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Hanigan S, Kong X, Haymart B, Kline-Rogers E, Kaatz S, Krol G, Shah V, Ali MA, Almany S, Kozlowski J, Froehlich J, Barnes G. Standard Versus Higher Intensity Anticoagulation for Patients With Mechanical Aortic Valve Replacement and Additional Risk Factors for Thromboembolism. Am J Cardiol 2021; 159:100-106. [PMID: 34656311 DOI: 10.1016/j.amjcard.2021.08.023] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/21/2021] [Revised: 08/03/2021] [Accepted: 08/09/2021] [Indexed: 12/15/2022]
Abstract
Current guidelines recommend targeting an international normalized ratio (INR) of 2.5 to 3.5 for patients with mechanical aortic valve replacement (AVR) and additional risk factors for thromboembolic events. Available literature supporting the higher intensity (INR) goal is lacking. We aimed to evaluate the association of standard and higher intensity anticoagulation on outcomes in this patient population. The Michigan Anticoagulation Quality Improvement Initiative database was used to identify patients with mechanical AVR and at least one additional risk factor. Patients were classified into 2 groups based on INR goal: standard-intensity (INR goal 2.5) or higher-intensity (INR goal 3.0). Cox-proportional hazard model was used to calculate adjusted hazard ratios. One hundred and forty-six patients were identified of whom 110 (75.3%) received standard-intensity anticoagulation and 36 (24.7%) received higher intensity anticoagulation. Standard-intensity patients were older and more likely to be on aspirin. Atrial fibrillation was the most common additional risk factor for inclusion. The primary outcome of thromboembolic events, bleeding, or all-cause death was 13.9 and 19.5/100-person-years in the standard-intensity and higher intensity groups, respectively (adjusted HR 2.58, 95% confidence interval 1.28 to 5.18). Higher-intensity anticoagulation was significantly associated with any bleeding (adjusted HR 2.52, 95% confidence interval 1.27 to 5.00) and there were few thromboembolic events across both groups (5 events total). These results challenge current guideline recommendations for anticoagulation management of mechanical AVR in patients with additional risk factors.
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Affiliation(s)
- Sarah Hanigan
- Department of Pharmacy, Michigan Medicine, Ann Arbor, Michigan; Department of Clinical Pharmacy, University of Michigan College of Pharmacy, Ann Arbor, Michigan.
| | - Xiaowen Kong
- Department of Internal Medicine, Frankel Cardiovascular Center, University of Michigan Medical Center, Ann Arbor, Michigan
| | - Brian Haymart
- Department of Internal Medicine, Frankel Cardiovascular Center, University of Michigan Medical Center, Ann Arbor, Michigan
| | - Eva Kline-Rogers
- Department of Internal Medicine, Frankel Cardiovascular Center, University of Michigan Medical Center, Ann Arbor, Michigan
| | - Scott Kaatz
- Division of Hospital Medicine, Henry Ford Hospital, Detroit, Michigan
| | - Gregory Krol
- Division of Hospital Medicine, Henry Ford Hospital, Detroit, Michigan
| | - Vinay Shah
- Division of Hospital Medicine, Henry Ford Hospital, Detroit, Michigan
| | - Mona A Ali
- Department of Heart and Vascular Services, Beaumont Hospital, Royal Oak, Michigan
| | - Steve Almany
- Department of Internal Medicine, Beaumont Health, Oakland University William Beaumont School of Medicine, Rochester, Michigan
| | - Jay Kozlowski
- Department of Cardiovascular Medicine, Huron Valley Sinai Hospital, Commerce Township, Michigan
| | - James Froehlich
- Department of Internal Medicine, Frankel Cardiovascular Center, University of Michigan Medical Center, Ann Arbor, Michigan
| | - Geoffrey Barnes
- Division of Cardiovascular Medicine, Department of Internal Medicine, University of Michigan, Ann Arbor, Michigan; Institute of Healthcare Policy and Innovation, University of Michigan, Ann Arbor, Michigan
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Lemor A, Basir MB, Patel K, Kolski B, Kaki A, Kapur NK, Riley R, Finley J, Goldsweig A, Aronow HD, Belford PM, Tehrani B, Truesdell AG, Lasorda D, Bharadwaj A, Hanson I, LaLonde T, Gorgis S, O'Neill W, Lemor A, Basir MB, O'Neill WW, Patel K, Kolski B, Schreiber T, Kaki A, Tehrani B, Truesdell AG, Lasorda D, Bharadwaj A, Hanson I, Almany S, Timmis S, Dixon S, Lalonde T, Attallah A, Todd J, Marso S, Wilkins C, Patel N, Senter S, McRae T, Rahman A, Gelormini J, Kapur N, Singh IM, Riley R, O'Neill B, Overly T, Sharma R, Dupont A, Green M, Lim M, Khuddus M, Caputo C, Larkin T, Askari R, Marso S, Nsair A, Akhtar Y, Hanson I, Lin L, McAllister D, Finley J, Goldsweig A, Park J, Gorwara S, Nazir R, Martin S, Foster M, Smith C, Rangaswamy C, Zuberi O, Federici R, Baker J, Cawich I, Korpas D, Srivastava N, Aronow HD, Schaeffer M, Wohns D, Belford PM, Mehra A, Blank N, Alraies MC, Ashbrook M, Abdel-Hafez O, Khandelwal A, Alaswad K, Gorgis S, Johnson T, Hacala M. Multivessel Versus Culprit-Vessel Percutaneous Coronary Intervention in Cardiogenic Shock. JACC Cardiovasc Interv 2020; 13:1171-1178. [DOI: 10.1016/j.jcin.2020.03.012] [Citation(s) in RCA: 18] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/15/2020] [Revised: 02/13/2020] [Accepted: 03/03/2020] [Indexed: 11/28/2022]
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Basir MB, Kapur NK, Patel K, Salam MA, Schreiber T, Kaki A, Hanson I, Almany S, Timmis S, Dixon S, Kolski B, Todd J, Senter S, Marso S, Lasorda D, Wilkins C, Lalonde T, Attallah A, Larkin T, Dupont A, Marshall J, Patel N, Overly T, Green M, Tehrani B, Truesdell AG, Sharma R, Akhtar Y, McRae T, O'Neill B, Finley J, Rahman A, Foster M, Askari R, Goldsweig A, Martin S, Bharadwaj A, Khuddus M, Caputo C, Korpas D, Cawich I, McAllister D, Blank N, Alraies MC, Fisher R, Khandelwal A, Alaswad K, Lemor A, Johnson T, Hacala M, O'Neill WW. Improved Outcomes Associated with the use of Shock Protocols: Updates from the National Cardiogenic Shock Initiative. Catheter Cardiovasc Interv 2019; 93:1173-1183. [PMID: 31025538 DOI: 10.1002/ccd.28307] [Citation(s) in RCA: 129] [Impact Index Per Article: 25.8] [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: 04/09/2019] [Accepted: 04/10/2019] [Indexed: 12/17/2022]
Abstract
BACKGROUND The National Cardiogenic Shock Initiative is a single-arm, prospective, multicenter study to assess outcomes associated with early mechanical circulatory support (MCS) in patients presenting with acute myocardial infarction and cardiogenic shock (AMICS) treated with percutaneous coronary intervention (PCI). METHODS Between July 2016 and February 2019, 35 sites participated and enrolled into the study. All centers agreed to treat patients with AMICS using a standard protocol emphasizing invasive hemodynamic monitoring and rapid initiation of MCS. Inclusion and exclusion criteria mimicked those of the "SHOCK" trial with an additional exclusion criteria of intra-aortic balloon pump counter-pulsation prior to MCS. RESULTS A total of 171 consecutive patients were enrolled. Patients had an average age of 63 years, 77% were male, and 68% were admitted with AMICS. About 83% of patients were on vasopressors or inotropes, 20% had a witnessed out of hospital cardiac arrest, 29% had in-hospital cardiac arrest, and 10% were under active cardiopulmonary resuscitation during MCS implantation. In accordance with the protocol, 74% of patients had MCS implanted prior to PCI. Right heart catheterization was performed in 92%. About 78% of patients presented with ST-elevation myocardial infarction with average door to support times of 85 ± 63 min and door to balloon times of 87 ± 58 min. Survival to discharge was 72%. Creatinine ≥2, lactate >4, cardiac power output (CPO) <0.6 W, and age ≥ 70 years were predictors of mortality. Lactate and CPO measurements at 12-24 hr reliably predicted overall mortality postindex procedure. CONCLUSION In contemporary practice, use of a shock protocol emphasizing best practices is associated with improved outcomes.
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Affiliation(s)
- Mir B Basir
- Department of Cardiology, Henry Ford Health System
| | | | - Kirit Patel
- Department of Cardiology, St. Joseph Mercy Oakland
| | | | | | - Amir Kaki
- Department of Cardiology, Ascension St. John Hospital
| | | | | | | | | | - Brian Kolski
- Department of Cardiology, St Joseph Hospital - Orange
| | - Josh Todd
- Department of Cardiology, Fort Sanders, Regional Medical Center
| | - Shaun Senter
- Department of Cardiology, Washington Regional Medical Center
| | - Steven Marso
- Department of Cardiology, Overland Park Regional Medical Center & Research Medical Center
| | - David Lasorda
- Department of Cardiology, Allegheny General Hospital
| | | | | | | | | | - Allison Dupont
- Department of Cardiology, Northeast Georgia Medical Center
| | | | | | - Tjuan Overly
- Department of Cardiology, University of Tennessee Medical Center
| | - Michael Green
- Department of Cardiology, Northwest Medical Center - Springdale, Springdale
| | - Behnam Tehrani
- Department of Cardiology, INOVA Heart and Vascular Institute
| | | | - Rahul Sharma
- Department of Cardiology, Carilion Roanoke Memorial Hospital
| | - Yasir Akhtar
- Department of Cardiology, Physicians Regional Medical Center
| | - Thomas McRae
- Department of Cardiology, Tristar Centennial Medical Center
| | - Brian O'Neill
- Department of Cardiology, Temple University Hospital
| | - John Finley
- Department of Cardiology, Mercy Fitzgerald Hospital
| | - Ayaz Rahman
- Department of Cardiology, Parkwest Medical Center
| | | | - Raza Askari
- Department of Cardiology, Methodist University Hospital - Memphis
| | | | | | | | - Matheen Khuddus
- Department of Cardiology, North Florida Regional Medical Center
| | | | - Denes Korpas
- Department of Cardiology, CHI Health Nebraska Heart
| | - Ian Cawich
- Department of Cardiology, Arkansas Heart Hospital
| | | | - Nimrod Blank
- Department of Cardiology, Detroit Medical Center
| | | | - Ruth Fisher
- Department of Cardiology, Henry Ford Health System
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Barnes GD, Kong X, Cole D, Haymart B, Kline-Rogers E, Almany S, Dahu M, Ekola M, Kaatz S, Kozlowski J, Froehlich JB. Extended International Normalized Ratio testing intervals for warfarin-treated patients. J Thromb Haemost 2018; 16:1307-1312. [PMID: 29763979 DOI: 10.1111/jth.14150] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [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: 02/02/2018] [Indexed: 12/22/2022]
Abstract
Essentials Warfarin typically requires International Normalized Ratio (INR) testing at least every 4 weeks. We implemented extended INR testing for stable warfarin patients in six anticoagulation clinics. Use of extended INR testing increased from 41.8% to 69.3% over the 3 year study. Use of extended INR testing appeared safe and effective. SUMMARY Background A previous single-center randomized trial suggested that patients with stable International Normalized Ratio (INR) values could safely receive INR testing as infrequently as every 12 weeks. Objective To test the success of implementation of an extended INR testing interval for stable warfarin patients in a practice-based, multicenter collaborative of anticoagulation clinics. Methods At six anticoagulation clinics, patients were identified as being eligible for extended INR testing on the basis of prior INR value stability and minimal warfarin dose changes between 2014 and 2016. We assessed the frequency with which anticoagulation clinic providers recommended an extended INR testing interval (> 5 weeks) to eligible patients. We also explored safety outcomes for eligible patients, including next INR values, bleeding events, and emergency department visits. Results At least one eligible period for extended INR testing was identified in 890 of 3362 (26.5%) warfarin-treated patients. Overall, the use of extended INR testing in eligible patients increased from 41.8% in the first quarter of 2014 to 69.3% in the fourth quarter of 2016. The number of subsequent out-of-range next INR values were similar between eligible patients who did and did not have an extended INR testing interval (27.3% versus 28.4%, respectively). The numbers of major bleeding events were not different between the two groups, but rates of clinically relevant non-major bleeding (0.02 per 100 patient-years versus 0.09 per 100 patient-years) and emergency department visits (0.07 per 100 patient-years versus 0.19 per 100 patient-years) were lower for eligible patients with extended INR testing intervals than for those with non-extended INR testing intervals. Conclusions Extended INR testing for stable warfarin patients can be successfully and safely implemented in diverse, practice-based anticoagulation clinic settings.
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Affiliation(s)
- G D Barnes
- Frankel Cardiovascular Center, University of Michigan, Ann Arbor, MI, USA
| | - X Kong
- Frankel Cardiovascular Center, University of Michigan, Ann Arbor, MI, USA
| | - D Cole
- Wayne State University School of Medicine, Detroit, MI, USA
| | - B Haymart
- Frankel Cardiovascular Center, University of Michigan, Ann Arbor, MI, USA
| | - E Kline-Rogers
- Frankel Cardiovascular Center, University of Michigan, Ann Arbor, MI, USA
| | - S Almany
- William Beaumont Hospital, Royal Oak, MI, USA
| | - M Dahu
- Spectrum Health System, Grand Rapids, MI, USA
| | - M Ekola
- Memorial Health System, Owosso, MI, USA
| | - S Kaatz
- Henry Ford Hospital, Detroit, MI, USA
| | - J Kozlowski
- Detroit Medical Center, Commerce Township, MI, USA
| | - J B Froehlich
- Frankel Cardiovascular Center, University of Michigan, Ann Arbor, MI, USA
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Hughey AB, Gu X, Haymart B, Kline-Rogers E, Almany S, Kozlowski J, Besley D, Krol GD, Ahsan S, Kaatz S, Froehlich JB, Barnes GD. Warfarin for prevention of thromboembolism in atrial fibrillation: comparison of patient characteristics and outcomes of the “Real-World” Michigan Anticoagulation Quality Improvement Initiative (MAQI2) registry to the RE-LY, ROCKET-AF, and ARISTOTLE trials. J Thromb Thrombolysis 2018; 46:316-324. [DOI: 10.1007/s11239-018-1698-y] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/14/2022]
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Hale ZD, Kong X, Haymart B, Gu X, Kline-Rogers E, Almany S, Kozlowski J, Krol GD, Kaatz S, Froehlich JB, Barnes GD. Prescribing trends of atrial fibrillation patients who switched from warfarin to a direct oral anticoagulant. J Thromb Thrombolysis 2017; 43:283-288. [PMID: 27837309 DOI: 10.1007/s11239-016-1452-2] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
Direct oral anticoagulant (DOAC) agents offer several lifestyle and therapeutic advantages for patients relative to warfarin in the treatment of atrial fibrillation (AF). These alternative agents are increasingly used in the treatment of AF, however the adoption practices, patient profiles, and reasons for switching to a DOAC from warfarin have not been well studied. Through the Michigan Anticoagulation Quality Improvement Initiative, abstracted data from 3873 AF patients, enrolled between 2010 and 2015, were collected on demographics and comorbid conditions, stroke and bleeding risk scores, and reasons for anticoagulant switching. Over the study period, patients who switched from warfarin to a DOAC had similar baseline characteristics, risk scores, and insurance status but differed in baseline CrCl. The most common reasons for switching were patient related ease of use concerns (37.5%) as opposed to clinical reasons (16.5% of patients). Only 13% of patients that switched to a DOAC switched back to warfarin by the end of the study period.
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Affiliation(s)
- Zachary D Hale
- Texas Heart Institute, CHI-Baylor St. Luke's Medical Center, 6720 Bertner Ave. MC-1-133, Houston, TX, 77030, USA.
| | - Xiowen Kong
- University of Michigan Cardiovascular Center, 24 Frank Lloyd Wright Dr., Lobby A Rm 3201, Ann Arbor, MI, 48106, USA
| | - Brian Haymart
- University of Michigan Cardiovascular Center, 24 Frank Lloyd Wright Dr., Lobby A Rm 3201, Ann Arbor, MI, 48106, USA
| | - Xiaokui Gu
- University of Michigan Cardiovascular Center, 24 Frank Lloyd Wright Dr., Lobby A Rm 3201, Ann Arbor, MI, 48106, USA
| | - Eva Kline-Rogers
- University of Michigan Cardiovascular Center, 24 Frank Lloyd Wright Dr., Lobby A Rm 3201, Ann Arbor, MI, 48106, USA
| | - Steve Almany
- William Beaumont Hospital, 4600 Investment Drive Suite 200, Troy, MI, 48098, USA
| | - Jay Kozlowski
- Huron Valley Sinai Hospital, 1 William Carls Drive, Commerce, MI, 48382, USA
| | - Gregory D Krol
- Henry Ford Hospital, 2799 W. Grand Blvd., Detroit, MI, 48202, USA
| | - Scott Kaatz
- Henry Ford Hospital, 2799 W. Grand Blvd., Detroit, MI, 48202, USA
| | - James B Froehlich
- University of Michigan Cardiovascular Center, 24 Frank Lloyd Wright Dr., Lobby A Rm 3201, Ann Arbor, MI, 48106, USA
| | - Geoffrey D Barnes
- University of Michigan Cardiovascular Center, 24 Frank Lloyd Wright Dr., Lobby A Rm 3201, Ann Arbor, MI, 48106, USA
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Lau W, Shannon F, Hanzel GS, Sakwa M, Abbas AE, Safian R, Hanson I, Almany S, Vivacqua A. OUTCOME-BASED COST ANALYSIS OF TRANSFEMORAL TRANSCATHETER AORTIC VALVE REPLACEMENT USING FASCIA ILIACA COMPARTMENT BLOCK AND MINIMALIST CONSCIOUS SEDATION APPROACH VERSUS GENERAL ANESTHESIA. J Am Coll Cardiol 2017. [DOI: 10.1016/s0735-1097(17)34719-8] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [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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Kataruka A, Kong X, Haymart B, Kline-Rogers E, Almany S, Kozlowski J, Krol GD, Kaatz S, McNamara MW, Froehlich JB, Barnes GD. SAMe-TT 2R 2 predicts quality of anticoagulation in patients with acute venous thromboembolism: The MAQI 2 experience. Vasc Med 2017; 22:197-203. [PMID: 28145152 DOI: 10.1177/1358863x16682863] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
A high SAMe-TT2R2 score predicted poor warfarin control and adverse events among atrial fibrillation patients. However, the SAMe-TT2R2 score has not been well validated in venous thromboembolism (VTE) patients. A cohort of 1943 warfarin-treated patients with acute VTE was analyzed to correlate the SAMe-TT2R2 score with time in therapeutic range (TTR) and clinical adverse events. A TTR <60% was more frequent among patients with a high (>2) versus low (0-1) SAMe-TT2R2 score (63.4% vs 52.3%, p<0.0001). A high SAMe-TT2R2 score (>2) correlated with increased overall adverse events (7.9 vs 4.5 overall adverse events/100 patient years, p=0.002), driven primarily by increased recurrent VTE rates (4.2 vs 1.5 recurrent VTE/100 patient years, p=0.0003). The SAMe-TT2R2 score had a modest predictive ability for international normalized ratio (INR) quality and adverse clinical events among warfarin-treated VTE patients. The utility of the SAMe-TT2R2 score to guide clinical decision-making remains to be investigated.
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Affiliation(s)
- Akash Kataruka
- 1 Department of Internal Medicine, University of Michigan Health System, Ann Arbor, MI, USA
| | - Xiaowen Kong
- 2 Department of Cardiovascular Medicine, University of Michigan Health System, Ann Arbor, MI, USA
| | - Brian Haymart
- 2 Department of Cardiovascular Medicine, University of Michigan Health System, Ann Arbor, MI, USA
| | - Eva Kline-Rogers
- 2 Department of Cardiovascular Medicine, University of Michigan Health System, Ann Arbor, MI, USA
| | - Steve Almany
- 3 Department of Cardiology, William Beaumont Hospital, Royal Oak, MI, USA
| | | | | | - Scott Kaatz
- 5 Henry Ford Health System, Detroit, MI, USA
| | | | - James B Froehlich
- 2 Department of Cardiovascular Medicine, University of Michigan Health System, Ann Arbor, MI, USA
| | - Geoffrey D Barnes
- 2 Department of Cardiovascular Medicine, University of Michigan Health System, Ann Arbor, MI, USA
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Putnam A, Gu X, Haymart B, Kline-Rogers E, Almany S, Kozlowski J, Krol GD, Kaatz S, Froehlich JB, Barnes GD. The changing characteristics of atrial fibrillation patients treated with warfarin. J Thromb Thrombolysis 2016; 40:488-93. [PMID: 26130229 DOI: 10.1007/s11239-015-1244-0] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [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] [Indexed: 11/25/2022]
Abstract
It has been suggested that direct oral anticoagulants are being preferentially used in low risk atrial fibrillation (AF) patients. Understanding the changing risk profile of new AF patients treated with warfarin is important for interpreting the quality of warfarin delivery through an anticoagulation clinic. Six anticoagulation clinics participating in the Michigan Anticoagulation Quality Improvement Initiative enrolled 1293 AF patients between 2010 and 2014 as an inception cohort. Abstracted data included demographics, comorbidities, medication use and all INR values. Risk scores including CHADS2, CHA2DS2-VASc, HAS-BLED, SAMe-TT2R2, and Charlson comorbidity index (CCI) were calculated for each patient at the time of warfarin initiation. The quality of anticoagulation was assessed using the Rosendaal time in the therapeutic range (TTR) during the first 6 months of treatment. Between 2010 and 2014, patients initiating warfarin therapy for AF had an increasing mean CHADS2 (2.0 ± 1.1 to 2.2 ± 1.4, p = 0.02) and CCI (4.7 ± 1.8 to 5.1 ± 2.0, p = 0.03), and a trend towards increasing mean CHA2DS2-VASc, HAS-BLED, and SAMe-TT2R2 scores. The actual TTR remained unchanged over the study period (62.6 ± 18.2 to 62.7 ± 17.0, p = 0.98), and the number of INR checks did not change (18.9 ± 5.2 to 18.5 ± 5.1, p = 0.06). Between 2010 and 2014, AF patients newly starting warfarin had mild increases in risk for stroke and death with sustained quality of warfarin therapy.
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Affiliation(s)
- Andrew Putnam
- University of Michigan Cardiovascular Center, 24 Frank Lloyd Wright Dr., Lobby A Rm 3201, Ann Arbor, MI, 48106, USA.
| | - Xiaokui Gu
- University of Michigan Cardiovascular Center, 24 Frank Lloyd Wright Dr., Lobby A Rm 3201, Ann Arbor, MI, 48106, USA
| | - Brian Haymart
- University of Michigan Cardiovascular Center, 24 Frank Lloyd Wright Dr., Lobby A Rm 3201, Ann Arbor, MI, 48106, USA
| | - Eva Kline-Rogers
- University of Michigan Cardiovascular Center, 24 Frank Lloyd Wright Dr., Lobby A Rm 3201, Ann Arbor, MI, 48106, USA
| | - Steve Almany
- William Beaumont Hospital, 4600 Investment Dr., Suite 200, Troy, MI, 48098, USA
| | - Jay Kozlowski
- Huron Valley Sinai Hospital, 1 William Carls Dr., Commerce, MI, 48382, USA
| | - Gregory D Krol
- Henry Ford Health System, 2799 W. Grand Blvd., Detroit, MI, 48202, USA
| | - Scott Kaatz
- Hurley Medical Center, 1 Hurley Plaza, Flint, MI, 48503, USA
| | - James B Froehlich
- University of Michigan Cardiovascular Center, 24 Frank Lloyd Wright Dr., Lobby A Rm 3201, Ann Arbor, MI, 48106, USA
| | - Geoffrey D Barnes
- University of Michigan Cardiovascular Center, 24 Frank Lloyd Wright Dr., Lobby A Rm 3201, Ann Arbor, MI, 48106, USA
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Vanhecke TE, Weber JE, Ebinger M, Bonzheim K, Tilli F, Rao S, Osman A, Silver M, Fliegner K, Almany S, Haines D. Implementation of ultraportable echocardiography in an adolescent sudden cardiac arrest screening program. Clin Med Insights Cardiol 2014; 8:87-92. [PMID: 25249762 PMCID: PMC4167321 DOI: 10.4137/cmc.s15779] [Citation(s) in RCA: 5] [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] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/31/2014] [Revised: 05/19/2014] [Accepted: 05/19/2014] [Indexed: 11/21/2022]
Abstract
BACKGROUND Over a 12-month period, adolescent heart-screening programs were performed for identifying at-risk adolescents for sudden cardiac death (SCD) in our community. Novel to our study, all adolescents received an abbreviated, ultraportable echocardiography (UPE). In this report, we describe the use of UPE in this screening program. METHODS AND RESULTS Four hundred thirty-two adolescents underwent cardiac screening with medical history questionnaire, physical examination, 12-lead electrocardiogram (ECG), and an abbreviated transthoracic echocardiographic examination. There were 11 abnormalities identified with uncertain/varying clinical risk significance. In this population, 75 adolescents had a murmur or high ECG voltage, of which only three had subsequent structural abnormalities on echocardiography that may pose risk. Conversely, UPE discovered four adolescents who had a cardiovascular structural abnormality that was not signaled by the 12-lead ECG, medical history questionnaire, and/or physical examination. CONCLUSIONS The utilization of ultraportable, handheld echocardiography is feasible in large-scale adolescent cardiovascular screening programs. UPE appears to be useful for finding additional structural abnormalities and for risk-stratifying abnormalities of uncertain potential of adolescents’ sudden death.
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Affiliation(s)
- Thomas E Vanhecke
- Department of Cardiovascular Medicine, Michigan State University/Genesys Regional Medical Center/Ascension Health, Grand Blanc, MI, USA
| | - James E Weber
- Department of Emergency Medicine, University of Michigan Medical School/Hurley Medical Center, Ann Arbor, MI, USA
| | - Matthew Ebinger
- Department of Cardiovascular Medicine, Michigan State University/Genesys Regional Medical Center/Ascension Health, Grand Blanc, MI, USA
| | - Kimberly Bonzheim
- Department of Cardiovascular Medicine, Michigan State University/Genesys Regional Medical Center/Ascension Health, Grand Blanc, MI, USA
| | - Frank Tilli
- Department of Cardiovascular Medicine, Michigan State University/Genesys Regional Medical Center/Ascension Health, Grand Blanc, MI, USA
| | - Sunilkumar Rao
- Department of Cardiovascular Medicine, Michigan State University/Genesys Regional Medical Center/Ascension Health, Grand Blanc, MI, USA
| | - Abdulfatah Osman
- Department of Cardiovascular Medicine, Michigan State University/Genesys Regional Medical Center/Ascension Health, Grand Blanc, MI, USA
| | - Marc Silver
- Department of Cardiovascular Medicine, Michigan State University/Genesys Regional Medical Center/Ascension Health, Grand Blanc, MI, USA
| | - Karsten Fliegner
- Department of Cardiovascular Medicine, Michigan State University/Genesys Regional Medical Center/Ascension Health, Grand Blanc, MI, USA
| | - Steve Almany
- Department of Cardiovascular Medicine, Oakland University/William Beaumont Hospital, Royal Oak, MI, USA
| | - David Haines
- Department of Cardiovascular Medicine, Oakland University/William Beaumont Hospital, Royal Oak, MI, USA
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Barnes GD, Gu X, Haymart B, Kline-Rogers E, Almany S, Kozlowski J, Besley D, Krol GD, Froehlich JB, Kaatz S. The Predictive Ability of the CHADS2 and CHA2DS2-VASc Scores for Bleeding Risk in Atrial Fibrillation: The MAQI2 Experience. Thromb Res 2014; 134:294-9. [DOI: 10.1016/j.thromres.2014.05.034] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/11/2013] [Revised: 04/22/2014] [Accepted: 05/20/2014] [Indexed: 10/25/2022]
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Barnes GD, Kaatz S, Winfield J, Gu X, Haymart B, Kline-Rogers E, Kozlowski J, Beasley D, Almany S, Leyden T, Froehlich JB. Warfarin use in atrial fibrillation patients at low risk for stroke: analysis of the Michigan Anticoagulation Quality Improvement Initiative (MAQI2). J Thromb Thrombolysis 2013; 37:171-6. [DOI: 10.1007/s11239-013-0934-8] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
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Sick PB, Schuler G, Hauptmann KE, Grube E, Yakubov S, Turi ZG, Mishkel G, Almany S, Holmes DR. Initial worldwide experience with the WATCHMAN left atrial appendage system for stroke prevention in atrial fibrillation. J Am Coll Cardiol 2007; 49:1490-5. [PMID: 17397680 DOI: 10.1016/j.jacc.2007.02.035] [Citation(s) in RCA: 243] [Impact Index Per Article: 14.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/08/2007] [Revised: 02/26/2007] [Accepted: 02/28/2007] [Indexed: 02/06/2023]
Abstract
OBJECTIVES This study assessed the feasibility of implanting a device in the left atrial appendage (LAA) in patients with atrial fibrillation (AF) to prevent thromboembolic stroke. BACKGROUND Meta-analyses confirmed that in cases of left atrial thrombus in nonrheumatic AF patients approximately 90% of them are in the LAA. METHODS The WATCHMAN Left Atrial Appendage System (Atritech Inc., Plymouth, Minnesota) is a nitinol device implanted percutaneously to seal the LAA. Patients were followed by clinical and transesophageal echocardiography at 45 days and 6 months with annual clinical follow-up thereafter. RESULTS Sixty-six patients underwent device implantation. Mean follow-up was 740 +/- 341 days. At 45 days, 93% (54 of 58) devices showed successful sealing of LAA according to protocol. Two patients experienced device embolization, both successfully retrieved percutaneously. No embolizations occurred in 53 patients enrolled after modification of fixation barbs. There were 2 cardiac tamponades, 1 air embolism, and 1 delivery wire fracture (first generation) with surgical explantation but no long-term sequelae for the patient. Four patients developed a flat thrombus layer on the device at 6 months that resolved with additional anticoagulation. Two patients experienced transient ischemic attack, 1 without visible thrombus. There were 2 deaths, neither device related. Autopsy documented a stable, fully endothelialized device 9 months after implantation. No strokes occurred during follow-up despite >90% of patients with discontinuation of anticoagulation. CONCLUSIONS Preliminary data suggest LAA occlusion with the WATCHMAN System to be safe and feasible. A randomized study is ongoing comparing oral anticoagulation with percutaneous closure.
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Affiliation(s)
- Peter B Sick
- Krankenhaus der Barmherzigen Brüder, Regensburg, Germany.
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Abstract
Left atrial appendage (LAA) filter implantation was attempted in an 89 year old male. The LAA size was estimated by transesophageal echocardiography (TEE). Complete LAA obliteration was not achieved. LAA angiography suggested that the LAA was multilobed, likely separated by a thin septae not seen with TEE. MRI or CT may be more appropriate imaging modalities to define LAA anatomy.
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Yadav JS, Ziada KM, Almany S, Davis TP, Castaneda F. Comparison of the QuickSeal Femoral Arterial Closure System with manual compression following diagnostic and interventional catheterization procedures. Am J Cardiol 2003; 91:1463-6, A6. [PMID: 12804735 DOI: 10.1016/s0002-9149(03)00399-0] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Affiliation(s)
- Jay S Yadav
- The Cleveland Clinic Foundation, Desk F25, 9500 Euclid Avenue, Cleveland, OH 44195, USA.
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Ochoa AB, O'Neill W, Almany S. Atrial fibrillation does not degrade the clinical benefits from enhanced external counterpulsation therapy in patients with chronic angina: Results from the international EECP patient registry. J Am Coll Cardiol 2003. [DOI: 10.1016/s0735-1097(03)81074-4] [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: 10/26/2022]
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Stone GW, Rogers C, Ramee S, White C, Kuntz RE, Popma JJ, George J, Almany S, Bailey S. Distal filter protection during saphenous vein graft stenting: technical and clinical correlates of efficacy. J Am Coll Cardiol 2002; 40:1882-8. [PMID: 12446075 DOI: 10.1016/s0735-1097(02)02129-0] [Citation(s) in RCA: 60] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
OBJECTIVES The aim of this study was to evaluate the clinical, angiographic, and technical factors related to successful stenting of diseased saphenous vein grafts (SVGs) using a novel filter-based distal protection device. BACKGROUND Protection of the distal microvasculature with a balloon occlusion and aspiration system has been shown to reduce atherothrombotic embolization and peri-procedural myocardial infarction (MI) after percutaneous coronary intervention (PCI) in SVGs. The safety, efficacy, and technical factors relating to procedural success with filter-based distal protection devices are unknown. METHODS Percutaneous coronary intervention was performed in 60 lesions in 48 patients undergoing SVG intervention with the FilterWire EX distal protection system in a phase I experience at six sites. A larger phase II study was then performed in 248 lesions in 230 SVGs at 65 U.S. centers. RESULTS Cumulative adverse events to 30 days occurred in 21.3% of patients in phase I, including a 19.1% rate of MI. Numerous anatomic, device-specific, and operator-related contributors to these adverse events were identified, resulting in significant changes to the protocol and instructions for use. Subsequently, despite similar clinical and angiographic characteristics to the phase I patients, the 30-day adverse event rate in phase II was reduced to 11.3% (p = 0.09), due primarily to a lower incidence of peri-procedural Q-wave and non-Q-wave MI. CONCLUSIONS Distal protection during SVG PCI with the FilterWire EX is associated with a low rate of peri-procedural adverse events compared to historical controls. A unique set of anatomic, technical, and operator-related issues exist with distal filters which, if ignored, may reduce their effectiveness.
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Affiliation(s)
- Gregg W Stone
- The Cardiovascular Research Foundation, 55 East 59th Street, 6th Floor, New York, NY 10022, USA.
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Safian RD, Hoffmann MA, Almany S, Kahn J, Reddy V, Marsalese D, Gangadharan V, Ajluni S, Friedman HZ, Schreiber TL. Comparison of coronary angioplasty with compliant and noncompliant balloons (the Angioplasty Compliance Trial). Am J Cardiol 1995; 76:518-20. [PMID: 7653457 DOI: 10.1016/s0002-9149(99)80143-x] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/26/2023]
Affiliation(s)
- R D Safian
- Division of Cardiology (Department of Medicine), William Beaumont Hospital, Royal Oak, Michigan 48073, USA
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