients with severe AS and CKD undergoing TAVR or SAVR are a challenging, understudied clinical subset. METHODS Intermediate-risk patients with moderate to severe CKD (estimated glomerular filtration rate <60 mL/min/m2) from the PARTNER (Placement of Aortic Transcatheter Valve) 2A trial (patients randomly assigned to SAPIEN XT TAVR or SAVR) and SAPIEN 3 Intermediate Risk Registry were pooled. The composite primary outcome of death, stroke, rehospitalization, and new hemodialysis was evaluated using Cox regression analysis. Patients with and without perioperative acute kidney injury (AKI) were followed through 5 years. A core laboratory-adjudicated analysis of structural valve deterioration and bioprosthetic valve failure was also performed. RESULTS The study population included 1,045 TAVR patients (512 SAPIEN XT, 533 SAPIEN 3) and 479 SAVR patients. At 5 years, SAVR was better than SAPIEN XT TAVR (52.8% vs 68.0%; P = 0.04) but similar to SAPIEN 3 TAVR (52.8% vs 58.7%; P = 0.89). Perioperative AKI was more common after SAVR than TAVR (26.3% vs 10.3%; P < 0.001) and was independently associated with long-term outcomes. Compared with SAVR, bioprosthetic valve failure and stage 2 or 3 structural valve deterioration were significantly greater for SAPIEN XT TAVR (P < 0.05) but not for SAPIEN 3 TAVR. CONCLUSIONS In intermediate-risk patients with AS and CKD, SAPIEN 3 TAVR and SAVR were associated with a similar risk for the primary endpoint at 5 years. AKI was more common after SAVR than TAVR, and SAPIEN 3 valve durability was comparable with that of surgical bioprostheses.
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Affiliation(s)
- Santiago Garcia
- Minneapolis Heart Institute, Abbott Northwestern Hospital, Minneapolis, Minnesota, USA; Valve Science Center, Minneapolis Heart Institute Foundation, Minneapolis, Minnesota, USA.
| | | | - Rebecca T Hahn
- Cardiovascular Research Foundation, New York, New York, USA; Division of Cardiology, Columbia University Medical Center/NewYork-Presbyterian Hospital, New York, New York, USA
| | - Julien Ternacle
- Institut Universitaire de Cardiologie et de Pneumologie de Québec/Québec Heart & Lung Institute, Laval University, Québec, Québec, Canada
| | - Samir R Kapadia
- Department of Cardiovascular Medicine, Heart, Vascular, and Thoracic Institute, Cleveland Clinic, Cleveland, Ohio, USA
| | - Susheel K Kodali
- Division of Cardiology, Columbia University Medical Center/NewYork-Presbyterian Hospital, New York, New York, USA
| | - Vinod H Thourani
- Department of Cardiovascular Surgery, Marcus Heart and Vascular Center, Piedmont Heart and Vascular Institute, Atlanta, Georgia, USA
| | - Wael A Jaber
- Heart and Vascular Institute, Cleveland Clinic, Cleveland, Ohio, USA
| | - Craig R Asher
- Department of Cardiovascular Medicine, Heart and Vascular Institute, Cleveland Clinic Weston, Weston, Florida, USA
| | - Sammy Elmariah
- Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Raj Makkar
- Cedars-Sinai Heart Institute, Los Angeles, California, USA
| | - John G Webb
- St. Paul's Hospital, Vancouver, British Columbia, Canada
| | - Howard C Herrmann
- Department of Cardiology, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Michael Lu
- Edwards Lifesciences, Irvine, California, USA
| | - Chandan M Devireddy
- Department of Cardiology, Emory University School of Medicine, Atlanta, Georgia, USA
| | - S Chris Malaisrie
- Department of Cardiac Surgery, Northwestern University Feinberg School of Medicine and Northwestern Memorial Hospital, Chicago, Illinois, USA
| | - Craig R Smith
- Cardiovascular Research Foundation, New York, New York, USA; Division of Cardiology, Columbia University Medical Center/NewYork-Presbyterian Hospital, New York, New York, USA
| | - Michael J Mack
- Department of Cardiothoracic Surgery, Baylor Scott & White Health, Plano, Texas, USA
| | - Paul Sorajja
- Minneapolis Heart Institute, Abbott Northwestern Hospital, Minneapolis, Minnesota, USA; Valve Science Center, Minneapolis Heart Institute Foundation, Minneapolis, Minnesota, USA
| | - João L Cavalcante
- Minneapolis Heart Institute, Abbott Northwestern Hospital, Minneapolis, Minnesota, USA; Valve Science Center, Minneapolis Heart Institute Foundation, Minneapolis, Minnesota, USA
| | - Mario Goessl
- Minneapolis Heart Institute, Abbott Northwestern Hospital, Minneapolis, Minnesota, USA; Valve Science Center, Minneapolis Heart Institute Foundation, Minneapolis, Minnesota, USA
| | - Gautam R Shroff
- Hennepin Healthcare and University of Minnesota Medical School, Minneapolis, Minnesota, USA
| | - Martin B Leon
- Cardiovascular Research Foundation, New York, New York, USA; Division of Cardiology, Columbia University Medical Center/NewYork-Presbyterian Hospital, New York, New York, USA
| | - Philippe Pibarot
- Institut Universitaire de Cardiologie et de Pneumologie de Québec/Québec Heart & Lung Institute, Laval University, Québec, Québec, Canada
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Ogugua F, Herzog CA, Sahadevan M, Davies S, Shroff GR. An indolent cause of high-output heart failure in end-stage kidney disease-Application of the Nicoladoni-Israel-Branham test: A case report. Echocardiography 2021; 38:1817-1820. [PMID: 34510536 DOI: 10.1111/echo.15195] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/21/2021] [Revised: 08/15/2021] [Accepted: 08/22/2021] [Indexed: 12/01/2022] Open
Abstract
BACKGROUND A hemodynamically significant arteriovenous fistula (AVF) in end-stage kidney disease (ESKD) causes a high flow state, resulting in pathologic cardiovascular remodeling, and deserves timely clinical recognition. CASE A 55-year-old woman with history of ESKD with deceased donor kidney transplant with failing graft function and baseline creatinine of 2.8 mg/dl presented to the clinic with nocturnal cough, orthopnea, dyspnea on exertion and pedal edema. Physical exam was notable for large, aneurysmal right brachial AVF. Transthoracic echocardiography (TTE) revealed left ventricular (LV) enlargement and hypertrophy and elevated cardiac output (CO) of 10 L/min, raising a clinical concern for high-output heart failure. DECISION MAKING A non-invasive assessment of the hemodynamic significance of the AVF was performed using a TTE. During temporary occlusion of the AVF, it was determined that about 27% of the resting CO was attributed to the AVF, suggesting hemodynamic significance. Nicoladoni-Israel-Branham sign was negative as there was no change in patient's heart rate, but this was potentially attributed to beta-blockade and chronic loading conditions. She underwent AVF banding and 2-month later her presenting symptoms resolved, and a TTE showed a decrease in resting CO of 7.6 L/min with normalization of LV size. CONCLUSION This case highlights several teaching points. Firstly, in patients with ESKD, a large AVF can contribute to a high CO state resulting in maladaptive cardiovascular remodeling. Secondly, TTE evaluation of the hemodynamic contribution of an AVF can be performed with the application of the Nicoladoni-Israel-Branham sign. Finally, some experts recommend pre-emptive banding or ligation of AVF after successful kidney transplantation as this has been shown to have symptomatic and cardiovascular benefits.
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Affiliation(s)
- Fredrick Ogugua
- Department of Medicine, Hennepin Healthcare, Minneapolis, Minnesota, USA
| | - Charles A Herzog
- Department of Medicine, Hennepin Healthcare, Minneapolis, Minnesota, USA
| | - Meena Sahadevan
- Department of Medicine, Hennepin Healthcare, Minneapolis, Minnesota, USA
| | - Scott Davies
- Department of Medicine, Hennepin Healthcare, Minneapolis, Minnesota, USA
| | - Gautam R Shroff
- Department of Medicine, Hennepin Healthcare, Minneapolis, Minnesota, USA
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18
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Shroff GR, Henry TD. Percutaneous coronary intervention in end-stage kidney disease: Trapped between a rock and a hard place. Catheter Cardiovasc Interv 2021; 98:215-216. [PMID: 34369057 DOI: 10.1002/ccd.29846] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [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: 06/11/2021] [Accepted: 06/14/2021] [Indexed: 11/05/2022]
Affiliation(s)
- Gautam R Shroff
- Division of Cardiology, Department of Internal Medicine, Hennepin Healthcare and University of Minnesota Medical School, Minneapolis, Minnesota, USA
| | - Timothy D Henry
- The Carl and Edyth Lindner Center for Research and Education at The Christ Hospital, Cincinnati, Ohio, USA
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19
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Choi Y, Steffen LM, Chu H, Duprez DA, Gallaher DD, Shikany JM, Schreiner PJ, Shroff GR, Jacobs DR. A Plant-Centered Diet and Markers of Early Chronic Kidney Disease during Young to Middle Adulthood: Findings from the Coronary Artery Risk Development in Young Adults (CARDIA) Cohort. J Nutr 2021; 151:2721-2730. [PMID: 34087933 PMCID: PMC8417917 DOI: 10.1093/jn/nxab155] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [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: 03/27/2021] [Revised: 04/13/2021] [Accepted: 04/28/2021] [Indexed: 12/13/2022] Open
Abstract
BACKGROUND Few studies have evaluated whether plant-centered diets prevent progression of early stage chronic kidney disease (CKD). OBJECTIVES We examined the association between plant-centered diet quality and early CKD markers. METHODS We prospectively examined 2869 black and white men and women in the Coronary Artery Risk Development in Young Adults Study free of diagnosed kidney failure in 2005-2006 [examination year 20 (Y20); mean age: 45.3 ± 3.6 y]. CKD marker changes from Y20 to 2015-2016 (Y30) were considered, including estimated glomerular filtration rate (eGFR; serum creatinine), urinary albumin-to-creatinine ratio (ACR), and both. Diet was assessed through interviewer-administered diet histories at Y0, Y7, and Y20, and plant-centered diet quality was quantified with the A Priori Diet Quality Score (APDQS). Linear regression models were used to examine the association of APDQS and subsequent 10-y changes in CKD markers. RESULTS After adjustment for sociodemographic, behavioral, and diet factors, we found that higher APDQS was related to less adverse changes in CKD markers in the subsequent 10-y period. Compared with the lowest APDQS quintile, the highest quintile was associated with an attenuated increase in lnACR (-0.25 mg/g; 95% CI: -0.37, -0.13 mg/g; P-trend < 0.001), whereas the highest quintile was associated with an attenuated decrease in eGFR (4.45 mL·min-1·1.73 m-2; 95% CI: 2.46, 6.43 mL·min-1·1.73 m-2). There was a 0.50 lower increase in combined CKD markers [ln(ACR) z score - eGFR z score] when comparing the extreme quintiles. Associations remained similar after further adjustment for hypertension, diabetes, and obesity as potential mediating factors. The attenuated worsening CKD marker changes associated with higher APDQS strengthened across increasing initial CKD category; those with the best diet and microalbuminuria in Y10-Y20 returned to high normal albuminuria (all P-interaction < 0.001). CONCLUSIONS Individuals who consumed plant-centered, high-quality diets were less likely to experience deterioration of kidney function through midlife, especially among participants with initial stage characterized as mild CKD.
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Affiliation(s)
- Yuni Choi
- Department of Food Science and Nutrition, University of Minnesota–Twin Cities, St. Paul, MN, USA
| | - Lyn M Steffen
- Division of Epidemiology and Community Health, University of Minnesota–Twin Cities, Minneapolis, MN, USA
| | - Haitao Chu
- Division of Biostatistics, University of Minnesota–Twin Cities, Minneapolis, MN, USA
| | - Daniel A Duprez
- Cardiovascular Division, Department of Medicine, University of Minnesota–Twin Cities, Minneapolis, MN, USA
| | - Daniel D Gallaher
- Department of Food Science and Nutrition, University of Minnesota–Twin Cities, St. Paul, MN, USA
| | - James M Shikany
- Division of Preventive Medicine, School of Medicine, University of Alabama at Birmingham, Birmingham, AL, USA
| | - Pamela J Schreiner
- Division of Epidemiology and Community Health, University of Minnesota–Twin Cities, Minneapolis, MN, USA
| | - Gautam R Shroff
- Division of Cardiology, Department of Medicine, Hennepin Healthcare and University of Minnesota–Twin Cities, Minneapolis, MN, USA
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Shroff GR, Bangalore S, Bhave NM, Chang TI, Garcia S, Mathew RO, Rangaswami J, Ternacle J, Thourani VH, Pibarot P. Evaluation and Management of Aortic Stenosis in Chronic Kidney Disease: A Scientific Statement From the American Heart Association. Circulation 2021; 143:e1088-e1114. [PMID: 33980041 DOI: 10.1161/cir.0000000000000979] [Citation(s) in RCA: 28] [Impact Index Per Article: 9.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Aortic stenosis with concomitant chronic kidney disease (CKD) represents a clinical challenge. Aortic stenosis is more prevalent and progresses more rapidly and unpredictably in CKD, and the presence of CKD is associated with worse short-term and long-term outcomes after aortic valve replacement. Because patients with advanced CKD and end-stage kidney disease have been excluded from randomized trials, clinicians need to make complex management decisions in this population that are based on retrospective and observational evidence. This statement summarizes the epidemiological and pathophysiological characteristics of aortic stenosis in the context of CKD, evaluates the nuances and prognostic information provided by noninvasive cardiovascular imaging with echocardiography and advanced imaging techniques, and outlines the special risks in this population. Furthermore, this statement provides a critical review of the existing literature pertaining to clinical outcomes of surgical versus transcatheter aortic valve replacement in this high-risk population to help guide clinical decision making in the choice of aortic valve replacement and specific prosthesis. Finally, this statement provides an approach to the perioperative management of these patients, with special attention to a multidisciplinary heart-kidney collaborative team-based approach.
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21
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Shroff GR, Schmidt C, Tannenbaum E, Pacheco R, Smith TD, Garberich R, Sharkey S, Aguirre F, Tannenbaum M, Shivapour D, Coulson T, Henry T, Garcia S. CHRONIC KIDNEY DISEASE AND MORTALITY IN UNCOMPLICATED VS COMPLICATED STEMI. J Am Coll Cardiol 2021. [DOI: 10.1016/s0735-1097(21)01414-5] [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: 10/21/2022]
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22
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Shroff GR, Rodin H, Mohandas A, Vickery KD. CONGESTIVE HEART FAILURE IN A SAFETY NET COMMUNITY HOSPITAL - THE IMPORTANCE OF SOCIAL DETERMINANTS OF HEALTH. J Am Coll Cardiol 2021. [DOI: 10.1016/s0735-1097(21)02053-2] [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: 10/21/2022]
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Shroff GR, Pacheco R, Shivapour D, Smith TD, Schmidt C, Tannenbaum E, Garberich R, Sharkey S, Aguirre F, Chambers J, Tannenbaum M, Henry T, Garcia S. PREVALENCE OF CHRONIC KIDNEY DISEASE IN COMPLICATED VS. UNCOMPLICATED STEMI. J Am Coll Cardiol 2021. [DOI: 10.1016/s0735-1097(21)01453-4] [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: 11/16/2022]
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Pendell Meyers H, Bracey A, Lee D, Lichtenheld A, Li WJ, Singer DD, Rollins Z, Kane JA, Dodd KW, Meyers KE, Shroff GR, Singer AJ, Smith SW. Accuracy of OMI ECG findings versus STEMI criteria for diagnosis of acute coronary occlusion myocardial infarction. Int J Cardiol Heart Vasc 2021; 33:100767. [PMID: 33912650 PMCID: PMC8065286 DOI: 10.1016/j.ijcha.2021.100767] [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] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/28/2020] [Revised: 03/05/2021] [Accepted: 03/16/2021] [Indexed: 01/17/2023]
Abstract
OBJECTIVE In the STEMI paradigm of Acute Myocardial Infarction (AMI), many NSTEMI patients have unrecognized acute coronary occlusion MI (OMI), may not receive emergent reperfusion, and have higher mortality than NSTEMI patients without occlusion. We have proposed a new OMI vs. Non-Occlusion MI (NOMI) paradigm shift. We sought to compare the diagnostic accuracy of OMI ECG findings vs. formal STEMI criteria for the diagnosis of OMI. We hypothesized that blinded interpretation for predefined OMI ECG findings would be more accurate than STEMI criteria for the diagnosis of OMI. METHODS We performed a retrospective case-control study of patients with suspected acute coronary syndrome. The primary definition of OMI was either 1) acute TIMI 0-2 flow culprit or 2) TIMI 3 flow culprit with peak troponin T ≥ 1.0 ng/mL or I ≥ 10.0 ng/mL. RESULTS 808 patients were included, of whom 49% had AMI (33% OMI; 16% NOMI). Sensitivity, specificity, and accuracy of STEMI criteria vs Interpreter 1 using OMI ECG findings among 808 patients were 41% vs 86%, 94% vs 91%, and 77% vs 89%, and for Interpreter 2 among 250 patients were 36% vs 80%, 91% vs 92%, and 76% vs 89%. STEMI(-) OMI patients had similar infarct size and mortality as STEMI(+) OMI patients, but greater delays to angiography. CONCLUSIONS Blinded interpretation using predefined OMI ECG findings was superior to STEMI criteria for the ECG diagnosis of Occlusion MI. These data support further investigation into the OMI vs. NOMI paradigm and suggest that STEMI(-) OMI patients could be identified rapidly and noninvasively for emergent reperfusion using more accurate ECG interpretation.
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Key Words
- ACS, Acute coronary syndrome
- AMI, acute myocardial infarction
- Acute coronary syndromes
- ECG, Electrocardiogram
- ED, Emergency department
- Electrocardiography
- LBBB, Left Bundle Branch Block
- MIRO, Myocardial Infarction Ruled Out
- MSC, Modified Sgarbossa Criteria
- NOMI, Non-occlusion myocardial infarction
- NSTEMI, Non-ST-segment elevation myocardial infarction
- OMI, Occlusion myocardial infarction
- Occlusion myocardial infarction
- ST elevation myocardial infarction
- STD, ST-segment depression
- STE, ST-segment elevation
- STEMI, ST-segment elevation myocardial infarction
- VPR, Ventricular Paced Rhythm
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Affiliation(s)
- H. Pendell Meyers
- Department of Emergency Medicine, Stony Brook University Hospital, Stony Brook, NY, USA
- Department of Emergency Medicine, Carolinas Medical Center, Charlotte, NC, USA
| | - Alexander Bracey
- Department of Emergency Medicine, Stony Brook University Hospital, Stony Brook, NY, USA
- Department of Emergency Medicine, Albany Medical Center, Albany NY, USA
| | - Daniel Lee
- Department of Emergency Medicine, Hennepin County Medical Center, Minneapolis, MN, USA
| | - Andrew Lichtenheld
- Department of Emergency Medicine, Hennepin County Medical Center, Minneapolis, MN, USA
| | - Wei J. Li
- Department of Emergency Medicine, Stony Brook University Hospital, Stony Brook, NY, USA
| | - Daniel D. Singer
- Department of Emergency Medicine, Stony Brook University Hospital, Stony Brook, NY, USA
| | - Zach Rollins
- William Beaumont School of Medicine, Oakland University, Rochester, MI, USA
| | - Jesse A. Kane
- Department of Cardiology, Stony Brook University Hospital, Stony Brook, NY, USA
| | - Kenneth W. Dodd
- Department of Emergency Medicine, Hennepin County Medical Center, Minneapolis, MN, USA
- Department of Medicine, Hennepin County Medical Center, Minneapolis, MN, USA
| | - Kristen E. Meyers
- Department of Emergency Medicine, Stony Brook University Hospital, Stony Brook, NY, USA
| | - Gautam R. Shroff
- Division of Cardiology, Department of Medicine, Hennepin County Medical Center, University of Minnesota Medical School, Minneapolis, MN, USA
| | - Adam J. Singer
- Department of Emergency Medicine, Stony Brook University Hospital, Stony Brook, NY, USA
| | - Stephen W. Smith
- Department of Emergency Medicine, Hennepin County Medical Center, Minneapolis, MN, USA
- Department of Emergency Medicine, University of Minnesota Medical Center, Minneapolis, MN, USA
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Meyers HP, Bracey A, Lee D, Lichtenheld A, Li WJ, Singer DD, Kane JA, Dodd KW, Meyers KE, Thode HC, Shroff GR, Singer AJ, Smith SW. Comparison of the ST-Elevation Myocardial Infarction (STEMI) vs. NSTEMI and Occlusion MI (OMI) vs. NOMI Paradigms of Acute MI. J Emerg Med 2021; 60:273-284. [DOI: 10.1016/j.jemermed.2020.10.026] [Citation(s) in RCA: 30] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/05/2020] [Revised: 09/30/2020] [Accepted: 10/07/2020] [Indexed: 01/09/2023]
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Sharma A, Miranda DF, Rodin H, Bart BA, Smith SW, Shroff GR. Do not disregard the initial 12 lead ECG after out-of-hospital cardiac arrest: It predicts angiographic culprit despite metabolic abnormalities. Resusc Plus 2020; 4:100032. [PMID: 34223310 PMCID: PMC8244459 DOI: 10.1016/j.resplu.2020.100032] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/07/2020] [Revised: 08/19/2020] [Accepted: 09/18/2020] [Indexed: 01/14/2023] Open
Abstract
Objectives The initial 12 lead electrocardiogram (ECG) following return of spontaneous circulation (ROSC) after out-of-hospital cardiac arrest (OHCA), is often disregarded by clinicians in ability to predict acute thrombotic coronary occlusion (ATCO) due to markedly abnormal metabolic milieu (AMM). We sought to evaluate the accuracy of initial vs. follow-up ECG prior to invasive coronary angiography (ICA) to predict ATCO following resuscitated OHCA. Methods We included OHCA patients with initial shockable rhythm who underwent invasive coronary angiography (ICA). AMM was defined as one of: pH < 7.1, lactate >2 mmol/L, serum potassium <2.8 or >6.0 mEq/L. Two ECGs A (initial) and B (follow-up) following ROSC but prior to ICA were adjudicated by 2 experienced readers using expanded ECG criteria to predict angiographic ATCO on ICA. Results 152 consecutive patients (mean age 58 years, 75% male) met inclusion criteria, 77% had AMM. Among those with both ECGs (n = 102), overall accuracy, sensitivity, specificity, positive predictive value, negative predictive value for correctly predicting angiographic ATCO for ECG A was 72%, 63%, 81%, 61%, 83% and for ECG B was 71%, 50%, 91%, 73%, 80% respectively. Predictive accuracy for angiographic ATCO was similar between ECG A [odds ratio (OR) 7.31, CI 2.87–18.62, p < 0.0001) and ECG B [OR 10.67; CI 3.6–31.61, p < 0.0001], and consistent in AMM. Conclusions In OHCA, despite AMM, the initial post ROSC ECG retains a statistically significant, and similar accuracy as the follow-up ECG to predict angiographic ATCO using expanded criteria.
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Affiliation(s)
- Amit Sharma
- Division of Cardiology, Department of Medicine, Hennepin Healthcare System, HCMC, Minneapolis, MN, USA.,Regions Hospital, St. Paul, MN, USA
| | - David F Miranda
- Division of Cardiology, Department of Medicine, Hennepin Healthcare System, HCMC, Minneapolis, MN, USA.,CentraCare Heart and Vascular Center, St. Cloud, MN, USA
| | - Holly Rodin
- Analytic Center of Excellence, Hennepin Healthcare System, HCMC, Minneapolis, MN, USA
| | - Bradley A Bart
- Division of Cardiology, Department of Medicine, Hennepin Healthcare System, HCMC and University of Minnesota Medical School, Minneapolis, MN, USA.,Veterans Affairs Medical Center, Minneapolis, MN, USA
| | - Stephen W Smith
- Emergency Department, Hennepin Healthcare System, HCMC and University of Minnesota Medical School, Minneapolis, MN, USA
| | - Gautam R Shroff
- Division of Cardiology, Department of Medicine, Hennepin Healthcare System, HCMC and University of Minnesota Medical School, Minneapolis, MN, USA
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Shroff GR, Sanchez OA, Miedema MD, Kramer H, Ix JH, Duprez DA, Jacobs DR. Coronary artery calcium progresses rapidly and discriminates incident cardiovascular events in chronic kidney disease regardless of diabetes: The Multi-Ethnic Study of Atherosclerosis (MESA). Atherosclerosis 2020; 310:75-82. [PMID: 32919188 PMCID: PMC10838623 DOI: 10.1016/j.atherosclerosis.2020.07.026] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/11/2020] [Revised: 07/05/2020] [Accepted: 07/28/2020] [Indexed: 11/29/2022]
Abstract
BACKGROUND AND AIMS Chronic kidney disease (CKD) is associated with high prevalence of cardiovascular disease (CVD) events. We sought to assess the prognostic utility of coronary artery calcium (CAC) scores in discriminating incident CVD events among subpopulations of CKD, particularly those without diabetes mellitus (DM). METHODS Using the Multi-Ethnic Study of Atherosclerosis, we identified 4 groups based on present/absent CKD/diabetes (CKD-/DM-, n = 5308; CKD-/DM+, n = 586, CKD+/DM-, n = 620; CKD+/DM+, n = 266). Baseline and follow-up CAC (Agatston units) measurements, and association between CAC and incident CVD events in median follow-up of 13 years were evaluated using proportional hazards regression adjusting for demographics, clinical, biomarker variables. RESULTS Prevalence of CKD and DM in the cohort was 13% and 12.5% respectively. Annual progression in adjusted median CAC score was 24.8%, 27.9%, 26.7%, 36.8% and unadjusted cumulative incident CVD rates were 12.6%, 22.3%, 23.1%, 39.8% for CKD-/DM-, CKD-/DM+, CKD+/DM-, CKD+/DM+, respectively. After full adjustment (CKD-/DM-referent), hazard ratios (HR, 95% CI) for incident CVD events were 1.25 (1.01-1.53) CKD-/DM+, 1.10 (0.90-1.33) CKD+/DM- and 2.18 (1.73-2.76) CKD+/DM+. Using CKD-/DM-/baseline CAC = 0 referent, adjusted HRs (95% CI) for incident CVD in CKD+/DM- were 1.30 (0.81-2.07), 2.05 (1.4-2.99), and 4.15 (2.94-5.86) for baseline CAC = 0, 1-100, and >300 Agatston units respectively while for CKD+/DM+, adjusted HRs were 3.15 (2.04-4.86), 3.56 (2.26-5.62), 7.90 (5.35-11.67), respectively. CONCLUSIONS CAC provides incremental prognostic information to predict incident CVD events in CKD regardless of DM. Moreover, baseline CAC categories discriminate incident CVD among CKD without DM, which may have implications in individualizing approach to primary prevention in this high-risk population.
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Affiliation(s)
- Gautam R Shroff
- Division of Cardiology and Department of Medicine, Hennepin Healthcare, University of Minnesota Medical School, Minneapolis, MN, USA.
| | - Otto A Sanchez
- School of Kinesiology, Division of Exercise Physiology, University of Minnesota, Minneapolis, MN, USA
| | - Michael D Miedema
- Minneapolis Heart Institute Foundation, Minneapolis Heart Institute, Minneapolis, MN, USA
| | - Holly Kramer
- Department of Public Health Sciences, Loyola University Chicago Stritch School of Medicine, Maywood, IL, USA; Department of Medicine, Loyola University Chicago Stritch School of Medicine, Maywood, IL, USA; Hines VA Medical Center, Hines, IL, USA
| | - Joachim H Ix
- Division of Nephrology and Hypertension, Department of Medicine, University of California San Diego, San Diego, CA, USA
| | - Daniel A Duprez
- Division of Cardiology, Department of Medicine, University of Minnesota Medical School, Minneapolis, MN, USA
| | - David R Jacobs
- Division of Epidemiology & Community Health, School of Public Health, University of Minnesota, Minneapolis, MN, USA
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Abstract
Patients with advanced chronic kidney disease have an enormous burden of cardiovascular morbidity and mortality, but, paradoxically, their representation in randomized trials for the evaluation and management of coronary artery disease has been limited. Clinicians therefore are faced with the conundrum of synergizing evidence from observational studies, expert opinion, and extrapolation from the general population to provide care to this complex and clinically distinct patient population. In this review, we address clinical risk stratification of patients with chronic kidney disease and end-stage kidney disease using traditional cardiovascular risk factors, noninvasive functional and structural cardiac imaging, invasive coronary angiography, and cardiovascular biomarkers. We highlight the unique characteristics of this population, including the high competing risk of all-cause mortality relative to the risk of major adverse cardiac events, likely owing to important contributions from nonatherosclerotic mechanisms. We further discuss the management of coronary artery disease in patients with chronic kidney disease and end-stage kidney disease, including evidence pertaining to medical management, coronary revascularization with percutaneous coronary intervention, and coronary artery bypass grafting. Our discussion includes considerations of drug-eluting versus bare metal stents for percutaneous coronary intervention and off-pump versus on-pump coronary artery bypass graft surgery. Finally, we address currently ongoing randomized trials, from which clinicians are optimistic about receiving guidance regarding the best strategies to incorporate into their practice for the evaluation and management of coronary artery disease in this high-risk population.
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Affiliation(s)
- Gautam R Shroff
- Division of Cardiology, Department of Medicine, Hennepin County Medical Center, University of Minnesota School of Medicine, Minneapolis, Minnesota.
| | - Tara I Chang
- Division of Nephrology, Stanford University School of Medicine, Palo Alto, California
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29
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Shroff GR, Raggi P. Exploring the elusive link between subclinical fibrosis and clinical events in end-stage renal disease: does cardiac magnetic resonance imaging hold the key? Kidney Int 2019; 90:729-32. [PMID: 27633865 DOI: 10.1016/j.kint.2016.07.020] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2016] [Revised: 07/15/2016] [Accepted: 07/15/2016] [Indexed: 10/21/2022]
Abstract
Extensive myocardial fibrosis is known to occur in patients undergoing dialysis due to a variety of mechanisms not necessarily restricted to coronary artery disease. Fibrosis may predispose to reentry arrhythmias and long-term myocardial dysfunction, and sudden death and congestive heart failure are the most frequent causes of death in patients undergoing renal replacement therapy. Despite the high accuracy of magnetic resonance for imaging of myocardial fibrosis, its use has been restricted by the risk of inducing nephrogenic systemic sclerosis with the injection of gadolinium. The development of new sequences that allow the detection and quantifying of the severity of extracellular myocardial fibrosis offers a chance to study the pathogenesis of this condition and identify potential interventions to retard or reverse it. Whether these will lead to an improved outcome needs to be prospectively tested.
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Affiliation(s)
- Gautam R Shroff
- Division of Cardiology, Department of Medicine, Hennepin County Medical Center and University of Minnesota, Minneapolis, Minnesota, USA
| | - Paolo Raggi
- Mazankowski Alberta Heart Institute, University of Alberta, Edmonton, Alberta, Canada.
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30
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Affiliation(s)
- Gautam R Shroff
- Division of Cardiology, Department of Internal Medicine, Hennepin County Medical Center, University of Minnesota Medical School, Minneapolis
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31
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Turakhia MP, Blankestijn PJ, Carrero JJ, Clase CM, Deo R, Herzog CA, Kasner SE, Passman RS, Pecoits-Filho R, Reinecke H, Shroff GR, Zareba W, Cheung M, Wheeler DC, Winkelmayer WC, Wanner C. Chronic kidney disease and arrhythmias: conclusions from a Kidney Disease: Improving Global Outcomes (KDIGO) Controversies Conference. Eur Heart J 2018; 39:2314-2325. [PMID: 29522134 PMCID: PMC6012907 DOI: 10.1093/eurheartj/ehy060] [Citation(s) in RCA: 151] [Impact Index Per Article: 25.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/13/2017] [Revised: 12/18/2017] [Accepted: 01/27/2018] [Indexed: 12/15/2022] Open
MESH Headings
- Arrhythmias, Cardiac/epidemiology
- Arrhythmias, Cardiac/therapy
- Atrial Fibrillation/complications
- Atrial Fibrillation/drug therapy
- Atrial Fibrillation/epidemiology
- Death, Sudden, Cardiac/prevention & control
- Defibrillators, Implantable
- Humans
- Hyperkalemia/epidemiology
- Hyperkalemia/metabolism
- Hypokalemia/epidemiology
- Hypokalemia/metabolism
- Inflammation
- Kidney Failure, Chronic/epidemiology
- Kidney Failure, Chronic/metabolism
- Kidney Failure, Chronic/therapy
- Oxidative Stress
- Potassium/metabolism
- Renal Dialysis
- Renal Insufficiency, Chronic/epidemiology
- Renal Insufficiency, Chronic/metabolism
- Renal Insufficiency, Chronic/therapy
- Risk Factors
- Stroke/etiology
- Stroke/prevention & control
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Affiliation(s)
- Mintu P Turakhia
- Stanford University School of Medicine, Veterans Affairs Palo Alto Health Care System, Miranda Ave, Palo Alto, CA, USA
| | - Peter J Blankestijn
- Department of Nephrology, room F03.220, University Medical Center, Utrecht, The Netherlands
| | - Juan-Jesus Carrero
- Department of Medical Epidemiology and Biostatistics, Karolinska Institutet, Nobels väg 12A, Stockholm, Sweden
| | - Catherine M Clase
- Department of Medicine and Department of Health Research Methods, Evidence, and Impact, McMaster University, St. Joseph’s Healthcare, Marian Wing, 3rd Floor, M333, 50 Charlton Ave. E, Hamilton, Ontario, Canada
| | - Rajat Deo
- Section of Electrophysiology, Division of Cardiovascular Medicine, Perelman School of Medicine at the University of Pennsylvania, 3400 Spruce Street, 9 Founders Cardiology, Philadelphia, PA, USA
| | - Charles A Herzog
- Division of Cardiology, Department of Medicine, Hennepin County Medical Center and University of Minnesota, Minneapolis, Minnesota and Chronic Disease Research Group, Minneapolis Medical Research Foundation, 914 S. 8th Street, S4.100, Minneapolis, MN, USA
| | - Scott E Kasner
- Department of Neurology, 3W Gates Bldg. Hospital of the University of Pennsylvania, 3400 Spruce St., Philadelphia, PA, USA
| | - Rod S Passman
- Northwestern University Feinberg School of Medicine and the Bluhm Cardiovascular Institute, 201 E. Huron St. Chicago, IL, USA
| | - Roberto Pecoits-Filho
- School of Medicine, Pontificia Universidade Catolica do Paraná, Rua Imaculada Conceição Curitiba PR, Brazil
| | - Holger Reinecke
- Department für Kardiologie und Angiologie Universitätsklinikum Münster, Albert-Schweitzer-Campus 1, Gebäude A1, Muenster, Germany
| | - Gautam R Shroff
- Division of Cardiology, Hennepin County Medical Center, 701 Park Avenue, Minneapolis, MN, USA
| | - Wojciech Zareba
- Heart Research Follow-up Program, Cardiology Division, University of Rochester Medical Center, Saunders Research Building, 265 Crittenden Blvd. CU, Rochester, NY, USA
| | | | - David C Wheeler
- Centre for Nephrology, University College London, Rowland Hill Street, London, UK
| | - Wolfgang C Winkelmayer
- Selzman Institute for Kidney Health, Section of Nephrology, Department of Medicine, Baylor College of Medicine, One Baylor Plaza, ABBR R705, MS: 395, Houston, TX, USA
| | - Christoph Wanner
- Division of Nephrology, Department of Medicine, University Hospital of Würzburg, Oberduerrbacherstr. 6 Würzburg, Germany
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Shroff GR, Stoecker R, Hart A. Non-Vitamin K-Dependent Oral Anticoagulants for Nonvalvular Atrial Fibrillation in Patients With CKD: Pragmatic Considerations for the Clinician. Am J Kidney Dis 2018; 72:717-727. [PMID: 29728318 DOI: 10.1053/j.ajkd.2018.02.360] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [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: 09/05/2017] [Accepted: 02/22/2018] [Indexed: 01/27/2023]
Abstract
Management of atrial fibrillation (AF) in patients with advanced chronic kidney disease (CKD) poses a complex conundrum because of higher risks for both thromboembolic and bleeding complications compared to the general population. This makes it particularly important for clinicians to carefully weigh the risks versus benefits of anticoagulation therapy to determine the individualized net clinical benefit for every patient. During the past few years, 4 non-vitamin K-dependent oral anticoagulant (NOAC) agents have supplemented warfarin in the therapeutic armamentarium for the prevention of systemic thromboembolism in nonvalvular AF. However, the use of NOACs in CKD specifically mandates a nuanced understanding due to their varying dependence on renal clearance, with resultant safety implications related to either underdosing (thromboembolism) or excessive drug exposure (bleeding). This pragmatic review highlights unique considerations pertaining to accurate estimation and temporal monitoring of kidney function in the context of NOAC use with specific clinical deliberations and variables when determining whether an NOAC is appropriate for a patient with CKD. The dependence of NOACs on renal clearance and several troubling safety signals in the published literature suggest that it is vital for nephrologists to be active members of a multidisciplinary team caring for these high-risk patients with CKD and AF.
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Affiliation(s)
- Gautam R Shroff
- Division of Cardiology, Department of Internal Medicine, Hennepin County Medical Center, Minneapolis, MN; University of Minnesota Medical School, Minneapolis, MN.
| | - Rachel Stoecker
- Department of Pharmacy, Hennepin County Medical Center, Minneapolis, MN
| | - Allyson Hart
- Division of Nephrology, Department of Internal Medicine, Hennepin County Medical Center, Minneapolis, MN; University of Minnesota Medical School, Minneapolis, MN
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Affiliation(s)
- Richard W. Asinger
- From the Division of Cardiology, Department of Medicine, Hennepin County Medical Center and University of Minnesota, Minneapolis (R.W.A., G.R.S., M.A.S., C.A.H.); and Chronic Disease Research Group, Minneapolis Medical Research Foundation, MN (C.A.H.)
| | - Gautam R. Shroff
- From the Division of Cardiology, Department of Medicine, Hennepin County Medical Center and University of Minnesota, Minneapolis (R.W.A., G.R.S., M.A.S., C.A.H.); and Chronic Disease Research Group, Minneapolis Medical Research Foundation, MN (C.A.H.)
| | - Mengistu A. Simegn
- From the Division of Cardiology, Department of Medicine, Hennepin County Medical Center and University of Minnesota, Minneapolis (R.W.A., G.R.S., M.A.S., C.A.H.); and Chronic Disease Research Group, Minneapolis Medical Research Foundation, MN (C.A.H.)
| | - Charles A. Herzog
- From the Division of Cardiology, Department of Medicine, Hennepin County Medical Center and University of Minnesota, Minneapolis (R.W.A., G.R.S., M.A.S., C.A.H.); and Chronic Disease Research Group, Minneapolis Medical Research Foundation, MN (C.A.H.)
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Abstract
Analysis of a contemporary cohort of patients on dialysis revealed that mortality from acute myocardial infarction (AMI) has decreased, whereas the prevalence of AMI has increased markedly, particularly among patients with non-ST elevation myocardial infarction (NSTEMI). Using inpatient discharge diagnosis codes (1993-2008), we determined that proportions of AMI claims decreased in the primary position (from 65% to 52%) but increased in the secondary position (from 35% to 48%). Proportions of NSTEMI codes increased remarkably in both the primary and secondary positions. The progressive increase in diagnostic claims for secondary AMI identifies a unique high-risk population and has important clinical, economic, and epidemiologic implications among patients on dialysis.
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Affiliation(s)
- Gautam R Shroff
- Division of Cardiology, Department of Medicine, Hennepin County Medical Center and University of Minnesota, Minneapolis, Minnesota; and
| | - Shuling Li
- Chronic Disease Research Group, Minneapolis Medical Research Foundation, Minneapolis, Minnesota
| | - Charles A Herzog
- Division of Cardiology, Department of Medicine, Hennepin County Medical Center and University of Minnesota, Minneapolis, Minnesota; and .,Chronic Disease Research Group, Minneapolis Medical Research Foundation, Minneapolis, Minnesota
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Hart MA, Shroff GR. Infective endocarditis causing mitral valve stenosis - a rare but deadly complication: a case report. J Med Case Rep 2017; 11:44. [PMID: 28209176 PMCID: PMC5314611 DOI: 10.1186/s13256-017-1197-3] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2016] [Accepted: 01/02/2017] [Indexed: 11/10/2022] Open
Abstract
Background Infective endocarditis rarely causes mitral valve stenosis. When present, it has the potential to cause severe hemodynamic decompensation and death. There are only 15 reported cases in the literature of mitral prosthetic valve bacterial endocarditis causing stenosis by obstruction. This case is even more unusual due to the mechanism by which functional mitral stenosis occurred. Case presentation We report a case of a 23-year-old white woman with a history of intravenous drug abuse who presented with acute heart failure. Transthoracic echocardiography failed to show valvular vegetation, but high clinical suspicion led to transesophageal imaging that demonstrated infiltrative prosthetic valve endocarditis causing severe mitral stenosis. Despite extensive efforts from a multidisciplinary team, she died as a result of her critical illness. Conclusions The discussion of this case highlights endocarditis physiology, the notable absence of stenosis in modified Duke criteria, and the utility of transesophageal echocardiography in clinching a diagnosis. It advances our knowledge of how endocarditis manifests, and serves as a valuable lesson for clinicians treating similar patients who present with stenosis but no regurgitation on transthoracic imaging, as a decision to forego a transesophageal echocardiography could cause this serious complication of endocarditis to be missed. Electronic supplementary material The online version of this article (doi:10.1186/s13256-017-1197-3) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Michael A Hart
- General Internal Medicine, Hennepin County Medical Center, 701 Park Avenue, Minneapolis, MN, 55415, USA.
| | - Gautam R Shroff
- Cardiology, Hennepin County Medical Center, 701 Park Avenue, Minneapolis, MN, 55415, USA
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36
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Shroff GR, Solid CA, Bloomgarden Z, Halperin JL, Herzog CA. Temporal trends in ischemic stroke and anticoagulation therapy for non-valvular atrial fibrillation: effect of diabetes. J Diabetes 2017; 9:115-122. [PMID: 26929264 DOI: 10.1111/1753-0407.12392] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/20/2015] [Revised: 01/29/2016] [Accepted: 02/06/2016] [Indexed: 12/31/2022] Open
Abstract
BACKGROUND Diabetes is an important risk factor for ischemic stroke in non-valvular atrial fibrillation (AF). The aim of the present study was to evaluate temporal trends in ischemic stroke and warfarin use among US Medicare patients with and without diabetes. METHODS In this retrospective cohort study, 1-year cohorts of patients with Medicare as the primary payer over the period 1992-2010 were created using the Medicare 5% sample (excluding patients with valvular disease and end-stage renal disease). International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM) codes were used to identify AF, ischemic and hemorrhagic stroke, and diabetes; three or more consecutive prothrombin time claims were used to identify warfarin use. RESULTS Demographic characteristics of subjects in 1992 (n = 40 255) and 2010 (n = 80 314), respectively, were as follows: age 65-74 years, 37% and 32%; age >85 years, 20% and 25%; White, 94% and 93%; hypertension, 46% and 80%; diabetes, 20% and 32%; and chronic kidney disease, 5% and 18%. Among Medicare AF patients with diabetes, ischemic stroke decreased by 71% (1992-2010) from 65 to 19 per 1000 patient-years; warfarin use increased from 28% to 62%. Among patients without diabetes, ischemic stroke decreased by 68% from 44 to 14 per 1000 patient-years, whereas warfarin use increased from 26% to 59%. Approximately 38% of Medicare AF patients with diabetes did not receive anticoagulation in 2010. CONCLUSIONS Ischemic stroke declined and warfarin use increased similarly in Medicare patients with and without diabetes. Ischemic stroke rates were consistently higher in diabetes patients, validating the inclusion of diabetes in risk calculators. The population of Medicare patients with diabetes who did not receive warfarin deserves future attention.
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Affiliation(s)
- Gautam R Shroff
- Division of Cardiology, Department of Medicine, Hennepin County Medical Center and University of Minnesota, Minneapolis, Minnesota, USA
| | - Craig A Solid
- Chronic Disease Research Group, Minneapolis Medical Research Foundation, Minneapolis, Minnesota, USA
| | - Zachary Bloomgarden
- Division of Medicine, Endocrinology, Diabetes, and Bone Disease, Icahn School of Medicine, Mount Sinai Medical Center, New York, USA
| | | | - Charles A Herzog
- Division of Cardiology, Department of Medicine, Hennepin County Medical Center and University of Minnesota, Minneapolis, Minnesota, USA
- Chronic Disease Research Group, Minneapolis Medical Research Foundation, Minneapolis, Minnesota, USA
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Asinger RW, Shroff GR, Herzog CA. Letter by Asinger et al Regarding Articles, "Should Patients With Atrial Fibrillation and 1 Stroke Risk Factor (CHA2DS2-VASc Score 1 in Men, 2 in Women) Be Anticoagulated? Yes: Even 1 Stroke Risk Factor Confers a Real Risk of Stroke" and "Should Patients With Atrial Fibrillation and 1 Stroke Risk Factor (CHA2DS2-VASc Score 1 in Men, 2 in Women) Be Anticoagulated?: The CHA2DS2-VASc 1 Conundrum: Decision Making at the Lower End of the Risk Spectrum". Circulation 2016; 134:e387-e388. [PMID: 27799260 DOI: 10.1161/circulationaha.116.023650] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Affiliation(s)
- Richard W Asinger
- From Division of Cardiology, Department of Medicine, Hennepin County Medical Center and the University of Minnesota, Minneapolis (R.W.A., G.A.S, C.A.H.); and Chronic Disease Research Group, Minneapolis Medical Research Foundation, MN (C.A.H.)
| | - Gautam R Shroff
- From Division of Cardiology, Department of Medicine, Hennepin County Medical Center and the University of Minnesota, Minneapolis (R.W.A., G.A.S, C.A.H.); and Chronic Disease Research Group, Minneapolis Medical Research Foundation, MN (C.A.H.)
| | - Charles A Herzog
- From Division of Cardiology, Department of Medicine, Hennepin County Medical Center and the University of Minnesota, Minneapolis (R.W.A., G.A.S, C.A.H.); and Chronic Disease Research Group, Minneapolis Medical Research Foundation, MN (C.A.H.)
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Abstract
Coronary revascularization decisions for patients with CKD stage 5D present a dilemma for clinicians because of high baseline risks of mortality and future cardiovascular events. This population differs from the general population regarding characteristics of coronary plaque composition and behavior, accuracy of noninvasive testing, and response to surgical and percutaneous revascularization, such that findings from the general population cannot be automatically extrapolated. However, this high-risk population has been excluded from all randomized trials evaluating outcomes of revascularization. Observational studies have attempted to address long-term outcomes after surgical versus percutaneous revascularization strategies, but inherent selection bias may limit accuracy. Compared with percutaneous strategies, surgical revascularization seems to have long-term survival benefit on the basis of observational data but associates with substantially higher short-term mortality rates. Percutaneous revascularization with drug-eluting and bare metal stents associates with a high risk of in-stent restenosis and need for future revascularization, perhaps contributing to the higher long-term mortality hazard. Off-pump coronary bypass surgery and the newest generation of drug-eluting stent platforms offer no definitive benefits. In this review, we address the nuances, complexities, and tradeoffs that clinicians face in determining the optimal method of coronary revascularization for this high-risk population.
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Affiliation(s)
- Gautam R Shroff
- Division of Cardiology, Department of Medicine, Hennepin County Medical Center and University of Minnesota, Minneapolis, Minnesota; and
| | - Charles A Herzog
- Division of Cardiology, Department of Medicine, Hennepin County Medical Center and University of Minnesota, Minneapolis, Minnesota; and .,Chronic Disease Research Group, Minneapolis Medical Research Foundation, Minneapolis, Minnesota
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Driver BE, Shroff GR, Smith SW. Posterior reperfusion T-waves: Wellens' syndrome of the posterior wall. Emerg Med J 2016; 34:119-123. [DOI: 10.1136/emermed-2016-205852] [Citation(s) in RCA: 4] [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: 03/04/2016] [Revised: 06/30/2016] [Accepted: 07/08/2016] [Indexed: 11/04/2022]
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Abstract
Background We sought to determine 15‐year trends in mortality rates among dialysis patients with acute myocardial infarction (AMI) in the contemporary era. Methods and Results Using the US Renal Data System database, we assembled 4 study cohorts of period‐prevalent dialysis patients in 1993, 1998, 2003, and 2008 who were hospitalized for an index AMI in that calendar year. ST‐segment elevation myocardial infarction (STEMI) and non‐STEMI were identified, and in‐hospital mortality was calculated. Cumulative probability of death during 2‐year follow‐up after AMI admission was estimated by the Kaplan–Meier method and adjusted for patient characteristics. A total of 42 933 dialysis patients with AMI were included. Between 1993 (n=4494) and 2008 (n=16 361), proportional increases occurred in patient groups aged ≥75 years (23% and 31%, respectively; P<0.001), of black race (25% and 31%, respectively; P<0.001), with end‐stage renal disease due to diabetes (42% and 55%, respectively; P<0.001), and with non‐STEMI (42.2% and 80.7%, respectively; P<0.001). For all patients with AMI, in‐hospital mortality rates decreased (31.9% in 1993, 18.8% in 2008; P<0.001), as did unadjusted 2‐year cumulative probability of death after AMI admission (76.5% in 1993, 71.5% in 2008; P<0.001). Between 1993 and 2008, among STEMI patients, in‐hospital mortality (38.2% and 25.9%, P<0.001) and unadjusted 2‐year cumulative probability of mortality (77.3% and 71.2%, P<0.001) decreased, but decreases did not occur among NSTEMI patients (14.2% and 14.9%, P=0.47, and 70.9% and 70.1%, P=0.52 respectively). Conclusions In‐hospital mortality and 2‐year cumulative probability of death following AMI among dialysis patients decreased between 1993 and 2008 but only among STEMI patients, coincident with increased in‐hospital percutaneous coronary intervention rates. Period‐prevalent cases of non‐STEMI markedly increased without interval change in survival.
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Affiliation(s)
- Gautam R Shroff
- Division of Cardiology, Department of Medicine, Hennepin County Medical Center and University of Minnesota, Minneapolis, MN (G.R.S., C.A.H.)
| | - Shuling Li
- Chronic Disease Research Group, Minneapolis Medical Research Foundation, Minneapolis, MN (S.L., C.A.H.)
| | - Charles A Herzog
- Division of Cardiology, Department of Medicine, Hennepin County Medical Center and University of Minnesota, Minneapolis, MN (G.R.S., C.A.H.) Chronic Disease Research Group, Minneapolis Medical Research Foundation, Minneapolis, MN (S.L., C.A.H.)
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Shroff GR. Acute Myocardial Infarction. In Response. Ann Intern Med 2015; 163:152. [PMID: 26192576 DOI: 10.7326/l15-5113-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Affiliation(s)
- Gautam R. Shroff
- From Hennepin County Medical Center and University of Minnesota, Minneapolis, Minnesota
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Klein LR, Shroff GR, Beeman W, Smith SW. Electrocardiographic criteria to differentiate acute anterior ST-elevation myocardial infarction from left ventricular aneurysm. Am J Emerg Med 2015; 33:786-90. [DOI: 10.1016/j.ajem.2015.03.044] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/18/2015] [Revised: 03/19/2015] [Accepted: 03/19/2015] [Indexed: 10/23/2022] Open
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Affiliation(s)
- Gautam R. Shroff
- From Hennepin County Medical Center and University of Minnesota, Minneapolis, Minnesota
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Shroff GR, Solid CA, Herzog CA. Impact of acute coronary syndromes on survival of dialysis patients following surgical or percutaneous coronary revascularization in the United States. European Heart Journal: Acute Cardiovascular Care 2015; 5:205-13. [DOI: 10.1177/2048872615574106] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/08/2014] [Accepted: 02/01/2015] [Indexed: 11/15/2022]
Affiliation(s)
- Gautam R Shroff
- Division of Cardiology, Department of Medicine, Hennepin County Medical Center and University of Minnesota, Minneapolis, USA
| | - Craig A Solid
- Chronic Disease Research Group, Minneapolis Medical Research Foundation, Minneapolis, USA
| | - Charles A Herzog
- Division of Cardiology, Department of Medicine, Hennepin County Medical Center and University of Minnesota, Minneapolis, USA
- Chronic Disease Research Group, Minneapolis Medical Research Foundation, Minneapolis, USA
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Affiliation(s)
- Gautam R Shroff
- Division of Cardiology, Department of Medicine, Hennepin County Medical Center and University of Minnesota, Minneapolis, Minnesota, and
| | - Charles A Herzog
- Division of Cardiology, Department of Medicine, Hennepin County Medical Center and University of Minnesota, Minneapolis, Minnesota, and Chronic Disease Research Group, Minneapolis Medical Research Foundation, Minneapolis, Minnesota
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Affiliation(s)
- Ankur Kalra
- Division of Cardiology, Department of Medicine, Hennepin County Medical Center, Minneapolis, Minnesota
| | - Gautam R Shroff
- Division of Cardiology, Department of Medicine, Hennepin County Medical Center, Minneapolis, Minnesota
| | - Charles A Herzog
- Division of Cardiology, Department of Medicine, Hennepin County Medical Center, Minneapolis, Minnesota; Chronic Disease Research Group, Minnesota Medical Research Foundation, Minneapolis, Minnesota
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Affiliation(s)
- Gautam R Shroff
- Division of Cardiology, Department of Medicine, Hennepin County Medical Center and University of Minnesota, Minneapolis
| | - Brooke M Heubner
- Chronic Disease Research Group, Minneapolis Medical Research Foundation, Minneapolis, Minnesota
| | - Charles A Herzog
- Division of Cardiology, Department of Medicine, Hennepin County Medical Center and University of Minnesota, Minneapolis 2Chronic Disease Research Group, Minneapolis Medical Research Foundation, Minneapolis, Minnesota
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Abstract
BACKGROUND We evaluated temporal trends in ischemic stroke and warfarin use among demographic subsets of the US Medicare population that are not well represented in randomized trials of warfarin for stroke prevention in nonvalvular atrial fibrillation (AF). METHODS AND RESULTS One-year cohorts of Medicare-primary payer patients (1992-2010) were created using the Medicare 5% sample. International Classification of Diseases, Ninth Revision, Clinical Modification codes were used to identify AF and ischemic and hemorrhagic stroke; ≥ 3 consecutive prothrombin time claims were used to identify warfarin use. Ischemic stroke rates (per 1000 patient-years) decreased markedly from 1992 to 2010. Among women, rates decreased from 37.1 to 13.6 for ages 65 to 74 years, from 55.2 to 16.5 for ages 74 to 84, and from 66.9 to 22.9 for age ≥ 85; warfarin use increased 31% to 59%, 27% to 63%, and 15% to 49%, respectively. Among men, rates decreased from 33.8 to 11.7 for ages 65 to 74 years, from 49.2 to 13.8 for ages 75 to 84, and from 51.5 to 18.0 for age ≥ 85; warfarin use increased 34% to 63%, 28% to 66%, and 15% to 55%, respectively. Rates decreased from 47.0 to 14.8 for whites and 73.0 to 29.3 for blacks; warfarin use increased 27% to 61% and 19% to 52%, respectively. In all age categories, the thromboembolic risk (CHADS [congestive heart failure, hypertension, age ≥ 75 years, diabetes, stroke]) score was significantly higher among women (versus men) and blacks (versus whites). CONCLUSIONS Ischemic stroke rates among Medicare AF patients decreased significantly in all demographic subpopulations from 1992-2010, coincident with increasing warfarin use. Ischemic stroke rates remained higher and warfarin use rates remained lower for women and blacks with AF, groups whose baseline CHADS scores were higher.
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Affiliation(s)
- Gautam R Shroff
- Division of Cardiology, Department of Medicine, Hennepin County Medical Center and University of Minnesota, Minneapolis, MN (G.R.S., C.A.H.)
| | - Craig A Solid
- Chronic Disease Research Group, Minneapolis Medical Research Foundation, Minneapolis, MN (C.A.S., C.A.H.)
| | - Charles A Herzog
- Division of Cardiology, Department of Medicine, Hennepin County Medical Center and University of Minnesota, Minneapolis, MN (G.R.S., C.A.H.) Chronic Disease Research Group, Minneapolis Medical Research Foundation, Minneapolis, MN (C.A.S., C.A.H.)
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Abstract
Patients with advanced chronic kidney disease sustain extremely high mortality rates following acute myocardial infarction. Nauta et al. evaluated temporal trends in 12,087 patients with acute myocardial infarction from a single institution over 24 years and report a reduction in 30-day mortality in the most recent decade for all patients, including patients with chronic kidney disease. This trend is optimistic, but understanding contributory factors would be critical in future studies to further improve survival.
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Affiliation(s)
- Gautam R Shroff
- Division of Cardiology, Department of Medicine, Hennepin County Medical Center and University of Minnesota, Minneapolis, Minnesota 55415, USA.
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