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Rawal H, Nguyen TD, Igbinomwanhia E, Klein LW. Clinical effects of physiologic lesion testing in influencing treatment strategy for multi-vessel coronary artery disease. Am Heart J Plus 2024; 40:100378. [PMID: 38510505 PMCID: PMC10945951 DOI: 10.1016/j.ahjo.2024.100378] [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] [Subscribe] [Scholar Register] [Received: 12/23/2023] [Revised: 02/24/2024] [Accepted: 02/26/2024] [Indexed: 03/22/2024]
Abstract
Background The application of fractional flow reserve (FFR) and instantaneous wave-free ratio (iFR) in multivessel coronary artery disease (CAD) patients has not been definitively explored. We herein assessed how treatment strategies were decided based on FFR/iFR values in vessels selected clinically. Specifically, we sought to determine whether treatment selection was based on whether the vessel tested was the clinical target stenosis. Methods 270 consecutive patients with angiographically determined multivessel disease who underwent FFR/iFR testing were included. Patients were classified initially based on their angiographic findings, then re-evaluated from FFR/iFR results (normal or abnormal). Tested lesions were classified into target or non-target lesions based on clinical and non-invasive evaluations. Results Abnormal FFR/iFR values were demonstrated in 51.9 % of patients, in whom 51.4 % received coronary stenting (PCI) and 44.3 % had bypass surgery (CABG). With two-vessel CAD patients, medical therapy was preferred when the target lesion was normal (72.6 %), while PCI was preferred when it was abnormal (78.4 %). In non-target lesions, PCI was preferred regardless of FFR/iFR results (78.0 %). With three-vessel CAD patients, CABG was preferred when the target lesion was abnormal (68.5 %), and there was no difference in the selected modality when it was normal. Furthermore, the incidence of tested lesions was higher in the left anterior descending (LAD) compared to other coronary arteries, and two-vessel CAD patients with LAD stenoses were more frequently treated by PCI. Conclusion The use of invasive physiologic testing in multivessel CAD patients may alter the preferred treatment strategy, leading to an overall increase in PCI selection.
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Affiliation(s)
- Harsh Rawal
- University of Connecticut, St Francis Hospital, Hartford, CT, United States of America
| | - Tung D. Nguyen
- Department of Physiology & Biophysics, University of Illinois at Chicago – College of Medicine, Chicago, IL, United States of America
| | - Efehi Igbinomwanhia
- Department of Cardiology, Advocate Illinois Masonic Medical Center, Chicago, IL, United States of America
| | - Lloyd W. Klein
- Department of Cardiology, University of California – San Francisco, San Francisco, CA, United States of America
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Klein LW. Attuning Percutaneous Coronary Interventional Quality Metrics and Practice Modification. JACC Asia 2024; 4:332-334. [PMID: 38660109 PMCID: PMC11035927 DOI: 10.1016/j.jacasi.2024.01.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Indexed: 04/26/2024]
Affiliation(s)
- Lloyd W. Klein
- Cardiology Division, University of California, San Francisco, California, USA
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Klein LW. Ticagrelor Versus Clopidogrel for Acute Coronary Syndrome: Have Things Changed? Am J Cardiol 2024; 210:315-316. [PMID: 37918476 DOI: 10.1016/j.amjcard.2023.10.078] [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: 10/24/2023] [Accepted: 10/28/2023] [Indexed: 11/04/2023]
Affiliation(s)
- Lloyd W Klein
- Cardiology Division, University of California, San Francisco, California.
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Klein LW. Coronary Intravascular Lithotripsy After Rotational Atherectomy: "Niche Within a Niche" or First Glimpse of a Paradigm Shift? Am J Cardiol 2023; 198:36-37. [PMID: 37196532 DOI: 10.1016/j.amjcard.2023.04.028] [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: 04/16/2023] [Accepted: 04/17/2023] [Indexed: 05/19/2023]
Affiliation(s)
- Lloyd W Klein
- Cardiology Division, Department of Medicine, University of California, San Francisco, San Francisco, California.
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Klein LW. Determinants of Long-Term Adherence to Cardioprotective Diabetes Medications. Am J Cardiol 2023; 196:87-88. [PMID: 37059610 DOI: 10.1016/j.amjcard.2023.02.033] [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: 02/17/2023] [Accepted: 02/25/2023] [Indexed: 04/16/2023]
Affiliation(s)
- Lloyd W Klein
- Cardiology Division, University of California, San Francisco, California.
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Klein LW. Training Interventional Cardiologists: Seeking Better Than How We Have Always Done it. JACC Cardiovasc Interv 2023; 16:258-260. [PMID: 36792251 PMCID: PMC9924374 DOI: 10.1016/j.jcin.2022.12.020] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/16/2022] [Accepted: 12/20/2022] [Indexed: 02/15/2023]
Affiliation(s)
- Lloyd W Klein
- University of California-San Francisco, San Francisco, California, USA.
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Linet MS, Applegate KE, McCollough CH, Bailey JE, Bright C, Bushberg JT, Chanock SJ, Coleman J, Dalal NH, Dauer LT, Davis PB, Eagar RY, Frija G, Held KD, Kachnic LA, Kiess AP, Klein LW, Kosti O, Miller CW, Miller-Thomas MM, Straus C, Vapiwala N, Wieder JS, Yoo DC, Brink JA, Dalrymple JL. A Multimedia Strategy to Integrate Introductory Broad-Based Radiation Science Education in US Medical Schools. J Am Coll Radiol 2023; 20:251-264. [PMID: 36130692 PMCID: PMC10578400 DOI: 10.1016/j.jacr.2022.08.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/21/2022] [Revised: 08/01/2022] [Accepted: 08/04/2022] [Indexed: 12/27/2022]
Abstract
US physicians in multiple specialties who order or conduct radiological procedures lack formal radiation science education and thus sometimes order procedures of limited benefit or fail to order what is necessary. To this end, a multidisciplinary expert group proposed an introductory broad-based radiation science educational program for US medical schools. Suggested preclinical elements of the curriculum include foundational education on ionizing and nonionizing radiation (eg, definitions, dose metrics, and risk measures) and short- and long-term radiation-related health effects as well as introduction to radiology, radiation therapy, and radiation protection concepts. Recommended clinical elements of the curriculum would impart knowledge and practical experience in radiology, fluoroscopically guided procedures, nuclear medicine, radiation oncology, and identification of patient subgroups requiring special considerations when selecting specific ionizing or nonionizing diagnostic or therapeutic radiation procedures. Critical components of the clinical program would also include educational material and direct experience with patient-centered communication on benefits of, risks of, and shared decision making about ionizing and nonionizing radiation procedures and on health effects and safety requirements for environmental and occupational exposure to ionizing and nonionizing radiation. Overarching is the introduction to evidence-based guidelines for procedures that maximize clinical benefit while limiting unnecessary risk. The content would be further developed, directed, and integrated within the curriculum by local faculties and would address multiple standard elements of the Liaison Committee on Medical Education and Core Entrustable Professional Activities for Entering Residency of the Association of American Medical Colleges.
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Affiliation(s)
- Martha S Linet
- Chief and Senior Investigator, Radiation Epidemiology Branch (retired) and currently NIH Scientist Emerita, Division of Cancer Epidemiology and Genetics, National Cancer Institute, National Institutes of Health, Bethesda, Maryland.
| | - Kimberly E Applegate
- Division Chief and Professor of Pediatric Radiology (retired), University of Kentucky Children's Hospital, University of Kentucky, Lexington, Kentucky, and currently Chair of Committee 3 of the International Commission on Radiological Protection, Ottawa, Canada
| | - Cynthia H McCollough
- Brooks-Hollern Professor of Medical Physics and Biomedical Engineering, Mayo Clinic, Rochester, Minnesota
| | - Janet E Bailey
- Professor of Radiology and Associate Chair for Education in Radiology, University of Michigan Health System, Ann Arbor, Michigan
| | - Cedric Bright
- Associate Dean for Admissions and Clinical Professor, Department of Internal Medicine, East Carolina's Brody School of Medicine, Greenville, North Carolina
| | - Jerrold T Bushberg
- Clinical Professor of Radiology and Radiation Oncology, University of California Davis School of Medicine, Sacramento, California, and Vice President, National Council of Radiation Protection and Measurements, Bethesda, Maryland
| | - Stephen J Chanock
- Director and Chief of the Cancer Genomics Research Laboratory, Division of Cancer Epidemiology and Genetics, National Cancer Institute, National Institutes of Health, Bethesda, Maryland
| | - Jenna Coleman
- Executive Director of the Medical Educational Council of Pensacola, Pensacola, Florida
| | - Nicole H Dalal
- Resident, Department of Internal Medicine, University of California San Francisco School of Medicine, San Francisco, California
| | - Lawrence T Dauer
- Attending Physicist, Departments of Medical Physics and Radiology, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Pamela B Davis
- Dean School of Medicine (emerita) and Arline H. and Curtis F. Garvin Research Professor, Center for Community Health Integration, and Professor of Pediatrics, Case Western Reserve University School of Medicine, Cleveland, Ohio
| | - Robert Y Eagar
- Diagnostic Radiology Resident, Department of Radiology, West Virginia University School of Medicine, Morgantown, West Virginia
| | - Guy Frija
- Professor of Radiology (Emeritus), Université de Paris, Paris, France
| | - Kathryn D Held
- President of the National Council on Radiation Protection and Measurements, Bethesda, Maryland, and Associate Radiation Biologist, Department of Radiation Oncology, Massachusetts General Hospital and Associate Professor of Radiation Oncology, Harvard Medical School, Boston, Massachusetts
| | - Lisa A Kachnic
- Chair, Department of Radiation Oncology, Columbia University Medical Center and the Herbert Irving Comprehensive Cancer Center, New York, New York
| | - Ana P Kiess
- Assistant Professor of Radiation Oncology and Molecular Radiation Sciences and Director of the Residency Program, Johns Hopkins School of Medicine, Baltimore, Maryland
| | - Lloyd W Klein
- Clinical Professor of Medicine, University of California San Francisco School of Medicine, San Francisco, California
| | - Ourania Kosti
- Senior Program Officer at the Nuclear and Radiation Studies Board of the National Academies of Sciences, Engineering, and Medicine, Washington, DC
| | - Charles W Miller
- Chief (retired) Radiation Studies Branch, Division of Environmental Hazards and Health Effects, Centers for Disease Control and Prevention, Atlanta, Georgia, and currently a Consultant in Nuclear and Radiological Environmental Health, Atlanta, Georgia
| | - Michelle M Miller-Thomas
- Associate Professor of Radiology and Director of Medical Student Education at Mallinckrodt Institute of Radiology, Washington University School of Medicine, St Louis, Missouri
| | - Christopher Straus
- Associate Professor of Radiology and Director of Medical Student Education, University of Chicago School of Medicine, Chicago, Illinois
| | - Neha Vapiwala
- Professor and Vice Chair of Education, Department of Radiation Oncology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Jessica S Wieder
- Director of the Center for Radiation Information and Outreach, US Environmental Protection Agency, Washington, DC
| | - Don C Yoo
- Director of Nuclear Medicine, Miriam Hospital and Professor of Diagnostic Imaging and Clinical Educator, Warren Alpert Medical School, Brown University, Providence, Rhode Island
| | - James A Brink
- Chair, Department of Radiology, Brigham and Women's Hospital and Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts
| | - John L Dalrymple
- Professor of Obstetrics, Gynecology and Reproductive Biology and Associate Dean for Medical Education Quality Improvement, Harvard Medical School, Boston, Massachusetts, and Associate Chair and Vice Chair for Faculty Development and Faculty Affairs and Gynecologic Oncology Fellowship Program Director, Department of Obstetrics and Gynecology, Beth Israel Deaconess Medical Center, Boston, Massachusetts
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Abstract
Clinical decisions are optimally made collaboratively, with patients and clinicians working together to review all available information and treatment options. A comprehensive dialogue that identifies and brings into focus individual patient goals within the context of the evidence base is the ideal approach. Shared decision-making (SDM) is essential to making choices about treatment preferences and characterizes the optimal practice of evidence-based medicine and good patient care. By supporting patient autonomy and engagement, the patient and family become partners in their health care. Decisions surrounding whether or not to proceed with diagnostic and therapeutic procedures after fully discussing appropriate alternatives are best made considering both the evidence base and patient goals. The central feature of SDM is that a clinician and a patient engage in a dialogue to jointly make decisions, with reciprocated sharing of information that both find beneficial to reach the best decision. SDM entails much more than patient education or informed consent: there must be bidirectional transfer of knowledge, discussion of patient preference, and a process of deliberation reaching consensus. Patient decision aids have been shown to improve patient understanding of options and risks, enhance the patient's involvement, and focus their comprehension of treatment preferences. Patient decision aids also may be of value in strengthening the physician-patient relationship. The need to emphasize SDM should be integrated into the quality process at every level to make it meaningful, not an apparently arbitrary obstacle that requires discovery of a shrewd work-around. A more patient-oriented consideration of the benefits of symptom relief and improved quality of life, in addition to survival and freedom from adverse events, could only be beneficial.
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Affiliation(s)
- Lloyd W Klein
- From the Cardiology Department, University of California, San Francisco, San Francisco, CA
| | - H Vernon Anderson
- Cardiology Division, Cardiology Department, University of Texas Health Science Center, Houston, TX
| | - Joaquin Cigarroa
- Cardiology Department, Oregon Health and Science University, Portland, OR
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Abstract
Tobacco product usage is the single most preventable cause of death in the United States. Smoking promotes atherosclerosis, producing disease in the coronary arteries, the aorta, the carotid and cerebral arteries and the large arteries in the peripheral circulation. The cardiovascular consequences of tobacco products have been the subject of intensive study for several decades. Despite the overwhelming epidemiologic association between smoking and vascular disease, the pathophysiologic mechanisms by which smoking exerts its deleterious effects remain incompletely understood. This review addresses the acute and long-term systemic and coronary hemodynamic effects of tobacco, with an emphasis of the impact on coronary blood flow and pathophysiologic mechanisms.
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Affiliation(s)
- Lloyd W Klein
- From the Cardiology Division, University of California, San Francisco, San Francisco, CA
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10
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Klein LW, Anderson HV, Cigarroa J. Integrating shared decision-making in coronary revascularization with quality assurance programs. Catheter Cardiovasc Interv 2022; 100:1-4. [PMID: 35644991 DOI: 10.1002/ccd.30222] [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: 08/09/2021] [Revised: 04/15/2022] [Accepted: 04/21/2022] [Indexed: 11/09/2022]
Affiliation(s)
- Lloyd W Klein
- University of California, San Francisco, San Francisco, California, USA
| | - H Vernon Anderson
- Cardiology Division, University of Texas Health Science Center, Houston, Texas, USA
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11
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Kern MJ, Applegate B, Bittl J, Block P, Butman S, Dehmer G, Garratt KN, Henry T, Hirshfeld J, Holmes DR, Kaplan A, King S, Klein LW, Krucoff MW, Kutcher MA, Naidu SS, Pichard A, Ruiz CE, Skelding KA, Tobis JM, Tommaso C, Weiner BH, White C. Conversations in cardiology: Late career transitions-Retool, retire, refocus. Catheter Cardiovasc Interv 2022; 99:2136-2144. [PMID: 35446473 DOI: 10.1002/ccd.30210] [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: 04/05/2022] [Accepted: 04/08/2022] [Indexed: 11/10/2022]
Affiliation(s)
- Morton J Kern
- Department of Cardiology, Veterans Administration Long Beach Health Care System, Long Beach, California, USA.,University of California Irvine, Orange, California, USA
| | - Bob Applegate
- Professor of Medicine, Wake Forest School of Medicine, Winston-Salem, North Carolina, USA
| | | | - Peter Block
- Emory University School of Medicine, Atlanta, Georgia, USA
| | | | - Gregory Dehmer
- Quality and Outcomes, Carilion Clinic and Cardiovascular Institute, Virginia Tech Carilion School of Medicine, Roanoke, Virginia, USA
| | | | - Tim Henry
- The Carl and Edyth Lindner Center for Research and Education, Cincinnati, Ohio, USA
| | - John Hirshfeld
- Professor Emeritus of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - David R Holmes
- Scripps Professor of Cardiovascular Medicine, Mayo Graduate School of Medicine, Rochester, Minnesota, USA
| | - Aaron Kaplan
- Dartmouth Device Development Symposium, Heart and Vascular Center, Dartmouth-Hitchcock Medical Center/Geisel School of Medicine, Lebanon, Dartmouth, New Hampshire, USA
| | - Spencer King
- Emory University School of Medicine, Atlanta, Georgia, USA
| | | | - Mitchell W Krucoff
- Medicine/Cardiology, Duke University Medical Center, Cardiovascular Devices Unit, eECG Core Laboratories Duke Clinical Research Institute, Raleigh, North Carolina, USA
| | - Michael A Kutcher
- Professor of Medicine, Wake Forest School of Medicine, Winston-Salem, North Carolina, USA
| | - Srihari S Naidu
- Cardiac Cath Labs, Westchester Medical Center, Winthrop, New York, USA
| | - Augusto Pichard
- Medstar Washington Hospital Center, Georgetown University, Washington, District of Columbia, USA
| | | | | | - Jonathan M Tobis
- David Geffen Shool of Medicine at UCLA, Santa Barbara, California, USA
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Klein LW, Abugroun A, Daoud H. Rates of revascularization and PCI:CABG ratio: a new indicator predicting in-hospital mortality in acute coronary syndromes. Coron Artery Dis 2022; 33:69-74. [PMID: 34074913 DOI: 10.1097/mca.0000000000001073] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
OBJECTIVE The principal trend in acute coronary syndrome (ACS) is increasing utilization of percutaneous coronary interventions (PCI) and declining coronary artery bypass graft surgery (CABG) utilization. This study was designed to evaluate whether higher PCI:CABG ratios lead to higher in-hospital PCI or CABG mortality. METHODS The National Readmission Database for years 2016 was queried for all hospitalized ACS patients who underwent coronary revascularization during their admission. The study population was derived from 355 US hospitals and included 103 021 patients. Hospitals were grouped based on their PCI:CABG ratio into low, intermediate, and high ratio quartiles with a median [interquartile ranges (IQR)] PCI:CABG ratio of 2.9 (2.5-3.2), 5.0 (4.3-5.9) and 8.9 (7.8-10.3), respectively multivariable logistic regression with adjustment for age, demographics and comorbidities were used to identify CABG:PCI ratio related risk for in-hospital CABG and PCI mortality. RESULTS Higher PCI:CABG ratios correlated with an increased CABG mortality. There was a median (IQR) mortality of 2.5% (1.6-4.3) in the low ratio quartile; 3.1% (1.9-5.3) in the intermediate quartiles; and 5.3% (3.2-9.1) in the high ratio quartile (P < 0.001). On multivariate analysis, the PCI:CABG ratio was associated with an increased risk for CABG mortality with an adjusted odds ratio of 1.38 (95% CI, 1.14-1.67, P < 0.001) and 2.17 (95% CI, 1.70-2.80, P < 0.001) for hospitals with intermediate and high PCI:CABG ratios, respectively. There was no significant association between PCI:CABG ratio and PCI mortality. CONCLUSIONS The programmatic PCI:CABG ratio is a valid indicator of optimal case selection. The PCI:CABG ratio correlates with in-hospital mortality in ACS.
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Affiliation(s)
- Lloyd W Klein
- Cardiology Section, University of California San Francisco, San Francisco, California
| | | | - Hussein Daoud
- Advocate Illinois Masonic Medical Center, Chicago, Illinois, USA
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Abstract
INTRODUCTION Despite the convincing epidemiologic association between smoking and vascular disease, the pathophysiologic mechanisms by which smoking initiates and contributes to the progression of atherosclerosis remain incompletely understood. A precise dose-dependent correlation has never been demonstrated, suggesting that the biological relationship is complex and influenced by individual genetic and possibly environmental factors. Although endothelial dysfunction and intimal damage appear to be central to atherogenesis, how tobacco products cause this effect has not been established. The purpose of this review is to describe the current state of knowledge of the main pathophysiologic pathways of how tobacco smoking abets atherosclerosis. Constituents of Tobacco Smoke: Tobacco combustion produces a mixture of organic substances. derived from burning organic materials. The predominant gaseous phase constituents include carbon monoxide, acetaldehyde, formaldehyde, acrolein, and other carbonyls, as well as nicotine and tobacco-specific nitrosamines. Potential Pathophysiologic Mechanisms: Smoking-induced changes in coronary vasomotor tone, platelet activation, and endothelial integrity are major components of both the development of atherosclerosis and its clinical presentation. Smoking may initiate and accelerate the progression of atherosclerosis by injuring the vascular intima. Other potential mechanisms include intimal damage and endothelial dysfunction, oxidative stress and injury, thrombosis, lipid abnormalities, and inflammation. CONCLUSION Smoking tobacco products contributes measurably to the incidence of acute vascular events and chronic disease. The causative compound, the exact mechanism of injury, and whether the atherogenic effect is modifiable are not known.
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Affiliation(s)
- Lloyd W. Klein
- Department of Medicine, Cardiology Division, University of California, San Francisco, CA
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Kleiman NS, Welt FGP, Truesdell AG, Sherwood M, Kadavath S, Shah PB, Klein LW, Hogan S, Kavinsky C, Rab T. Should Interventional Cardiologists Super-Subspecialize?: Moving From Patient Selection to Operator Selection. JACC Cardiovasc Interv 2021; 14:97-100. [PMID: 33413871 DOI: 10.1016/j.jcin.2020.10.029] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/08/2020] [Accepted: 10/13/2020] [Indexed: 10/22/2022]
Abstract
The field of interventional cardiology has expanded rapidly. As a result, four evolving areas have evolved - peripheral vascular interventions, structural heart interventions, adult congenital heart intervention, and chronic total occlusion. The complexity of these procedures and the number of devices available has grown rapidly. In addition, the professional and public expectations of procedural success and of minimizing case-avoidance have also grown. Specific issues include volume-outcome relationships, maintaining currency and proficiency, accessibility to specialized procedures, and the need to maintain a fundamental level of expertise in acute coronary interventions.
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Affiliation(s)
- Neal S Kleiman
- Houston Methodist DeBakey Heart and Vascular Center, Houston, Texas, USA.
| | | | | | | | | | - Pinak B Shah
- Brigham and Womens Hospital, Boston, Massachusetts, USA
| | - Lloyd W Klein
- University of California at San Francisco, San Francisco, California, USA
| | - Shea Hogan
- Denver Health and University of Colorado, Denver, Colorado, USA
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Klein LW, Tamis-Holland J, Kirtane AJ, Anderson HV, Cigarroa J, Duffy PL, Blankenship J, Valentine CM, Welt FG. The appropriate use criteria: Improvements for its integration into real world clinical practice. Catheter Cardiovasc Interv 2021; 98:1349-1357. [PMID: 34080774 DOI: 10.1002/ccd.29784] [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: 01/12/2021] [Revised: 04/27/2021] [Accepted: 05/09/2021] [Indexed: 01/09/2023]
Abstract
The purpose of this position statement is to suggest ways in which future appropriate use criteria (AUC) for coronary revascularization might be restructured to: (1) incorporate improvement in quality of life and angina relief as primary goals of therapy, (2) integrate the findings of recent trials into quality appraisal, (3) employ the combined information of the coronary angiogram and invasive physiologic measurements together with the results of stress test imaging to assess risk, and (4) recognize the essential role that patient preference plays in making individualized therapeutic decisions. The AUC is a valuable tool within the quality assurance process; it is vital that interventionists ensure that percutaneous coronary intervention case selection is both evidence-based and patient oriented. Appropriate patient selection is an important quality indicator and adherence to evidence-based practice should be one metric in a portfolio of process and outcome indicators that measure quality.
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Affiliation(s)
- Lloyd W Klein
- Cardiology Section, University of California, San Francisco, California, USA
| | | | - Ajay J Kirtane
- Columbia University Irving Medical Center/New York-Presbyterian Hospital, Cardiovascular Research Foundation, New York, New York, USA
| | - H Vernon Anderson
- Cardiology Division, University of Texas Health Science Center, Houston, Texas, USA
| | - Joaquin Cigarroa
- Cardiovascular Division, Knight Cardiovascular Institute, Oregon Health & Sciences University, Portland, Oregon, USA
| | - Peter L Duffy
- Reid Heart Center, First Health of the Carolinas, Pinehurst, North Carolina, USA
| | | | | | - Frederick Gp Welt
- Division of Cardiology, University of Utah Health, Salt Lake City, Utah, USA
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Klein LW. Proper Shielding Technique in Protecting Operators and Staff From Radiation Exposure in the Fluoroscopy Environment. J Invasive Cardiol 2021; 33:E342-E343. [PMID: 33932280] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 06/12/2023]
Affiliation(s)
- Lloyd W Klein
- University of California, San Francisco, Cardiology Section, 505 Parnassus Ave, M1177A, San Francisco, CA 94143 USA.
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Klein LW, Rao SV. Sounding the alarm: Academic interventional cardiology at a crossroads. Am Heart J 2021; 233:14-19. [PMID: 33249094 DOI: 10.1016/j.ahj.2020.11.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/31/2020] [Accepted: 11/23/2020] [Indexed: 10/22/2022]
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Abugroun A, Osman M, Awadalla S, Klein LW. Outcomes of Transcatheter Aortic Valve Replacement With Percutaneous Coronary Intervention versus Surgical Aortic Valve Replacement With Coronary Artery Bypass Grafting. Am J Cardiol 2020; 137:83-88. [PMID: 32991856 DOI: 10.1016/j.amjcard.2020.09.040] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/04/2020] [Revised: 09/17/2020] [Accepted: 09/21/2020] [Indexed: 10/23/2022]
Abstract
We aimed to compare the outcomes of combined surgical aortic valve replacement (SAVR) with coronary artery bypass grafting (CABG) to concurrent transcatheter aortic valve replacement (TAVR) with percutaneous coronary intervention (PCI) in a large U.S. population sample. The National Inpatient Sample was queried for all patients diagnosed with aortic valve stenosis who underwent SAVR with CABG or TAVR with PCI during the years 2016 to 2017. Study outcomes included all-cause in-hospital mortality, acute stroke, pacemaker insertion, vascular complications, major bleeding, acute kidney injury, sepsis, non-home discharge, length of stay and cost. Outcomes of hospitalization were modeled using logistic regression for binary outcomes and generalized linear models for continuous outcomes. Overall, 31,205 patients were included (TAVR + PCI = 2,185, SAVR + CABG = 29,020). In reference to SAVR + CABG, recipients of TAVR + PCI were older with mean age 82 versus 73 years, effect size (d) = 0.9, had higher proportions of females 47.6% versus 26.6%, d = 0.4 and higher prevalence of congestive heart failure and chronic renal failure. On multivariable analysis, TAVR + PCI was associated with lowers odds for mortality adjusted OR: 0.32 (95% CI: 0.17 to 0.62) p = 0.001, lower odds for acute kidney injury, sepsis, non-home discharge, shorter length of stay and higher odds for vascular complications, need for pacemaker insertion and higher cost. The occurrence of stroke was similar between both groups. In conclusion, results from real-world observational data shows less rates of mortality and periprocedural complications in TAVR + PCI compared to SAVR + CABG.
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19
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Klein LW, Dehmer GJ, Anderson HV, Rao SV. Overcoming Obstacles in Designing and Sustaining a High-Quality Cardiovascular Procedure Environment. JACC Cardiovasc Interv 2020; 13:2806-2810. [PMID: 33069644 DOI: 10.1016/j.jcin.2020.06.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/13/2020] [Revised: 05/07/2020] [Accepted: 06/02/2020] [Indexed: 11/30/2022]
Abstract
Accurate evaluation of the quality of invasive cardiology procedures requires appraisal of case selection, technical performance, and procedural and clinical outcomes. Regrettably, the medical care delivery system poses a number of obstacles to developing and sustaining a high-quality environment. The purposes of this viewpoint are to summarize the most common impediments, followed to summarize the most common impediments, followed by the optimal ways to design and sustain a quality assurance program to overcome these barriers. A 7-step program to create and implement an effective quality assurance program is outlined.
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Affiliation(s)
- Lloyd W Klein
- University of California-San Francisco, San Francisco, California, USA.
| | - Gregory J Dehmer
- Carilion Clinic Cardiology and the Virginia Tech Carilion School of Medicine, Roanoke, Virginia, USA
| | | | - Sunil V Rao
- The Duke Clinical Research Institute, Durham, North Carolina, USA
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20
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Abugroun A, Taha A, Abdel-Rahman M, Patel P, Ali I, Klein LW. Cardiovascular Risk Among Patients ≥65 Years of Age with Parkinson's Disease (From the National Inpatient Sample). Am J Cardiol 2020; 136:56-61. [PMID: 32941821 DOI: 10.1016/j.amjcard.2020.09.021] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/15/2020] [Revised: 08/28/2020] [Accepted: 09/01/2020] [Indexed: 10/23/2022]
Abstract
In this study, we aimed to investigate the relationship between Parkinson's disease (PD) and vascular disease and risk factors using a nationally representative sample. The National Inpatient Sample was queried for all patients aged ≥65 who were diagnosed with PD during the year 2016. Patients were identified using the International Classification of Diseases-Tenth Revision (ICD-10) diagnosis code: "G20." Each patient diagnosed with PD was frequency-matched to controls at a 1:4 ratio by age and gender. Study outcomes were hypertension, hyperlipidemia, diabetes mellitus, coronary artery disease, and stroke. Outcomes were modeled using logistic regression analysis and further validation was obtained using a propensity score-matched analysis. A total of 57,914 patients (weighted: 289,570) with PD were included. Most patients were of Caucasian race (80.8%). Females were 42.4% and the mean age was 79 years, standard error of the mean (0.03). PD correlated with lower odds for hyperlipidemia adjusted odd ratio (a-OR): 0.77 (95% confidence interval [CI]: 0.75 to 0.79) p <0.001, diabetes mellitus a-OR 0.73 (95% CI 0.71 to 0.75) p <0.001, hypertension a-OR 0.68 (95% CI: 0.67 to 0.70) p <0.001, coronary artery disease a-OR 0.64 (95% CI: 0.63 to 0.66) p <0.001 and higher odds for stroke a-OR: 1.27 (95% CI: 1.24 to 1.31) p <0.001. Following propensity score matching, identical findings were found. In conclusion, patients with PD have a distinct cardiovascular profile with higher rates of stroke and lower rates of coronary artery disease and vascular disease risk factors.
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21
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Khan AJ, Jan Liao C, Kabir C, Hallak O, Samee M, Potts S, Klein LW. Etiology and Determinants of In-Hospital Survival in Patients Resuscitated After Out-of-Hospital Cardiac Arrest in an Urban Medical Center. Am J Cardiol 2020; 130:78-84. [PMID: 32674809 DOI: 10.1016/j.amjcard.2020.06.019] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/20/2020] [Revised: 06/01/2020] [Accepted: 06/05/2020] [Indexed: 12/13/2022]
Abstract
Out-of-hospital cardiac arrest (OHCA) is a leading cause of mortality globally. The goals of this study were to describe common causes of OHCA in an urban US medical center, identify predictive factors for survival, and to assess whether neurological status upon return of spontaneous circulation might be predictive of outcomes: 124 consecutive patients aged 18 years and older with OHCA admitted at Advocate Illinois Masonic Medical Center were studied. All patients resuscitated in the field with return of spontaneous circulation then transferred to the emergency department were included. The Glasgow Coma Score (GCS) was evaluated immediately on hospital arrival. In the total group, 34% (42 of 124) were discharged alive. In patients with coronary artery disease (CAD), 51% (20 of 39) were discharged alive versus 26% (22 of 85) of non-CAD patients (p <0.01). Initial GCS ≥ 9 was highly predictive of survival: 94% (34 of 36) of patients with GCS ≥ 9 survived versus 9% (8 of 88) with GCS ≤ 8 (p <0.0001). Defibrillation in the field was predictive of survival (chi-square = 7.81, p = 0.005). In the CAD group, all 16 patients with GCS ≥ 9 on presentation to the Emergency Department survived whereas all 13 with GCS ≤ 5 died (both p <0.0001). In the non-CAD group, 18 of 20 patients with GCS ≥ 9 survived, whereas only 2 of 52 with GCS ≤ 5 survived (both p <0.0001). Multivariate analysis by logistic regression showed that the strongest predictor of survival in the non-CAD subgroup was GCS (OR 0.27, CI 0.19 to 0.55, p <0.001). In conclusion, the etiology of the OHCA, immediate neurologic status, and defibrillation in the field (suggesting presenting arrhythmia) were predictive of survival. Immediate neurological recovery (GCS ≥ 9) regardless of etiology was a strong predictor of survival to discharge. Additional predictive factors depend on the etiology of the OHCA event. These data suggest that these straightforward factors can be helpful in predicting outcome in patients resuscitated after OHCA.
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Affiliation(s)
| | | | - Sunil V. Rao
- Duke Clinical Research Institute, Durham, North Carolina
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23
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Klein LW, Box L, Krishnan S, Kar S, Ing F, Cigarroa J, Mahmud E. In defense of the
AMA
/specialty society
RVS
update committee (
RUC
). Catheter Cardiovasc Interv 2020; 96:156-157. [DOI: 10.1002/ccd.28875] [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: 12/24/2019] [Accepted: 03/18/2020] [Indexed: 11/09/2022]
Affiliation(s)
| | - Lyndon Box
- West Valley Medical Center Caldwell Idaho USA
| | | | - Subrata Kar
- Texas Tech University Health Sciences Center El Paso Texas USA
| | - Frank Ing
- University of California Sacramento California USA
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24
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Lotfi A, Klein LW, Hira RS, Mallidi J, Mehran R, Messenger JC, Pinto DS, Mooney MR, Rab T, Yannopoulos D, van Diepen S. SCAI expert consensus statement on out of hospital cardiac arrest. Catheter Cardiovasc Interv 2020; 96:844-861. [PMID: 32406999 DOI: 10.1002/ccd.28990] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [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: 05/06/2020] [Accepted: 05/08/2020] [Indexed: 12/13/2022]
Affiliation(s)
- Amir Lotfi
- Division of Cardiology, Baystate Medical Center, Springfield, Massachusetts, USA
| | - Lloyd W Klein
- Division of Cardiology, University of California, San Francisco, California, USA
| | - Ravi S Hira
- Division of Cardiology, University of Washington, Seattle, Washington, USA
| | - Jaya Mallidi
- Santa Rosa Memorial Hospital, St. Joseph Cardiology Medical Group, Santa Rosa, California, USA
| | - Roxana Mehran
- Zena and Michael A. Wiener Cardiovascular Institute, Mount Sinai School of Medicine, New York, New York, USA
| | - John C Messenger
- Division of Cardiology, University of Colorado School of Medicine, Aurora, Colorado, USA
| | - Duane S Pinto
- Division of Cardiology, Beth Israel Deaconess Medical Center, Boston, Massachusetts, USA
| | - Michael R Mooney
- Minneapolis Heart Institute, Minneapolis Heart Institute Foundation, Minneapolis, Minnesota, USA
| | - Tanveer Rab
- Division of Cardiology, Emory University, Atlanta, Georgia, USA
| | - Demetri Yannopoulos
- Division of Cardiology, University of Minnesota, Minneapolis, Minnesota, USA
| | - Sean van Diepen
- Department of Critical Care Medicine and Division of Cardiology, University of Alberta, Edmonton, Canada
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Abugroun A, Hassan A, Gaznabi S, Ayinde H, Subahi A, Samee M, Shroff A, Klein LW. Modified CHA 2DS 2-VASc score predicts in-hospital mortality and procedural complications in acute coronary syndrome treated with percutaneous coronary intervention. Int J Cardiol Heart Vasc 2020; 28:100532. [PMID: 32455161 PMCID: PMC7235953 DOI: 10.1016/j.ijcha.2020.100532] [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: 01/31/2020] [Revised: 04/20/2020] [Accepted: 05/03/2020] [Indexed: 11/16/2022]
Abstract
Background Current risk prediction models in acute coronary syndrome (ACS) patients undergoing PCI are mathematically complex. This study was undertaken to assess the accuracy of a modified CHA2DS2-VASc score, comprised of easily accessible clinical factors in predicting adverse events. Methods The National Inpatient Sample (NIS) was queried for ACS patients who underwent PCI between 2010 and 2014. We developed a modified CHA2DS2-VASc score for risk prediction in ACS patients. Multivariate mixed effect logistic regression was utilized to study the adjusted risk for adverse outcomes based on the score. The primary outcome evaluated was in-hospital mortality. Secondary outcomes assessed were stroke, respiratory failure, acute kidney injury, all-cause bleeding, pacemaker insertion, vascular complications, length of stay and cost. Results There were 252,443 patients admitted with ACS included. Mean age was 62 ± 12 years. The mean CH3A2DS-VASc score was 1.6 ± 1.6. The in-hospital mortality rate was 2.5%. CH3A2DS-VASc score was highly correlated with increased rate of mortality and all secondary outcomes. ROC curve analysis for association of CH3A2DS-VASc score with mortality demonstrates that area under the curve (AUC) = 0.83 (95%C: 0.82–0.84). Stepwise increases in CH3A2DS-VASc score correlated with incremental risk, and total score was an independent predictor of mortality (adjusted OR: 1.99 (95%CI: 1.96–2.03) p < 0.001) and all secondary outcomes. Conclusion This study supports the applicability of the CH3A2DS-VASc score as an accurate risk prediction model for ACS patients undergoing PCI and could supplant more complicated models for quality assurance.
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Affiliation(s)
- Ashraf Abugroun
- Wayne State University/Detroit Medical Center, Detroit, MI, United States
| | - Abdalla Hassan
- University of Massachusetts Medical School, Worcester, MA, United States
| | - Safwan Gaznabi
- University Hospitals Cleveland Medical Center, Case Western Reserve University, United States
| | | | - Ahmed Subahi
- Wayne State University/Detroit Medical Center, Detroit, MI, United States
| | - Mohammed Samee
- Advocate Illinois Masonic Medical Center, Chicago, IL, United States
| | - Adhir Shroff
- University of Illinois-Chicago, Chicago, IL, United States
| | - Lloyd W Klein
- Wayne State University/Detroit Medical Center, Detroit, MI, United States.,University of California, San Francisco, San Francisco, CA, United States
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26
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Abugroun A, Patel P, Natarajan S, Elawad A, Gaznabi S, Abdel-Rahman ME, Klein LW. Relation of Age to Survival in Patients with Obstructive Sleep Apnea who Develop an Acute Coronary Event (from the National Inpatient Sample). Am J Cardiol 2020; 125:1571-1576. [PMID: 32245633 DOI: 10.1016/j.amjcard.2020.02.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/18/2019] [Revised: 02/14/2020] [Accepted: 02/18/2020] [Indexed: 10/24/2022]
Abstract
This study was undertaken to investigate whether obstructive sleep apnea (OSA) produces a survival advantage in acute coronary syndrome (ACS), and to evaluate the mechanism of any benefit, including the impact of age and other risk factors. The National Inpatient Sample was queried for all patients who were admitted for ACS during the years 2013 to 2014. The primary outcomes were all-cause in-hospital mortality and cardiogenic shock (CS). Multivariable logistic regression was used for analysis. A total of 1,080,340 patients with ACS were included, 63,255 patients had OSA. The majority of patients were males (60.3%) and of Caucasian race (75%). The mean age was 67 years (SEM: 0.1). Despite a higher burden of risk factors and older age, OSA patients had a lower risk for mortality and cardiogenic shock adjusted OR 0.68 (95%CI 0.61-0.75), p <0.001 and 0.81 (95%CI: 0.74 to 0.89), p <0.001 respectively. Age was an important effect modifier. Survival advantage and lower risk for CS arises at the age above 55 and become more apparent with increasing age. In conclusion, despite a higher CV risk profile, and older age, OSA produces a survival benefit in ACS. Age is a significant modifier of risk in OSA patients with ACS. Ischemic preconditioning might explain these results.
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Affiliation(s)
| | | | | | | | - Safwan Gaznabi
- University Hospitals Cleveland Medical Center, Case Western Reserve University, Cleveland, Ohio
| | | | - Lloyd W Klein
- Advocate Illinois Masonic Medical Center, Chicago, Illinois; University of California, San Francisco, California
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27
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Klein LW, Goldstein JA, Haines D, Chambers C, Mehran R, Kort S, Valentine CM, Cox D. SCAI Multi-Society Position Statement on Occupational Health Hazards of the Catheterization Laboratory: Shifting the Paradigm for Healthcare Workers' Protection. J Am Coll Cardiol 2020; 75:1718-1724. [PMID: 32273037 DOI: 10.1016/j.jacc.2020.02.015] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
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28
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Abugroun A, Patel P, Natarajan S, Gaznabi S, Elawad A, Elhassan M, Klein LW. AGE MODIFIES THE SURVIVAL OF PATIENTS WITH OBSTRUCTIVE SLEEP APNEA WHO DEVELOP ACUTE CORONARY EVENTS: FROM THE NATIONAL INPATIENT SAMPLE. J Am Coll Cardiol 2020. [DOI: 10.1016/s0735-1097(20)30838-x] [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: 10/24/2022]
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29
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Klein LW, Goldstein JA, Haines D, Chambers C, Mehran R, Kort S, Valentine CM, Cox D. SCAI multi‐society position statement on occupational health hazards of the catheterization laboratory: Shifting the paradigm for Healthcare Workers' Protection. Catheter Cardiovasc Interv 2020; 95:1327-1333. [DOI: 10.1002/ccd.28579] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/25/2019] [Accepted: 10/26/2019] [Indexed: 11/08/2022]
Affiliation(s)
- Lloyd W. Klein
- University of California, San Francisco San Francisco California
| | | | - David Haines
- William Beaumont School of Medicine Royal Oak Michigan
| | | | | | | | | | - David Cox
- Brookwood Baptist Health Birmingham Alabama
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30
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Affiliation(s)
- Lloyd W. Klein
- Division of Cardiology, University of California, San Francisco
| | | | - Sunil V. Rao
- Duke Clinical Research Institute, Durham, North Carolina
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31
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Klein LW, Campos EP. The Embryologic Origin of Vieussens' Ring. J Invasive Cardiol 2019; 31:49-51. [PMID: 30819974] [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] [Subscribe] [Scholar Register] [Indexed: 06/09/2023]
Abstract
Vieussens' ring is an embryologic remnant that acquires clinical significance as an intercoronary collateral vessel in advanced coronary artery disease. Its origin as a peritruncal structure early in embryologic development, and its association with congenital pulmonary artery fistula, provides a crucial insight into the early stages of the coronary circulation. This review describes the embryologic basis of Vieussens' ring in relation to the formation of the coronary arteries, which explains its location, appearance, and clinical importance.
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Affiliation(s)
- Lloyd W Klein
- Advocate Illinois Masonic Medical Center, 1953 North Clybourn Avenue, Suite #R-221, Chicago, IL 60614 USA.
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32
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Abugroun A, Iskander F, Hallak O, Iskander M, Klein LW. PATIENTS WITH TAKOTSUBO CARDIOMYOPATHY HAVE HIGHER PREVALENCE OF DEPRESSION AND ANXIETY THAN PATIENTS WITH ACUTE CORONARY SYNDROME: FROM THE NATIONAL INPATIENT SAMPLE. J Am Coll Cardiol 2019. [DOI: 10.1016/s0735-1097(19)31420-2] [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: 11/16/2022]
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Abugroun A, Ayinde H, Ogunbayo G, Taha A, Chami ME, Klein LW. NATIONWIDE PERI-PROCEDURAL OUTCOMES OF PERCUTANEOUS LEFT ATRIAL APPENDAGE OCCLUSION WITH THE WATCHMAN DEVICE. J Am Coll Cardiol 2019. [DOI: 10.1016/s0735-1097(19)31032-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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34
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Klein LW. The cardiac catheterization conference: Improving its performance as a teaching tool. Catheter Cardiovasc Interv 2019; 93:451-454. [PMID: 30506917 DOI: 10.1002/ccd.28008] [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: 09/11/2018] [Revised: 10/02/2018] [Accepted: 11/04/2018] [Indexed: 11/09/2022]
Affiliation(s)
- Lloyd W Klein
- Professor of Medicine, Rush Medical College, Chicago, Illinois
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35
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Welt FGP, Klein LW, Tamis-Holland J, Blankenship J, Duffy PL, Cigarroa J, Anderson HV. Views of Appropriate Use Criteria for catheterization and percutaneous coronary revascularization by practicing interventional cardiologists: Results of a survey of American College of Cardiology Interventional Section members. Catheter Cardiovasc Interv 2018; 93:875-879. [PMID: 30298614 DOI: 10.1002/ccd.27931] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/13/2018] [Accepted: 09/23/2018] [Indexed: 01/09/2023]
Abstract
OBJECTIVES The American College of Cardiology (ACC) Interventional Section Council leadership sought to examine the views of interventional cardiologists regarding the practical implementation and the value of the Appropriate Use Criteria (AUC) in their clinical practice. BACKGROUND The ACC AUC for revascularization were originally intended to assess trends in revascularization patterns by hospitals and physicians to ensure that both under- and over-utilization were minimized. As a quality assurance tool, the AUC were designed to allow physicians to obtain insight into their practice patterns and improve their practice. Recent trends toward tying payment to performance have raised concerns that these criteria will be incorrectly applied to individual patient reimbursement, which is not what they were designed to do. Consequently, the AUC have become controversial, not for their value in quality assessment, but for the manner in which agencies have used the AUC as a tool to potentially deny payment for certain patients. METHODS Utilizing an online survey, members of the ACC Interventional Section were queried regarding the use of AUC, how they use them, and how they feel utilization impacts the care of patients. RESULTS We found substantial variability in how the AUC were utilized and concern regarding the value of AUC. Among our findings was that respondents were split (51% vs 49%) regarding the value of AUC to patients and/or their laboratory. CONCLUSIONS In this article, we discuss the implications of these findings and consider options on how AUC might be made a better-accepted and more impactful tool for clinicians and patients.
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Affiliation(s)
| | - Lloyd W Klein
- Advocate Illinois Masonic Medical Center, Chicago, Illinois
| | | | | | - Peter L Duffy
- Reid Heart Center, First Health of the Carolinas, Pinehurst, North Carolina
| | - Joaquin Cigarroa
- Cardiovascular Division, Knight Cardiovascular Institute, Oregon Health & Sciences University, Portland, Oregon
| | - H Vernon Anderson
- Cardiology Division, University of Texas Health Science Center, Houston, Texas
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36
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Lotfi A, Davies JE, Fearon WF, Grines CL, Kern MJ, Klein LW. Focused update of expert consensus statement: Use of invasive assessments of coronary physiology and structure: A position statement of the society of cardiac angiography and interventions. Catheter Cardiovasc Interv 2018; 92:336-347. [DOI: 10.1002/ccd.27672] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/22/2018] [Accepted: 04/23/2018] [Indexed: 01/10/2023]
Affiliation(s)
- Amir Lotfi
- Baystate Medical Center; Tufts University School of Medicine; Springfield Massachusetts
| | | | | | - Cindy L. Grines
- Northwell Health, North Shore University Hospital; Manhasset New York
| | - Morton J. Kern
- Long Beach Veterans Administration Hospital; University of California, Irvine; Irvine California
| | - Lloyd W. Klein
- Advocate Illinois Masonic Medical Center, Rush Medical College; Chicago Illinois
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Klein LW, Weintraub WS. A Comprehensive Evidence-Based Decision Algorithm for Assisting Clinicians and Patients With Stable Ischemic Heart Disease in Selecting Revascularization Strategy in Multivessel Disease. J Invasive Cardiol 2018; 30:182-185. [PMID: 29715166] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 06/08/2023]
Abstract
We propose an evidenced-based algorithm for the selection of revascularization strategy (coronary artery bypass surgery, percutaneous coronary intervention, or optimal medical therapy) to be applied in multivessel, non-acute coronary syndrome presentations. This algorithm provides a highly effective tool that is comprehensible to both physicians and patients.
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Affiliation(s)
- Lloyd W Klein
- Rush Medical College, 3000 North Halsted Ave, Suite 625, Chicago, IL 60614 USA.
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38
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Klein LW. The Apophenia of Interventional Cardiology. J Invasive Cardiol 2018; 30:119-120. [PMID: 29493514] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 06/08/2023]
Affiliation(s)
- Lloyd W Klein
- Rush Medical College, 3000 North Halsted Ave, Suite 625, Chicago, IL 60614 USA.
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39
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Klein LW, Campos EP. Occupational Hazards in the Cath Lab - Physician, Protect Thyself! J Invasive Cardiol 2018; 30:75-76. [PMID: 29245155] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 06/07/2023]
Affiliation(s)
- Lloyd W Klein
- Specialty Services Clinic Advocate Illinois Masonic Medical Center, Fourth Floor, Chicago, IL 60657 USA.
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40
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Klein LW, Miller DL, Balter S, Laskey W, Naito N, Haines D, Ross A, Mauro MA, Goldstein JA. Occupational health hazards in the interventional laboratory: Time for a safer environment. Catheter Cardiovasc Interv 2018. [PMID: 29667719 DOI: 10.1002/ccd.21772] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/06/2008] [Accepted: 08/07/2008] [Indexed: 11/06/2022]
Abstract
Over the past 30 years, the advent of fluoroscopically guided interventional procedures has resulted in dramatic increments in both X-ray exposure and physical demands that predispose interventionists to distinct occupational health hazards. The hazards of accumulated radiation exposure have been known for years, but until recently the other potential risks have been ill-defined and under-appreciated. The physical stresses inherent in this career choice appear to be associated with a predilection to orthopedic injuries, attributable in great part to the cumulative adverse effects of bearing the weight and design of personal protective apparel worn to reduce radiation risk and to the poor ergonomic design of interventional suites. These occupational health concerns pertain to cardiologists, radiologists and surgeons working with fluoroscopy, pain management specialists performing nonvascular fluoroscopic procedures, and the many support personnel working in these environments. This position paper is the work of representatives of the major societies of physicians who work in the interventional laboratory environment, and has been formally endorsed by all. In this paper, the available data delineating the prevalence of these occupational health risks is reviewed and ongoing epidemiological studies designed to further elucidate these risks are summarized. The main purpose is to publicly state speaking with a single voice that the interventional laboratory poses workplace hazards that must be acknowledged, better understood and mitigated to the greatest extent possible, and to advocate vigorously on behalf of efforts to reduce these hazards. Interventional physicians and their professional societies, working together with industry, should strive toward the ultimate zero radiation exposure work environment that would eliminate the need for personal protective apparel and prevent its orthopedic and ergonomic consequences. © 2008 Wiley-Liss, Inc.
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Affiliation(s)
- Lloyd W Klein
- Rush Medical College, 675 West North Avenue, Suite 202, Melrose Park, IL 60160
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Lotfi AS, Klein LW. The Metamorphosis of ST-Segment Elevation Myocardial Infarction Programs. JACC Cardiovasc Interv 2017; 10:2574-2576. [DOI: 10.1016/j.jcin.2017.06.056] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/10/2017] [Revised: 06/16/2017] [Accepted: 06/20/2017] [Indexed: 10/18/2022]
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Klein LW, Korpu D. Damped and Ventricularized Coronary Pressure Waveforms. J Invasive Cardiol 2017; 29:387-389. [PMID: 29086728] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 06/07/2023]
Abstract
Although the terms ventricularization and damping are commonly used in the cath lab and are widely recognized as indicating possible flow limitation due to catheter position, their hemodynamic origins and mechanism have not been well studied. Often, they are thought to be synonymous terms. Both patterns are due to distortion of the normal harmonic frequencies of wave conduction. Pressure damping is seen when the outer diameter of the catheter is larger than the ostial diameter or when the tip of the catheter is pressed against the vessel wall. It is characterized by an abrupt decline of mean coronary pressure with narrow pulse pressure and delayed upstroke and downstroke. Conversely, ventricularization is seen when the catheter tip is advanced into an ostial stenosis, partially obstructing flow, and is characterized by a steep decline of pressure in diastole with large pulse pressure, absence of the dicrotic notch, and appearance of presystolic positive deflection. A ventricularized pressure waveform can be considered a hybrid between coronary arterial pressure and coronary wedge pressure.
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Affiliation(s)
- Lloyd W Klein
- Advocate Illinois Masonic Medical Center, 836 West Wellington Avenue, Chicago, IL 60657 USA.
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Klein LW, Lotfi A. Ambiguities in Selecting the Optimal Strategy for the Nonculprit Stenosis in STEMI. JACC Cardiovasc Interv 2017; 10:325-328. [PMID: 28231900 DOI: 10.1016/j.jcin.2016.12.272] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/19/2016] [Accepted: 12/29/2016] [Indexed: 11/26/2022]
Affiliation(s)
| | - Amir Lotfi
- Baystate Medical Center, Springfield, Massachusetts
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Ramee S, Anwaruddin S, Kumar G, Piana RN, Babaliaros V, Rab T, Klein LW. The Rationale for Performance of Coronary Angiography and Stenting Before Transcatheter Aortic Valve Replacement. JACC Cardiovasc Interv 2016; 9:2371-2375. [DOI: 10.1016/j.jcin.2016.09.024] [Citation(s) in RCA: 37] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/21/2016] [Revised: 08/19/2016] [Accepted: 09/14/2016] [Indexed: 01/10/2023]
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Klein LW, Korpu D, Colina I. The Evolution of Plaque Composition in CTOs. J Invasive Cardiol 2016; 28:489-490. [PMID: 27922806] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 06/06/2023]
Affiliation(s)
- Lloyd W Klein
- Advocate Illinois Masonic Medical Center, 3000 North Halsted, Suite 625, Chicago, IL 60614 USA.
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Klein LW, Harjai KJ, Resnic F, Weintraub WS, Vernon Anderson H, Yeh RW, Feldman DN, Gigliotti OS, Rosenfeld K, Duffy P. 2016 Revision of the SCAI position statement on public reporting. Catheter Cardiovasc Interv 2016; 89:269-279. [PMID: 27755653 DOI: 10.1002/ccd.26818] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.8] [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: 10/03/2016] [Accepted: 10/08/2016] [Indexed: 11/06/2022]
Affiliation(s)
| | | | - Fred Resnic
- Lahey Hospital and Medical Center, Burlington, Massachusetts.,Tufts University School of Medicine, Boston, Massachusetts
| | | | - H Vernon Anderson
- University of Texas Health Science Center Houston, McGovern Medical School, Houston, Texas
| | - Robert W Yeh
- Smith Center for Outcomes Research in Cardiology, Beth Israel Deaconess Medical Center, Boston, Massachusetts
| | - Dmitriy N Feldman
- New York Presbyterian Hospital, Weill Cornell Medical College, New York, New York
| | | | - Kenneth Rosenfeld
- Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts
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Klein LW, Colina I, McKay C. The "May Be Appropriate" PCI: Ambiguities in the Appropriate Use Classification. J Invasive Cardiol 2016; 28:456-458. [PMID: 27801657] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 06/06/2023]
Affiliation(s)
- Lloyd W Klein
- Advocate Illinois Medical Center and Rush Medical College, Chicago, IL 60614 USA.
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Gupta A, Yeh RW, Tamis-Holland JE, Patel SH, Guyton RA, Klein LW, Rab T, Kirtane AJ. Implications of Public Reporting of Risk-Adjusted Mortality Following Percutaneous Coronary Intervention. JACC Cardiovasc Interv 2016; 9:2077-2085. [DOI: 10.1016/j.jcin.2016.08.012] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/20/2016] [Revised: 08/05/2016] [Accepted: 08/11/2016] [Indexed: 12/01/2022]
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Affiliation(s)
- Lloyd W. Klein
- From the Cardiology Department, Advocate Illinois Masonic Medical Center, and Rush Medical College, Chicago, IL
| | - Mugurel Bazavan
- From the Cardiology Department, Advocate Illinois Masonic Medical Center, and Rush Medical College, Chicago, IL
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Klein LW, Blankenship JC, Kolansky DM, Dean LS, Naidu SS, Chambers CE, Duffy PL. SCAI position statement concerning coverage policies for percutaneous coronary interventions based on the appropriate use criteria. Catheter Cardiovasc Interv 2016; 87:1127-9. [DOI: 10.1002/ccd.26499] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/08/2016] [Accepted: 02/20/2016] [Indexed: 11/08/2022]
Affiliation(s)
| | | | | | | | | | | | - Peter L. Duffy
- FirstHealth of the Carolinas; Reid Heart Center; Pinehurst NC
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