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Oesterle A, Pellegrini CN, Dhruva SS, Kizer JR, Raitt MH, Liem LB. Systematic reprogramming of implantable cardioverter-defibrillators to match the 2019 consensus recommendations. Heart Rhythm 2024; 21:119-121. [PMID: 37805017 DOI: 10.1016/j.hrthm.2023.09.027] [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] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/09/2023] [Revised: 09/26/2023] [Accepted: 09/26/2023] [Indexed: 10/09/2023]
Affiliation(s)
- Adam Oesterle
- Division of Cardiology, Department of Medicine, University of California, San Francisco, San Francisco Veterans Affairs Health Care System, San Francisco, California.
| | - Cara N Pellegrini
- Division of Cardiology, Department of Medicine, University of California, San Francisco, San Francisco Veterans Affairs Health Care System, San Francisco, California
| | - Sanket S Dhruva
- Division of Cardiology, Department of Medicine, University of California, San Francisco, San Francisco Veterans Affairs Health Care System, San Francisco, California
| | - Jorge R Kizer
- Division of Cardiology, Department of Medicine, University of California, San Francisco, San Francisco Veterans Affairs Health Care System, San Francisco, California
| | - Merritt H Raitt
- Division of Cardiology, Department of Internal Medicine, Oregon Health & Sciences University, Veterans Affairs Portland Health Care System, Portland, Oregon
| | - L Bing Liem
- Division of Cardiology, Department of Medicine, University of California, San Francisco, San Francisco Veterans Affairs Health Care System, San Francisco, California
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Yuan N, Duffy G, Dhruva SS, Oesterle A, Pellegrini CN, Theurer J, Vali M, Heidenreich PA, Keyhani S, Ouyang D. Deep Learning of Electrocardiograms in Sinus Rhythm From US Veterans to Predict Atrial Fibrillation. JAMA Cardiol 2023; 8:1131-1139. [PMID: 37851434 PMCID: PMC10585587 DOI: 10.1001/jamacardio.2023.3701] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/22/2023] [Accepted: 07/31/2023] [Indexed: 10/19/2023]
Abstract
Importance Early detection of atrial fibrillation (AF) may help prevent adverse cardiovascular events such as stroke. Deep learning applied to electrocardiograms (ECGs) has been successfully used for early identification of several cardiovascular diseases. Objective To determine whether deep learning models applied to outpatient ECGs in sinus rhythm can predict AF in a large and diverse patient population. Design, Setting, and Participants This prognostic study was performed on ECGs acquired from January 1, 1987, to December 31, 2022, at 6 US Veterans Affairs (VA) hospital networks and 1 large non-VA academic medical center. Participants included all outpatients with 12-lead ECGs in sinus rhythm. Main Outcomes and Measures A convolutional neural network using 12-lead ECGs from 2 US VA hospital networks was trained to predict the presence of AF within 31 days of sinus rhythm ECGs. The model was tested on ECGs held out from training at the 2 VA networks as well as 4 additional VA networks and 1 large non-VA academic medical center. Results A total of 907 858 ECGs from patients across 6 VA sites were included in the analysis. These patients had a mean (SD) age of 62.4 (13.5) years, 6.4% were female, and 93.6% were male, with a mean (SD) CHA2DS2-VASc (congestive heart failure, hypertension, age, diabetes mellitus, prior stroke or transient ischemic attack or thromboembolism, vascular disease, age, sex category) score of 1.9 (1.6). A total of 0.2% were American Indian or Alaska Native, 2.7% were Asian, 10.7% were Black, 4.6% were Latinx, 0.7% were Native Hawaiian or Other Pacific Islander, 62.4% were White, 0.4% were of other race or ethnicity (which is not broken down into subcategories in the VA data set), and 18.4% were of unknown race or ethnicity. At the non-VA academic medical center (72 483 ECGs), the mean (SD) age was 59.5 (15.4) years and 52.5% were female, with a mean (SD) CHA2DS2-VASc score of 1.6 (1.4). A total of 0.1% were American Indian or Alaska Native, 7.9% were Asian, 9.4% were Black, 2.9% were Latinx, 0.03% were Native Hawaiian or Other Pacific Islander, 74.8% were White, 0.1% were of other race or ethnicity, and 4.7% were of unknown race or ethnicity. A deep learning model predicted the presence of AF within 31 days of a sinus rhythm ECG on held-out test ECGs at VA sites with an area under the receiver operating characteristic curve (AUROC) of 0.86 (95% CI, 0.85-0.86), accuracy of 0.78 (95% CI, 0.77-0.78), and F1 score of 0.30 (95% CI, 0.30-0.31). At the non-VA site, AUROC was 0.93 (95% CI, 0.93-0.94); accuracy, 0.87 (95% CI, 0.86-0.88); and F1 score, 0.46 (95% CI, 0.44-0.48). The model was well calibrated, with a Brier score of 0.02 across all sites. Among individuals deemed high risk by deep learning, the number needed to screen to detect a positive case of AF was 2.47 individuals for a testing sensitivity of 25% and 11.48 for 75%. Model performance was similar in patients who were Black, female, or younger than 65 years or who had CHA2DS2-VASc scores of 2 or greater. Conclusions and Relevance Deep learning of outpatient sinus rhythm ECGs predicted AF within 31 days in populations with diverse demographics and comorbidities. Similar models could be used in future AF screening efforts to reduce adverse complications associated with this disease.
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Affiliation(s)
- Neal Yuan
- Department of Medicine, University of California, San Francisco
- Division of Cardiology, San Francisco Veterans Affairs Medical Center, San Francisco, California
| | - Grant Duffy
- Smidt Heart Institute, Cedars-Sinai Medical Center, Los Angeles, California
- Division of Artificial Intelligence in Medicine, Department of Medicine, Cedars-Sinai Medical Center, Los Angeles, California
| | - Sanket S. Dhruva
- Department of Medicine, University of California, San Francisco
- Division of Cardiology, San Francisco Veterans Affairs Medical Center, San Francisco, California
| | - Adam Oesterle
- Department of Medicine, University of California, San Francisco
- Division of Cardiology, San Francisco Veterans Affairs Medical Center, San Francisco, California
| | - Cara N. Pellegrini
- Department of Medicine, University of California, San Francisco
- Division of Cardiology, San Francisco Veterans Affairs Medical Center, San Francisco, California
| | - John Theurer
- Smidt Heart Institute, Cedars-Sinai Medical Center, Los Angeles, California
- Division of Artificial Intelligence in Medicine, Department of Medicine, Cedars-Sinai Medical Center, Los Angeles, California
| | - Marzieh Vali
- Department of Medicine, University of California, San Francisco
- Division of General Internal Medicine, San Francisco Veterans Affairs Medical Center, San Francisco, California
| | - Paul A. Heidenreich
- Division of Cardiology, Palo Alto Veterans Affairs Medical Center, Palo Alto, California
- Division of Cardiovascular Medicine, Department of Medicine, Stanford University, Palo Alto, California
| | - Salomeh Keyhani
- Department of Medicine, University of California, San Francisco
- Division of General Internal Medicine, San Francisco Veterans Affairs Medical Center, San Francisco, California
| | - David Ouyang
- Division of Cardiology, San Francisco Veterans Affairs Medical Center, San Francisco, California
- Smidt Heart Institute, Cedars-Sinai Medical Center, Los Angeles, California
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Oesterle A, Dhruva SS, Pellegrini CN, Liem B, Raitt MH. Ventricular arrhythmia detection for contemporary Biotronik and Abbott implantable cardioverter defibrillators with markedly prolonged detection in Biotronik devices. J Interv Card Electrophysiol 2023; 66:1679-1691. [PMID: 36737506 DOI: 10.1007/s10840-023-01498-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/27/2022] [Accepted: 01/27/2023] [Indexed: 02/05/2023]
Abstract
BACKGROUND Implantable cardioverter defibrillators (ICDs) are typically programed with both ventricular tachycardia (VT) and ventricular fibrillation (VF) treatment zones. Biotronik and Abbott ICDs do not increment the VT counter when the tachycardia accelerates to the VF zone, which could result in a prolonged delay in tachycardia detection. METHODS Patients with Biotronik and Abbott ICDs receiving care at Veterans Affairs facilities in Northern California were identified. Patient information and device tracings for patients with any ICD therapies were examined to assess for possible delayed tachycardia detection. RESULTS Among 52 patients with Biotronik ICDs, 8 (15%) experienced appropriate ICD therapy over a median follow-up of 29 months. Among 68 patients with Abbott ICDs, 26 (38%) experienced appropriate ICD therapy over a median follow-up of 83 months. Three of the patients with Biotronik ICDs who received appropriate therapy experienced a delay in VT/VF detection due to the tachycardia rate oscillating between the VT and VF treatment zones (longest 31.2 s on detection), compared with four of the patients with Abbott ICDs (longest 4.1 s on the detection and 8 s on redetect). One of the patients with a Biotronik ICD experienced recurrent syncope associated with delayed detection and another died on the day of delayed detection. One of the patients with an Abbott ICD experienced syncope. CONCLUSIONS Because contemporary Biotronik and Abbott ICDs freeze the VT counters when tachycardia is in the VF zone, ICD therapies can be markedly delayed when the tachycardia oscillates between the VT and VF zone.
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Affiliation(s)
- Adam Oesterle
- Division of Cardiology, Department of Medicine, University of California San Francisco - Veterans Affairs San Francisco Health Care System, 4150 Clement Street, Building 203, Room 2A-25, San Francisco, CA, 94121, USA.
| | - Sanket S Dhruva
- Division of Cardiology, Department of Medicine, University of California San Francisco - Veterans Affairs San Francisco Health Care System, 4150 Clement Street, Building 203, Room 2A-25, San Francisco, CA, 94121, USA
| | - Cara N Pellegrini
- Division of Cardiology, Department of Medicine, University of California San Francisco - Veterans Affairs San Francisco Health Care System, 4150 Clement Street, Building 203, Room 2A-25, San Francisco, CA, 94121, USA
| | - Bing Liem
- Division of Cardiology, Department of Medicine, University of California San Francisco - Veterans Affairs San Francisco Health Care System, 4150 Clement Street, Building 203, Room 2A-25, San Francisco, CA, 94121, USA
| | - Merritt H Raitt
- Division of Cardiology, Veterans Affairs Portland Health Care System, Portland, OR, USA
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Oesterle A, Liem LB, Dhruva SS, Friday G, Raitt MH, Pellegrini CN. Reply: The Challenge of Minimizing Unnecessary ICD Shocks While Also Preventing Syncope. JACC Clin Electrophysiol 2023; 9:2005. [PMID: 37758373 DOI: 10.1016/j.jacep.2023.07.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/04/2023] [Accepted: 07/05/2023] [Indexed: 10/03/2023]
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Oesterle A, Buzkova P, Pellegrini CN, Hirsch C, Tracy R, Siscovick D, Djousse L, Mukamal K, Kizer J. Fasting and Post-Load Glucose and Non-Esterified Fatty Acids and Risk of Heart Failure and Its Subtypes in Older Adults. J Gerontol A Biol Sci Med Sci 2023; 78:1164-1171. [PMID: 36373954 PMCID: PMC10329227 DOI: 10.1093/gerona/glac229] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [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: 05/03/2022] [Indexed: 07/20/2023] Open
Abstract
BACKGROUND Glucose and non-esterified fatty acids (NEFA) are myocardial fuels whose fasting and post-prandial levels are under different homeostatic regulation. The relationships of fasting and post-load glucose and NEFA with incident heart failure (HF) remain incompletely defined. METHODS Serum glucose and NEFA were measured during fasting and 2 hours post-oral glucose tolerance test, performed in Cardiovascular Health Study participants not receiving hypoglycemic medication. Participants with prevalent HF or lacking relevant data were excluded. Outcomes were incident HF (primary), and HF with preserved (HFpEF) and reduced (HFrEF) ejection fraction (secondary). RESULTS Among 2 238 participants (age 78 ± 4) with a median follow-up of 9.9 years, there were 737 HF events. After adjustment for demographic and lifestyle factors, both fasting (hazard ratio [HR] = 1.11 per SD [95% confidence interval {CI} = 1.01-1.23], p = .040) and post-load (HR = 1.14 per SD [1.05-1.24], p = 0.002) glucose were significantly associated with incident HF. No association was seen for fasting or post-load NEFA. Upon mutual adjustment, only post-load glucose (HR = 1.11 [1.003-1.22], p = .044), but not fasting glucose (HR = 1.06 [0.94-1.20], p = .340), remained associated with HF. Further adjustment for cardiovascular disease and other risk factors in the causal pathway did not affect the association for post-load glucose, but eliminated that for fasting glucose. Associations for fasting and post-load glucose appeared stronger with higher adiposity and were observed specifically for HFrEF but not HFpEF. CONCLUSIONS Fasting and post-load glucose, but not NEFA, were associated with incident HF. The association was especially robust for post-load glucose, suggesting that pathways involved in post-prandial dysglycemia could offer new targets for HF prevention late in life.
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Affiliation(s)
- Adam Oesterle
- Department of Medicine, Division of Cardiology San Francisco VA & University of California San Francisco, San Francisco, California, USA
| | - Petra Buzkova
- Department of Biostatistics, University of Washington, Seattle, Washington, USA
| | - Cara N Pellegrini
- Department of Medicine, Division of Cardiology San Francisco VA & University of California San Francisco, San Francisco, California, USA
| | - Calvin Hirsch
- Department of Medicine, University of California Davis, Davis, California, USA
| | - Russell P Tracy
- Department of Pathology and Laboratory Medicine, University of Vermont, Burlington, Vermont, USA
| | | | - Luc Djousse
- Department of Medicine, Brigham and Women’s Hospital, Boston, Massachusetts, USA
| | - Ken J Mukamal
- Department of Medicine, Beth Israel Deaconess Medical Center, Boston, Massachusetts, USA
| | - Jorge R Kizer
- Department of Medicine, Division of Cardiology San Francisco VA & University of California San Francisco, San Francisco, California, USA
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Pellegrini CN, Buzkova P, Oesterle A, Heckbert SR, Tracy RP, Siscovick DS, Mukamal KJ, Djoussé L, Kizer JR. Dysregulated carbohydrate and lipid metabolism and risk of atrial fibrillation in advanced old age. Heart 2023; 109:606-611. [PMID: 36549682 PMCID: PMC10285028 DOI: 10.1136/heartjnl-2022-321633] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/12/2022] [Accepted: 12/07/2022] [Indexed: 12/24/2022] Open
Abstract
OBJECTIVE Obesity and dysmetabolism are major risk factors for atrial fibrillation (AF). Fasting and postload levels of glucose and non-esterified fatty acids (NEFAs) reflect different facets of metabolic regulation. We sought to study their respective contributions to AF risk concurrently. METHODS We assessed levels of fasting and postload glucose and NEFA in the Cardiovascular Health Study to identify associations with AF incidence and, secondarily, with ECG parameters of AF risk available at baseline. Linear and Cox regressions were performed. RESULTS The study included 1876 participants (age 77.7±4.4). During the median follow-up of 11.4 years, 717 cases of incident AF occurred. After adjustment for potential confounders, postload glucose showed an association with incident AF (HR per SD increment of postload glucose=1.11, 95% CI 1.02 to 1.21, p=0.017). Both glucose measures, but not NEFA, were positively associated with higher P wave terminal force in V1 (PTFV1); the association remained significant only for postload glucose when the two measures were entered together (β per SD increment=138 μV·ms, 95% CI 15 to 260, p=0.028). Exploratory analyses showed significant interaction by sex for fasting NEFA (pinteraction=0.044) and postload glucose (pinteraction=0.015) relative to AF, with relationships stronger in women. For postload glucose, the association with incident AF was observed among women but not among men. CONCLUSIONS Among older adults, postload glucose was positively associated with incident AF, with consistent findings for PTFV1. In exploratory analyses, the relationship with AF appeared specific to women. These findings require further study but suggest that interventions to address postprandial dysglycaemia late in life might reduce AF.
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Affiliation(s)
- Cara N Pellegrini
- Medical Service, San Francisco VA Health Care System, San Francisco, CA, USA
- Medicine, University of California, San Francisco, San Francisco, CA, USA
| | - Petra Buzkova
- Biostatics, University of Washington, Seattle, Washington, USA
| | - Adam Oesterle
- Medical Service, San Francisco VA Health Care System, San Francisco, CA, USA
- Medicine, University of California, San Francisco, San Francisco, CA, USA
| | | | - Russell P Tracy
- Pathology and Biochemistry, University of Vermont, Burlington, Vermont, USA
| | - David S Siscovick
- Medicine and Epidemiology, New York Academy of Medicine, New York, New York, USA
| | - Kenneth J Mukamal
- Medicine, Beth Israel Deaconess Medical Center, Boston, Massachusetts, USA
| | - Luc Djoussé
- Medicine, Brigham and Women's Hospital, Boston, Massachusetts, USA
| | - Jorge R Kizer
- Medical Service, San Francisco VA Health Care System, San Francisco, CA, USA
- Medicine, University of California, San Francisco, San Francisco, CA, USA
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Oesterle A, Liem LB, Dhruva SS, Friday G, Raitt MH, Pellegrini CN. Traumatic Syncope Caused by Prolonged Ventricular Arrhythmias With a Defibrillator Programmed to 2019 Consensus Recommendations. JACC Clin Electrophysiol 2023; 9:442-443. [PMID: 36702697 DOI: 10.1016/j.jacep.2022.11.012] [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] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/21/2022] [Revised: 11/02/2022] [Accepted: 11/09/2022] [Indexed: 01/20/2023]
Affiliation(s)
- Adam Oesterle
- Division of Cardiology, Department of Internal Medicine, University of California-San Francisco, San Francisco Veterans Affairs Health Care System, San Francisco, California, USA.
| | - L Bing Liem
- Division of Cardiology, Department of Internal Medicine, University of California-San Francisco, San Francisco Veterans Affairs Health Care System, San Francisco, California, USA
| | - Sanket S Dhruva
- Division of Cardiology, Department of Internal Medicine, University of California-San Francisco, San Francisco Veterans Affairs Health Care System, San Francisco, California, USA
| | - Gareth Friday
- Boston Scientific Corporation, Marlborough, Massachusetts, USA
| | - Merritt H Raitt
- Division of Cardiology, Department of Internal Medicine, Oregon Health & Sciences University, Veterans Affairs Portland Health Care System, Portland, Oregon, USA
| | - Cara N Pellegrini
- Division of Cardiology, Department of Internal Medicine, University of California-San Francisco, San Francisco Veterans Affairs Health Care System, San Francisco, California, USA
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Yuan N, Oesterle A, Botting P, Chugh S, Albert C, Ebinger J, Ouyang D. High-Throughput Assessment of Real-World Medication Effects on QT Interval Prolongation: Observational Study. JMIR Cardio 2023; 7:e41055. [PMID: 36662566 PMCID: PMC9898836 DOI: 10.2196/41055] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/13/2022] [Revised: 12/28/2022] [Accepted: 12/29/2022] [Indexed: 01/21/2023] Open
Abstract
BACKGROUND Drug-induced prolongation of the corrected QT interval (QTc) increases the risk for Torsades de Pointes (TdP) and sudden cardiac death. Medication effects on the QTc have been studied in controlled settings but may not be well evaluated in real-world settings where medication effects may be modulated by patient demographics and comorbidities as well as the usage of other concomitant medications. OBJECTIVE We demonstrate a new, high-throughput method leveraging electronic health records (EHRs) and the Surescripts pharmacy database to monitor real-world QTc-prolonging medication and potential interacting effects from demographics and comorbidities. METHODS We included all outpatient electrocardiograms (ECGs) from September 2008 to December 2019 at a large academic medical system, which were in sinus rhythm with a heart rate of 40-100 beats per minute, QRS duration of <120 milliseconds, and QTc of 300-700 milliseconds, determined using the Bazett formula. We used prescription information from the Surescripts pharmacy database and EHR medication lists to classify whether a patient was on a medication during an ECG. Negative control ECGs were obtained from patients not currently on the medication but who had been or would be on that medication within 1 year. We calculated the difference in mean QTc between ECGs of patients who are on and those who are off a medication and made comparisons to known medication TdP risks per the CredibleMeds.org database. Using linear regression analysis, we studied the interaction of patient-level demographics or comorbidities on medication-related QTc prolongation. RESULTS We analyzed the effects of 272 medications on 310,335 ECGs from 159,397 individuals. Medications associated with the greatest QTc prolongation were dofetilide (mean QTc difference 21.52, 95% CI 10.58-32.70 milliseconds), mexiletine (mean QTc difference 18.56, 95% CI 7.70-29.27 milliseconds), amiodarone (mean QTc difference 14.96, 95% CI 13.52-16.33 milliseconds), rifaximin (mean QTc difference 14.50, 95% CI 12.12-17.13 milliseconds), and sotalol (mean QTc difference 10.73, 95% CI 7.09-14.37 milliseconds). Several top QT prolonging medications such as rifaximin, lactulose, cinacalcet, and lenalidomide were not previously known but have plausible mechanistic explanations. Significant interactions were observed between demographics or comorbidities and QTc prolongation with many medications, such as coronary disease and amiodarone. CONCLUSIONS We demonstrate a new, high-throughput technique for monitoring real-world effects of QTc-prolonging medications from readily accessible clinical data. Using this approach, we confirmed known medications for QTc prolongation and identified potential new associations and demographic or comorbidity interactions that could supplement findings in curated databases. Our single-center results would benefit from additional verification in future multisite studies that incorporate larger numbers of patients and ECGs along with more precise medication adherence and comorbidity data.
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Affiliation(s)
- Neal Yuan
- Division of Cardiology, Department of Medicine, San Francisco Veteran Affairs Medical Center, San Francisco, CA, United States
| | - Adam Oesterle
- Division of Cardiology, Department of Medicine, San Francisco Veteran Affairs Medical Center, San Francisco, CA, United States
| | - Patrick Botting
- Smidt Heart Institute, Department of Cardiology, Cedars-Sinai Medical Center, Los Angeles, CA, United States
| | - Sumeet Chugh
- Smidt Heart Institute, Department of Cardiology, Cedars-Sinai Medical Center, Los Angeles, CA, United States
| | - Christine Albert
- Smidt Heart Institute, Department of Cardiology, Cedars-Sinai Medical Center, Los Angeles, CA, United States
| | - Joseph Ebinger
- Smidt Heart Institute, Department of Cardiology, Cedars-Sinai Medical Center, Los Angeles, CA, United States
| | - David Ouyang
- Smidt Heart Institute, Department of Cardiology, Cedars-Sinai Medical Center, Los Angeles, CA, United States
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Haghighat L, Goldschlager N, Oesterle A. ECG Challenge: AV Block or Something Else? Circulation 2023; 147:267-270. [PMID: 36649396 DOI: 10.1161/circulationaha.122.063243] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
Affiliation(s)
- Leila Haghighat
- Division of Cardiology (L.H.), Department of Medicine, University of California, San Francisco
| | - Nora Goldschlager
- Section of Cardiac Electrophysiology (N.G., A.O.), Department of Medicine, University of California, San Francisco.,Division of Cardiology, Department of Medicine, Zuckerberg San Francisco General Hospital, CA (N.G.)
| | - Adam Oesterle
- Section of Cardiac Electrophysiology (N.G., A.O.), Department of Medicine, University of California, San Francisco.,Division of Cardiology, Department of Medicine, San Francisco Veterans Affairs Health Care System, CA (A.O.)
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Oesterle A, Giancaterino S, Van Noord MG, Pellegrini CN, Fan D, Srivatsa UN, Amsterdam EA. Effects of Supervised Exercise Training on Atrial Fibrillation: A META-ANALYSIS OF RANDOMIZED CONTROLLED TRIALS. J Cardiopulm Rehabil Prev 2022; 42:258-265. [PMID: 35235540 DOI: 10.1097/hcr.0000000000000665] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
PURPOSE Atrial fibrillation (AF) is associated with the comorbidities of a sedentary lifestyle. Endurance athletes also show an increased incidence of AF. The role of exercise in the treatment of AF is unknown so this study aimed to examine the effects of supervised exercise on AF. METHODS A meta-analysis of randomized controlled trials (RCTs) examining supervised exercise training in participants with AF was performed. The primary outcome was AF recurrence and burden. Secondary outcomes included AF symptoms, quality of life, and cardiorespiratory fitness (CRF). RESULTS Thirteen RCTs, involving 1155 participants, were included. Paroxysmal AF was present in 34% and persistent AF in 64%. The types of exercise were diverse and included cardiac rehabilitation (64%), aerobic training (7%), Qi Gong (4%), interval training (11%), and yoga (15%). Exercise training reduced AF recurrence (relative risk = 0.77: 95% CI, 0.60-0.99), improved quality of life in 5 of the 10 components of the Short Form 36 survey, and improved CRF (standardized mean difference [SMD] = 0.56: 95% CI, 0.27-0.85). The AF burden was reduced only in studies that included continuous ambulatory monitoring (SMD =-0.49: 95% CI, -0.96 to -0.01) but not when all studies were included (SMD =-0.12: 95% CI, -0.61 to 0.38). There was no difference in adverse events between exercise and control. CONCLUSIONS Supervised exercise training is safe, reduces AF recurrence, and improves quality of life and CRF in participants with AF. Further large RCTs with ambulatory monitoring and robust exercise regimens are needed to assess the effects of exercise training on AF burden and AF symptoms.
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Affiliation(s)
- Adam Oesterle
- Department of Cardiology, University of California, San Francisco-Veterans Affairs Medical Center, San Francisco (Drs Oesterle and Pellegrini); Department of Cardiology, University of California, Davis (Drs Giancaterino, Fan, Srivatsa and Amsterdam); and University of California, Davis (Ms Van Noord)
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Oesterle A, Dhruva SS. Reply to the Editor-Denominator neglect in meta-analysis: electrical abnormalities in St. Jude/Abbott pacing leads. Heart Rhythm 2021; 18:2226-2227. [PMID: 34563689 DOI: 10.1016/j.hrthm.2021.09.022] [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: 09/14/2021] [Accepted: 09/15/2021] [Indexed: 11/25/2022]
Affiliation(s)
- Adam Oesterle
- Division of Cardiology, Department of Medicine, University of California San Francisco - Veterans Affairs Medical Center, San Francisco, California.
| | - Sanket S Dhruva
- Division of Cardiology, Department of Medicine, University of California San Francisco - Veterans Affairs Medical Center, San Francisco, California
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Oesterle A, Giancaterino S, Van Noord MG, Pellegrini CN, Fan D, Srivatsa UN, Amsterdam E. B-PO02-141 EXERCISE TRAINING REDUCES ATRIAL FIBRILLATION RECURRENCE AND BURDEN: A META-ANALYSIS OF RANDOMIZED CONTROLLED TRIALS. Heart Rhythm 2021. [DOI: 10.1016/j.hrthm.2021.06.394] [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: 10/20/2022]
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Khatiwala RV, Mullins E, Fan D, Srivatsa UN, Oesterle A. B-PO04-054 A SUGGESTION OF INCREASED LEAD MALFUNCTION WITH ST. JUDE/ ABBOTT PACING LEADS: A SYSTEMATIC REVIEW AND META-ANALYSIS OF OBSERVATIONAL DATA. Heart Rhythm 2021. [DOI: 10.1016/j.hrthm.2021.06.750] [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: 10/20/2022]
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Grinstein J, Garan AR, Oesterle A, Fried J, Imamura T, Mai X, Kalantari S, Sayer G, Kim GH, Sarswat N, Raikhelkar J, Adatya S, Jeevanandam V, Flatley E, Moss J, Uriel N. Increased Rate of Pump Thrombosis and Cardioembolic Events Following Ventricular Tachycardia Ablation in Patients Supported With Left Ventricular Assist Devices. ASAIO J 2021; 66:1127-1136. [PMID: 33136600 PMCID: PMC10024475 DOI: 10.1097/mat.0000000000001155] [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] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/03/2023] Open
Abstract
Ventricular arrhythmias are common following left ventricular assist device implantation (LVAD), and the effects of ventricular tachycardia (VT) ablation on thrombosis and embolic events are unknown. We aimed to assess LVAD thrombosis, stroke, and embolic event rates after VT ablation. Left ventricular assist device implantation patients from two academic centers who underwent endocardial VT ablation between 2009 and 2016 were compared to a control group with VT who were not ablated and followed for one year. The primary composite outcome was confirmed or suspected LVAD thrombosis, stroke, or other embolic event. Survival analysis was conducted with Kaplan-Meier curves, log-rank tests, and Cox regression. Forty-three LVAD patients underwent VT ablation, and 73 LVAD patients had VT but were not ablated. Patients who were ablated were more likely have VT prior to LVAD (p = 0.04), monomorphic VT (p < 0.01), and to be on antiarrhythmics (p < 0.01). Fifty-eight percent of the patients in the ablation group experienced the primary composite outcome (11% had confirmed device thrombosis [DT], 41% suspected DT, 39% had a stroke or embolic event) compared to 30% in the control group (12% with confirmed DT, 11% with suspected DT, 14% with stroke or embolic event) (p = 0.002). In multivariable regression, ablation was an independent predictor of the primary composite outcome (hazard ratios, 2.24; 95% confidence interval, 1.09-4.61; p = 0.03). Patients with LVADs referred for endocardial VT ablation had elevated rates of DT and embolic events.
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Affiliation(s)
| | | | | | - Justin Fried
- Division of Cardiology, Columbia University, New York, NY
| | | | - Xingchen Mai
- Division of Cardiology, Columbia University, New York, NY
| | - Sara Kalantari
- Department of Medicine, University of Chicago, Chicago, IL
| | - Gabriel Sayer
- Division of Cardiology, Columbia University, New York, NY
| | - Gene H. Kim
- Department of Medicine, University of Chicago, Chicago, IL
| | | | | | - Sirtaz Adatya
- Kaiser Permanente Advanced Heart Failure, Santa Clara, CA
| | - Valluvan Jeevanandam
- Department of Surgery, University of Chicago Medical Center, University of Chicago, Chicago, IL
| | - Erin Flatley
- Division of Cardiology, University of California San Francisco, San Francisco, CA
| | - Joshua Moss
- Division of Cardiology, University of California San Francisco, San Francisco, CA
| | - Nir Uriel
- Division of Cardiology, Columbia University, New York, NY
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Zhang X, Fan D, Srivatsa UN, Oesterle A. Implantable cardioverter-defibrillator shocks due to tachycardia with more atrial depolarizations than ventricular depolarizations with a far-field ventricular morphology shift: What is the mechanism? HeartRhythm Case Rep 2021; 7:59-62. [PMID: 33505858 PMCID: PMC7813785 DOI: 10.1016/j.hrcr.2020.10.007] [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] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Affiliation(s)
- Xin Zhang
- Division of Cardiovascular Medicine, Department of Internal Medicine, University of California Davis, Sacramento, California
| | - Dali Fan
- Division of Cardiovascular Medicine, Department of Internal Medicine, University of California Davis, Sacramento, California
| | - Uma N Srivatsa
- Division of Cardiovascular Medicine, Department of Internal Medicine, University of California Davis, Sacramento, California
| | - Adam Oesterle
- Division of Cardiovascular Medicine, Department of Internal Medicine, University of California Davis, Sacramento, California
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Oesterle A, Lee AC, Voskoboinik A, Moss JD, Vedantham V, Walters TE, Lee BK, Tseng ZH, Gerstenfeld EP, Scheinman MM. Electrophysiologic approach to diagnosis and ablation of patients with permanent junctional reciprocating tachycardia associated with complex anatomy and/or physiology. J Cardiovasc Electrophysiol 2020; 31:3232-3242. [PMID: 33107135 DOI: 10.1111/jce.14788] [Citation(s) in RCA: 4] [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: 06/25/2020] [Revised: 10/04/2020] [Accepted: 10/11/2020] [Indexed: 12/13/2022]
Abstract
INTRODUCTION Permanent junctional reciprocating tachycardia (PJRT) is a rare supraventricular tachycardia (SVT), typically involving a single decremental posteroseptal accessory pathway (AP). METHODS Four patients with long RP SVT underwent electrophysiology (EP) study and ablation. The cases were reviewed. RESULTS Case 1 recurred despite 3 prior ablations at the site of earliest retrograde atrial activation during orthodromic reciprocating tachycardia (ORT). Mapping during a repeat EP study demonstrated a prepotential in the coronary sinus (CS). Ablation over the earliest atrial activation in the CS resulted in dissociation of the potential from the atrium during sinus rhythm. The potential was traced back to the CS os and ablated. Case 2 underwent successful ablation at 6 o'clock on the mitral annulus (MA). ORT recurred and successful ablation was performed at 1 o'clock on the MA. Case 3 had tachycardia with variation in both V-A and A-H intervals which precluded the use of usual maneuvers so we used simultaneous atrial and ventricular pacing and introduced a premature atrial contraction with a closely coupled premature ventricular contraction. Case 4 had had two prior atrial fibrillation ablations with continued SVT over a decremental atrioventricular bypass tract that was successfully ablated at 5 o'clock on the tricuspid annulus. A second SVT consistent with a concealed nodoventricular pathway was successfully ablated at the right inferior extension of the AV nodal slow pathway. CONCLUSION We describe challenging cases of PJRT by virtue of complex anatomy, diagnostic features, and multiple arrhythmia mechanisms.
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Affiliation(s)
- Adam Oesterle
- Division of Cardiovascular Medicine, Department of Medicine, University of California Davis, Sacramento, California, USA
| | - Adam C Lee
- Division of Cardiology, Department of Medicine, University of California San Francisco, San Francisco, California, USA
| | - Aleksandr Voskoboinik
- Division of Cardiology, Department of Medicine, University of California San Francisco, San Francisco, California, USA
| | - Joshua D Moss
- Division of Cardiology, Department of Medicine, University of California San Francisco, San Francisco, California, USA
| | - Vasanth Vedantham
- Division of Cardiology, Department of Medicine, University of California San Francisco, San Francisco, California, USA
| | - Tomos E Walters
- Division of Cardiology, Department of Medicine, University of California San Francisco, San Francisco, California, USA
| | - Byron K Lee
- Division of Cardiology, Department of Medicine, University of California San Francisco, San Francisco, California, USA
| | - Zian H Tseng
- Division of Cardiology, Department of Medicine, University of California San Francisco, San Francisco, California, USA
| | - Edward P Gerstenfeld
- Division of Cardiology, Department of Medicine, University of California San Francisco, San Francisco, California, USA
| | - Melvin M Scheinman
- Division of Cardiology, Department of Medicine, University of California San Francisco, San Francisco, California, USA
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Zhang X, Fan D, Gamp P, Pezeshkian N, Srivatsa U, Oesterle A. Pacing inhibition after biventricular implantable cardioverter defibrillator upgrade: What is the mechanism? Pacing Clin Electrophysiol 2020; 43:756-759. [PMID: 32519767 DOI: 10.1111/pace.13976] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/19/2020] [Revised: 05/28/2020] [Accepted: 06/07/2020] [Indexed: 11/28/2022]
Affiliation(s)
- Xin Zhang
- UC Davis Medical Center, Cardiology, UC Davis Department of Medicine, Sacramento, California
| | - Dali Fan
- Division of Cardiovascular Medicine, University of California Davis Department of Internal Medicine, Sacramento, California
| | - Patrick Gamp
- Division of Cardiovascular Medicine, University of California Davis Department of Internal Medicine, Sacramento, California
| | - Nayereh Pezeshkian
- Division of Cardiovascular Medicine, University of California Davis Department of Internal Medicine, Sacramento, California
| | - Uma Srivatsa
- Division of Cardiovascular Medicine, University of California Davis Department of Internal Medicine, Sacramento, California
| | - Adam Oesterle
- Division of Cardiovascular Medicine, University of California Davis Department of Internal Medicine, Sacramento, California
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Oesterle A, Liao JK. The Pleiotropic Effects of Statins - From Coronary Artery Disease and Stroke to Atrial Fibrillation and Ventricular Tachyarrhythmia. Curr Vasc Pharmacol 2020; 17:222-232. [PMID: 30124154 DOI: 10.2174/1570161116666180817155058] [Citation(s) in RCA: 44] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2018] [Revised: 04/06/2018] [Accepted: 06/06/2018] [Indexed: 12/11/2022]
Abstract
Statins, 3-hydroxy-methylglutaryl coenzyme A reductase inhibitors, have been used for decades for the prevention of coronary artery disease and stroke. They act primarily by lowering serum cholesterol through the inhibition of cholesterol synthesis in the liver, which results in the upregulation of low-density lipoprotein receptors in the liver. This results in the removal of low-density lipoproteincholesterol. Studies have suggested that statins may demonstrate additional effects that are independent of their effects on low-density lipoprotein-cholesterol. These have been termed "pleiotropic" effects. Pleiotropic effects may be due to the inhibition of isoprenoid intermediates by statins. Isoprenoid inhibition has effects on the small guanosine triphosphate binding proteins Rac and Rho which in turn effects nicotinamide adenine dinucleotide phosphate oxidases. Therefore, there are changes in endothelial nitric oxide synthase expression, atherosclerotic plaque stability, pro-inflammatory cytokines and reactive oxygen species production, platelet reactivity, and cardiac fibrosis and hypetrophy development. Recently, statins have been compared to the ezetimibe and the recently published outcomes data on the proprotein convertase subtilisin kexin type 9 inhibitors has allowed for a reexamination of statin pleiotropy. As a result of these diverse effects, it has been suggested that statins also have anti-arrhythmic effects. This review focuses on the mechanisms of statin pleiotropy and discusses evidence from the statin clinical trials as well as examining the possible anti-arrhythmic effects atrial fibrillation and ventricular tachyarrhythmias.
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Affiliation(s)
- Adam Oesterle
- The Section of Cardiology, Department of Medicine, The University of Chicago, Chicago, IL 60637, United States
| | - James K Liao
- The Section of Cardiology, Department of Medicine, The University of Chicago, Chicago, IL 60637, United States
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Srivatsa UN, Joy KC, Zhang XJ, Fan D, Oesterle A, Birgersdotter-Green U. Patient Perception of the Remote Versus Clinic Visits for Interrogation of Implantable Cardioverter Defibrillators. Crit Pathw Cardiol 2020; 19:22-25. [PMID: 31599784 DOI: 10.1097/hpc.0000000000000201] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/10/2023]
Abstract
Implantable Cardioverter Defibrillators (ICDs) are used in the management of sudden cardiac arrest. Compared with clinic visits, remote interrogation of these devices has shown clinical benefit and lower cost. We hypothesize that demographic and socioeconomic factors influence patient satisfaction with remote monitoring and therefore the choice of a pathway for follow-up. Questionnaires were mailed to 85 patients (mean age 63 ± 13.5 years, 73% male), with ICDs implanted for primary prevention of sudden cardiac arrest. Information regarding education, social support, employment, and income was collected. To compare clinic and remote monitoring, patients were given questionnaires to assess which parameters they consider important: convenience, accuracy, human contact, scheduling, and cost. Of the 34 responders, patients rated clinic visit to be as accurate with better opportunity to ask questions and better human contact, but there was no difference in perception of convenience, scheduling, or cost between the 2 groups. Significant number of patients dropped from the labor market after ICD implantation; however labor status, education, or income did not influence the preference of clinic appointment. Survey respondents preferred clinic to remote interrogation because they believe clinic appointments allow better interaction. Educating patients about the benefits of remote interrogation and improved communication will enhance utilization of this sophisticated technology for superior patient care.
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Affiliation(s)
- Uma N Srivatsa
- From the Division of Cardiovascular Medicine, University of California Davis, Davis, CA
| | - Kelly C Joy
- From the Division of Cardiovascular Medicine, University of California Davis, Davis, CA
| | - Xin J Zhang
- From the Division of Cardiovascular Medicine, University of California Davis, Davis, CA
| | - Dali Fan
- From the Division of Cardiovascular Medicine, University of California Davis, Davis, CA
| | - Adam Oesterle
- From the Division of Cardiovascular Medicine, University of California Davis, Davis, CA
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20
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Cardona‐Guarache R, Åström‐Aneq M, Oesterle A, Asirvatham R, Svetlichnaya J, Marcus GM, Gerstenfeld EP, Klein L, Scheinman MM. Atrial arrhythmias in patients with arrhythmogenic right ventricular cardiomyopathy: Prevalence, echocardiographic predictors, and treatment. J Cardiovasc Electrophysiol 2019; 30:1801-1810. [DOI: 10.1111/jce.14069] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [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: 03/31/2019] [Revised: 06/04/2019] [Accepted: 06/27/2019] [Indexed: 12/24/2022]
Affiliation(s)
- Ricardo Cardona‐Guarache
- Division of CardiologyDepartment of MedicineUniversity of California San FranciscoSan Francisco California
| | - Meriam Åström‐Aneq
- Division of Clinical PhysiologyDepartment of MedicineLinköping UniversityLinköping Sweden
| | - Adam Oesterle
- Division of CardiologyDepartment of MedicineUniversity of California San FranciscoSan Francisco California
| | - Roshini Asirvatham
- Division of CardiologyDepartment of MedicineUniversity of California San FranciscoSan Francisco California
| | - Jana Svetlichnaya
- Division of CardiologyDepartment of MedicineKaiser PermanenteSan Francisco California
| | - Gregory M. Marcus
- Division of CardiologyDepartment of MedicineUniversity of California San FranciscoSan Francisco California
| | - Edward P. Gerstenfeld
- Division of CardiologyDepartment of MedicineUniversity of California San FranciscoSan Francisco California
| | - Liviu Klein
- Division of CardiologyDepartment of MedicineUniversity of California San FranciscoSan Francisco California
| | - Melvin M. Scheinman
- Division of CardiologyDepartment of MedicineUniversity of California San FranciscoSan Francisco California
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21
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Oesterle A, Goldschlager N. Continuous veno-venous hemodialysis and suspected pacemaker malfunction on telemetry monitoring. J Electrocardiol 2019; 54:82-84. [PMID: 30933746 DOI: 10.1016/j.jelectrocard.2019.03.012] [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] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/09/2019] [Revised: 02/21/2019] [Accepted: 03/22/2019] [Indexed: 11/25/2022]
Affiliation(s)
- Adam Oesterle
- Division of Cardiology, Section of Electrophysiology, University of California, San Francisco, United States of America.
| | - Nora Goldschlager
- Division of Cardiology, University of California, San Francisco, United States of America; Division of Cardiology, Department of Medicine, Zuckerberg San Francisco General Hospital, San Francisco, United States of America
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22
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Oesterle A, Upadhyay GA. The Reply. Am J Med 2019; 132:e549-e550. [PMID: 30935464 DOI: 10.1016/j.amjmed.2018.11.032] [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: 11/28/2018] [Accepted: 11/28/2018] [Indexed: 11/26/2022]
Affiliation(s)
| | - Gaurav A Upadhyay
- The University of Chicago Medicine Center for Arrhythmia Care, Heart and Vascular Center, Chicago, Ill.
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23
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Moss JD, Oesterle A, Raiman M, Flatley EE, Beaser AD, Jeevanandam V, Klein L, Ota T, Wieselthaler G, Uriel N, Tung R. Feasibility and utility of intraoperative epicardial scar characterization during left ventricular assist device implantation. J Cardiovasc Electrophysiol 2018; 30:183-192. [PMID: 30516301 DOI: 10.1111/jce.13803] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [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: 10/14/2018] [Revised: 10/29/2018] [Accepted: 11/06/2018] [Indexed: 02/03/2023]
Abstract
INTRODUCTION Ventricular arrhythmias (VA) after left ventricular assist device (LVAD) placement are associated with increased morbidity and mortality. We sought to assess epicardial voltage characteristics at the time of LVAD implantation and investigate relationships between scar burden and postimplant VA. METHODS AND RESULTS Consecutive patients underwent open chest epicardial electroanatomic mapping immediately before LVAD implantation. Areas of low voltage and sites with local abnormal potentials were identified. Patients were followed prospectively for postimplant VA and clinical outcomes. Between 2015 and 2017, 36 patients underwent high-density intraoperative epicardial voltage mapping; 15 had complete maps suitable for analysis. Mapping required a median of 11.8 (interquartile range [IQR], 8.5-12.7) minutes, with a median of 2650 (IQR, 2139-3191) points sampled per patient. Over a median follow-up of 311 (IQR, 168-469) postoperative days, four patients (27%) experienced sustained VA. Patients with postimplant VA were more likely to have had preimplant implantable cardioverter defibrillator shocks (100% vs 27%; P = 0.03), ventricular tachycardia storm (75% vs 9%; P = 0.03), and lower ejection fraction (13.5 vs 19.0%, P = 0.05). Patients with postimplant VA also had a significantly higher burden of epicardial low bipolar voltage points: 55.4% vs 24.9% of points were less than 0.5 mV (P = 0.01), and 88.9% vs 63.7% of points less than 1.5 mV (P = 0.004). CONCLUSIONS Intraoperative high-density epicardial mapping during LVAD implantation is safe and efficient, facilitating characterization of a potentially arrhythmogenic substrate. An increased burden of the epicardial scar may be associated with a higher incidence of postimplant VA. The role of empiric intraoperative epicardial ablation to mitigate risk of postimplant VA requires further study.
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Affiliation(s)
- Joshua D Moss
- Department of Medicine, Division of Cardiology, Section of Cardiac Electrophysiology, University of California San Francisco, San Francisco, California
| | - Adam Oesterle
- Department of Medicine, Division of Cardiology, Section of Cardiac Electrophysiology, University of California San Francisco, San Francisco, California
| | | | - Erin E Flatley
- Department of Medicine, Division of Cardiology, Section of Cardiac Electrophysiology, University of California San Francisco, San Francisco, California
| | - Andrew D Beaser
- Department of Medicine, Section of Cardiology, Center for Arrhythmia Care, University of Chicago Medicine, Chicago, Illinois
| | - Valluvan Jeevanandam
- Department of Surgery, Section of Cardiac and Thoracic Surgery, University of Chicago Medicine, Chicago, Illinois
| | - Liviu Klein
- Department of Medicine, Division of Cardiology, Section of Heart Failure, University of California San Francisco, San Francisco, California
| | - Takeyoshi Ota
- Department of Surgery, Section of Cardiac and Thoracic Surgery, University of Chicago Medicine, Chicago, Illinois
| | - Georg Wieselthaler
- Department of Surgery, Division of Adult Cardiothoracic Surgery, University of California San Francisco, San Francisco, California
| | - Nir Uriel
- Department of Medicine, Section of Cardiology, University of Chicago Medicine, Chicago, IL
| | - Roderick Tung
- Department of Medicine, Section of Cardiology, Center for Arrhythmia Care, University of Chicago Medicine, Chicago, Illinois
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Oesterle A, Ermakov S, Goldschlager N. Does prematurity unmask disease? J Electrocardiol 2018; 51:1117-1119. [DOI: 10.1016/j.jelectrocard.2018.10.090] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2018] [Revised: 10/06/2018] [Accepted: 10/07/2018] [Indexed: 01/09/2023]
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25
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Oesterle A, Tseng ZH. Irregular Narrow Complex Tachycardia in the Setting of Congenital Heart Disease. JAMA Intern Med 2018; 178:1117-1119. [PMID: 29913014 DOI: 10.1001/jamainternmed.2018.2477] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Affiliation(s)
- Adam Oesterle
- Section of Electrophysiology, Division of Cardiology, University of California, San Francisco
| | - Zian H Tseng
- Section of Electrophysiology, Division of Cardiology, University of California, San Francisco
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26
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Oesterle A, Weber B, Tung R, Choudhry NK, Singh JP, Upadhyay GA. Preventing Postoperative Atrial Fibrillation After Noncardiac Surgery: A Meta-analysis. Am J Med 2018; 131:795-804.e5. [PMID: 29476748 DOI: 10.1016/j.amjmed.2018.01.032] [Citation(s) in RCA: 27] [Impact Index Per Article: 4.5] [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: 01/13/2018] [Revised: 01/24/2018] [Accepted: 01/26/2018] [Indexed: 12/22/2022]
Abstract
BACKGROUND Although postoperative atrial fibrillation is common after noncardiac surgery, there is a paucity of data regarding prophylaxis. We sought to determine whether pharmacologic prophylaxis reduces the incidence of postoperative atrial fibrillation after noncardiac surgery. METHODS We performed an electronic search of Ovid MEDLINE, the Cochrane central register of controlled trials database, and SCOPUS from inception to September 7, 2016 and included prospective randomized studies in which patients in sinus rhythm underwent noncardiac surgery and examined the incidence of postoperative atrial fibrillation as well as secondary safety outcomes. RESULTS Twenty-one studies including 11,608 patients were included. Types of surgery included vascular surgery (3465 patients), thoracic surgery (2757 patients), general surgery (2292 patients), orthopedic surgery (1756 patients), and other surgery (1338 patients). Beta-blockers (relative risk [RR] 0.32; 95% confidence interval [CI], 0.11-0.87), amiodarone (RR 0.42; 95% CI, 0.26 to 0.67), and statins (RR 0.43; 95% CI, 0.27 to 0.68) reduced postoperative atrial fibrillation compared with placebo or active controls. Calcium channel blockers (RR 0.55; 95% CI, 0.30 to 1.01), digoxin (RR 1.62; 95% CI, 0.95 to 2.76), and magnesium (RR 0.73; 95% CI, 0.23 to 2.33) had no statistically significant effect on postoperative atrial fibrillation incidence. The incidence of adverse events was comparable across agents, except for increased mortality (RR 1.33; 95% CI, 1.03 to 1.37) and bradycardia (RR 2.74; 95% CI, 2.19 to 3.43) in patients receiving beta-blockers. CONCLUSIONS Pharmacologic prophylaxis with amiodarone, beta-blockers, or statins reduces the incidence of postoperative atrial fibrillation after noncardiac surgery. Amiodarone and statins have a relatively low overall risk of short-term adverse events.
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Affiliation(s)
- Adam Oesterle
- Center for Arrhythmia Care, The University of Chicago, Ill
| | - Benjamin Weber
- Center for Arrhythmia Care, The University of Chicago, Ill
| | - Roderick Tung
- Center for Arrhythmia Care, The University of Chicago, Ill
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27
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Oesterle A, Marcus GM. Termination of tachycardia with resolution of left bundle branch block: What is the mechanism? HeartRhythm Case Rep 2018; 4:434-436. [PMID: 30228972 PMCID: PMC6140618 DOI: 10.1016/j.hrcr.2018.06.010] [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] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/28/2022] Open
Affiliation(s)
| | - Gregory M. Marcus
- Address reprint requests and correspondence: Dr Gregory M. Marcus, Section of Electrophysiology, Division of Cardiology, University of California, San Francisco, 500 Parnassus, MUE 434, San Francisco, CA 94143.
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28
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Oesterle A, Singh A, Balkhy H, Husain AN, Moyer D, Tung R, Nayak HM. Late presentation of constrictive pericarditis after limited epicardial ablation for inappropriate sinus tachycardia. HeartRhythm Case Rep 2017; 2:441-445. [PMID: 28491729 PMCID: PMC5419970 DOI: 10.1016/j.hrcr.2016.07.003] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022] Open
Affiliation(s)
- Adam Oesterle
- Center for Arrhythmia Care, Heart and Vascular Center, The University of Chicago Medicine, Chicago, Illinois
| | - Amita Singh
- Center for Arrhythmia Care, Heart and Vascular Center, The University of Chicago Medicine, Chicago, Illinois
| | - Husam Balkhy
- Center for Arrhythmia Care, Heart and Vascular Center, The University of Chicago Medicine, Chicago, Illinois
| | - Aliya N Husain
- Department of Pathology, The University of Chicago Medicine, Chicago, Illinois
| | - Deborah Moyer
- Center for Arrhythmia Care, Heart and Vascular Center, The University of Chicago Medicine, Chicago, Illinois
| | - Roderick Tung
- Center for Arrhythmia Care, Heart and Vascular Center, The University of Chicago Medicine, Chicago, Illinois
| | - Hemal M Nayak
- Center for Arrhythmia Care, Heart and Vascular Center, The University of Chicago Medicine, Chicago, Illinois
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Abstract
The statins have been used for 30 years to prevent coronary artery disease and stroke. Their primary mechanism of action is the lowering of serum cholesterol through inhibiting hepatic cholesterol biosynthesis thereby upregulating the hepatic low-density lipoprotein (LDL) receptors and increasing the clearance of LDL-cholesterol. Statins may exert cardiovascular protective effects that are independent of LDL-cholesterol lowering called pleiotropic effects. Because statins inhibit the production of isoprenoid intermediates in the cholesterol biosynthetic pathway, the post-translational prenylation of small GTP-binding proteins such as Rho and Rac, and their downstream effectors such as Rho kinase and nicotinamide adenine dinucleotide phosphate oxidases are also inhibited. In cell culture and animal studies, these effects alter the expression of endothelial nitric oxide synthase, the stability of atherosclerotic plaques, the production of proinflammatory cytokines and reactive oxygen species, the reactivity of platelets, and the development of cardiac hypertrophy and fibrosis. The relative contributions of statin pleiotropy to clinical outcomes, however, remain a matter of debate and are hard to quantify because the degree of isoprenoid inhibition by statins correlates to some extent with the amount of LDL-cholesterol reduction. This review examines some of the currently proposed molecular mechanisms for statin pleiotropy and discusses whether they could have any clinical relevance in cardiovascular disease.
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Affiliation(s)
- Adam Oesterle
- From the Section of Cardiology, Department of Medicine, The University of Chicago, IL (A.O., J.K.L.); and Division of Cardiology, Department of Medicine, The University of Saarland, Homburg, Germany (U.L.)
| | - Ulrich Laufs
- From the Section of Cardiology, Department of Medicine, The University of Chicago, IL (A.O., J.K.L.); and Division of Cardiology, Department of Medicine, The University of Saarland, Homburg, Germany (U.L.)
| | - James K Liao
- From the Section of Cardiology, Department of Medicine, The University of Chicago, IL (A.O., J.K.L.); and Division of Cardiology, Department of Medicine, The University of Saarland, Homburg, Germany (U.L.).
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Grinstein J, Garan A, Flatley E, Kim G, Mai X, Sarswat N, Kalantari S, Adatya S, Raikhelkar J, Sayer G, Oesterle A, Jeevanandam V, Moss J, Uriel N. Increased Rate of Pump Thrombosis and Cardioembolic Events Following Ventricular Tachycardia Ablation in Patients Supported with Left Ventricular Assist Devices. J Heart Lung Transplant 2017. [DOI: 10.1016/j.healun.2017.01.093] [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] [Subscribe] [Scholar Register] [Indexed: 10/19/2022] Open
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Oesterle A, Balkhy HH, Green J, Burke MC. Late Manifestation of Coronary Sinus and Left Atrial Perforation of a Left Ventricular Pacemaker Lead at Extraction. Pacing Clin Electrophysiol 2016; 39:502-6. [PMID: 26846355 DOI: 10.1111/pace.12822] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/07/2015] [Revised: 01/03/2016] [Accepted: 01/19/2016] [Indexed: 11/26/2022]
Abstract
A 56-year-old man presented for lead extraction of a left ventricular (LV) lead that had been deactivated due to hiccups and of a right ventricular (RV) lead with a high threshold. Pus was noted upon entering the pocket. The right atrial and RV leads were extracted, but traction on the LV lead caused ischemia and was not performed. An echocardiogram demonstrated the lead in the left atrium and a robotic-assisted thoracotomy was used to remove the lead that had unroofed the coronary sinus, gone into the left atrium, and perforated through the free wall into the pericardium.
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Affiliation(s)
- Adam Oesterle
- Department of Medicine and Surgery, University of Chicago, Chicago, Illinois
| | - Husam H Balkhy
- Sections of Cardiology and Cardiothoracic Surgery and the Heart Rhythm Center, University of Chicago, Chicago, Illinois
| | - John Green
- Department of Medicine and Surgery, University of Chicago, Chicago, Illinois
| | - Martin C Burke
- Department of Medicine and Surgery, University of Chicago, Chicago, Illinois
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Oesterle A, Bowman MAH. S100A12 and the S100/Calgranulins: Emerging Biomarkers for Atherosclerosis and Possibly Therapeutic Targets. Arterioscler Thromb Vasc Biol 2015; 35:2496-507. [PMID: 26515415 DOI: 10.1161/atvbaha.115.302072] [Citation(s) in RCA: 65] [Impact Index Per Article: 7.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/10/2015] [Accepted: 10/14/2015] [Indexed: 11/16/2022]
Abstract
Atherosclerosis is mediated by local and systematic inflammation. The multiligand receptor for advanced glycation end products (RAGE) has been studied in animals and humans and is an important mediator of inflammation and atherosclerosis. This review focuses on S100/calgranulin proteins (S100A8, S100A9, and S100A12) and their receptor RAGE in mediating vascular inflammation. Mice lack the gene for S100A12, which in humans is located on chromosome 3 between S100A8 and S100A9. Transgenic mice with smooth muscle cell-targeted expression of S100A12 demonstrate increased coronary and aortic calcification, as well as increased plaque vulnerability. Serum S100A12 has recently been shown to predict future cardiovascular events in a longitudinal population study, underscoring a role for S100A12 as a potential biomarker for coronary artery disease. Genetic ablation of S100A9 or RAGE in atherosclerosis-susceptible apolipoprotein E null mice results in reduced atherosclerosis. Importantly, S100A12 and the RAGE axis can be modified pharmacologically. For example, soluble RAGE reduces murine atherosclerosis and vascular inflammation. Additionally, a class of compounds currently in phase III clinical trials for multiple sclerosis and rheumatologic conditions, the quinoline-3-carboxamides, reduce atherosclerotic plaque burden and complexity in transgenic S100A12 apolipoprotein E null mice, but have not been tested with regards to human atherosclerosis. The RAGE axis is an important mediator for inflammation-induced atherosclerosis, and S100A12 has emerged as biomarker for human atherosclerosis. Decreasing inflammation by inhibiting S100/calgranulin-mediated activation of RAGE attenuates murine atherosclerosis, and future studies in patients with coronary artery disease are warranted to confirm S100/RAGE as therapeutic target for atherosclerosis.
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Affiliation(s)
- Adam Oesterle
- From the Department of Medicine, The University of Chicago, IL
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Agusala K, Oesterle A, Kulkarni C, Caprio T, Subacius H, Passman R. Risk prediction for adverse events during initiation of sotalol and dofetilide for the treatment of atrial fibrillation. Pacing Clin Electrophysiol 2015; 38:490-8. [PMID: 25626340 DOI: 10.1111/pace.12586] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/07/2014] [Revised: 11/24/2014] [Accepted: 12/21/2014] [Indexed: 11/29/2022]
Abstract
BACKGROUND Inpatient antiarrhythmic drug initiation for atrial fibrillation is mandated for dofetilide (DF) and is often performed for sotalol (SL), particularly if proarrhythmia risk factors are present. Whether low-risk patients can be identified to safely allow outpatient initiation is unknown. METHODS A single-center retrospective cohort study was performed on patients initiated with DF or SL. Risk factors for adverse events (AEs), defined as any arrhythmia or electrocardiogram change requiring dose reduction or cessation, were identified. RESULTS Of 329 patients, 227 (69%) received SL and 102 (31%) DF. The cohort had a mean age of 63 ± 13 years; 70% of patients were male and had a baseline QTc of 440 ± 37 ms. A total of 105 AEs occurred in 92 patients: QTc prolongation or ventricular tachyarrhythmia in 70 patients (67% of AEs), bradyarrhythmias in 35 patients (33% of AEs), with some experiencing both AE types. Ventricular arrhythmias were seen in 23 patients (7%) and torsades de pointes in one (0.3%). Total AE rates were similar between drugs (P = 0.09); however, DF patients had more QTc prolongation or ventricular arrhythmias (P = 0.001). In SL patients, there were no predictors for QTc prolongation or ventricular proarrhythmia. In DF patients, higher baseline QTc interval (odds ratio = 1.64/25 ms, P = 0.01) was an independent predictor of QTc prolongation or ventricular proarrhythmias. For patients without proarrhythmia risk factors, overall AE rate was 26%. CONCLUSIONS In conclusion, AEs are common during DF and SL initiation but rarely severe in hospitalized inpatients. Baseline QTc predicts AEs for DF patients only and AE are common even in "low-risk" patients. These results support in-hospital drug initiation for all DF and SL patients.
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Affiliation(s)
- Kartik Agusala
- From Northwestern University, Feinberg School of Medicine, Chicago, Illinois
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Boland EA, Grey M, Oesterle A, Fredrickson L, Tamborlane WV. Continuous subcutaneous insulin infusion. A new way to lower risk of severe hypoglycemia, improve metabolic control, and enhance coping in adolescents with type 1 diabetes. Diabetes Care 1999; 22:1779-84. [PMID: 10546007 DOI: 10.2337/diacare.22.11.1779] [Citation(s) in RCA: 337] [Impact Index Per Article: 13.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
OBJECTIVE Recommendations from the Diabetes Control and Complications Trial (DCCT) indicate that adolescents with type 1 diabetes should be treated with intensive therapy involving multiple daily injections (MDI) of insulin or insulin pump therapy (continuous subcutaneous insulin infusion [CSII] to help obtain better metabolic control and prevent later complications. Interest has thus focused on insulin pump therapy to help adolescents meet this challenge. The purpose of this study was to examine responses to CSII and MDI in a large group of adolescents with established type 1 diabetes during a 12-month period and to determine whether either treatment regimen more favorably affected clinical and psychosocial outcomes. RESEARCH DESIGN AND METHODS One-third of 75 youths aged 12-20 years who were candidates for intensive therapy chose CSII as their mode of treatment. Patients received intensive treatment and education as described by the DCCT investigators. Psychosocial data (e.g., quality of life, depression, self-efficacy, and coping) were collected at baseline and at 6-month intervals, and clinical data (e.g., HbA1c levels, adverse events) were collected every 4-6 weeks. RESULTS Although both MDI- and CSII-treated adolescents initially exhibited improved metabolic control, this level of control was more difficult to sustain for 12 months in the MDI group (at 6 months HbA1c = 8.1, at 12 months HbA1c = 8.3), whereas average HbA1c levels in the CSII group continued to decrease during the 12 months of treatment (at 6 months HbA1c = 7.7, at 12 months HbA1c = 7.5). Despite lower HbA1c levels in CSII-versus MDI-treated patients, the rate of severe hypoglycemic events was reduced by almost 50% in the CSII group (P = 0.01). Self-reported questionnaires demonstrated that there was improvement in self-efficacy, depression, and quality of life in both MDI- and CSII-treated patients. Finally, adolescents using CSII found coping with diabetes to be less difficult than adolescents using MDI did. CONCLUSIONS CSII is an alternative means to lower HbA1c levels and reduce the risk of hypoglycemia without adversely affecting psychosocial outcomes in adolescents with type 1 diabetes.
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Affiliation(s)
- E A Boland
- Yale Children's Clinical Research Center, Yale University School of Nursing, New Haven, Connecticut, USA.
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Herz J, Qiu SQ, Oesterle A, DeSilva HV, Shafi S, Havel RJ. Initial hepatic removal of chylomicron remnants is unaffected but endocytosis is delayed in mice lacking the low density lipoprotein receptor. Proc Natl Acad Sci U S A 1995; 92:4611-5. [PMID: 7753850 PMCID: PMC41994 DOI: 10.1073/pnas.92.10.4611] [Citation(s) in RCA: 78] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/26/2023] Open
Abstract
Two endocytic receptors, the low density lipoprotein (LDL) receptor (LDLR) and the LDLR-related protein (LRP), are thought to act in concert in the hepatic uptake of partially metabolized dietary lipoproteins, the chylomicron remnants. We have evaluated the role of these two receptors in the hepatic metabolism of chylomicron remnants in normal mice and in LDLR-deficient [LDLR (-/-)] mice. The rate of chylomicron remnant removal by the liver was normal up to 30 min after intravenous injection of chylomicrons into LDLR (-/-) mice and was unaffected by receptor-associated protein (RAP), a potent inhibitor of ligand binding to LRP. In contrast, endocytosis of the remnants by the hepatocytes, measured by their accumulation in the endosomal fraction and by the rate of hydrolysis of component cholesteryl esters, was dramatically reduced in the absence of the LDLR. Coadministration of RAP prevented the continuing hepatic removal of chylomicron remnants in LDL (-/-) mice after 30 min, consistent with blockade of the slow endocytosis by a RAP-sensitive process. Taken together with previous studies, our results are consistent with a model in which the initial hepatic removal of chylomicron remnants is primarily mediated by mechanisms that do not include LDLR or LRP, possibly involving glycosaminoglycan-bound hepatic lipase and apolipoprotein E. After the remnants bind to these alternative sites on the hepatocyte surface, endocytosis is predominantly mediated by the LDLR and also by a slower and less efficient backup process that is RAP sensitive and therefore most likely involves LRP.
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Affiliation(s)
- J Herz
- Department of Molecular Genetics, University of Texas Southwestern Medical Center, Dallas 75235, USA
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Wetter LA, Hamadeh RM, Griffiss JM, Oesterle A, Aagaard B, Way LW. Differences in outer membrane characteristics between gallstone-associated bacteria and normal bacterial flora. Lancet 1994; 343:444-8. [PMID: 7905954 DOI: 10.1016/s0140-6736(94)92691-3] [Citation(s) in RCA: 34] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/27/2023]
Abstract
Previous studies with scanning electron microscopy (SEM) have suggested that pigment gallstones contain bacteria. We set out to culture these bacteria and to study their membrane characteristics. We studied gallstones from 54 patients (36 men, 18 women; mean age 55.4 years) admitted consecutively to two hospitals for cholecystectomy. SEM detected bacteria in all of 14 brown pigment stones, 2 of 14 black pigment stones, and in the pigmented centres of 9 of 19 mixed cholesterol stones; no bacteria were detected in 14 pure cholesterol stones or within the cholesterol portions of mixed stones. We were able to culture bacteria from all gallstones with bacteria seen on SEM and for which sufficient material was available (n = 16). 20 bacterial species were recovered from these stones. Gallstones containing bacteria were associated with clinical sepsis and cholangitis. All bacteria obtained from gallstones agglutinated human O P1 erythrocytes, which reflects the presence of P1-specific fimbriae. 5 strains were positive for Forssman-antigen-specific fimbriae. None showed evidence of mannose-specific fimbriae. All of the organisms bound anti-Gal, a ubiquitous naturally occurring IgG specific for alpha-galactosyl residues. The presence of P1 fimbriae and alpha-galactosyl residues and the absence of mannose-specific fimbriae distinguish these organisms from gut flora. We postulate that possession of these unusual properties may enhance the ability of bacteria to colonise the biliary tree and initiate pigment gallstone formation.
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Affiliation(s)
- L A Wetter
- Department of Surgery, University of California, San Francisco
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