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Fanaroff AC, Dayoub EJ, Yang L, Schultz K, Ramadan OI, Wang GJ, Damrauer SM, Genovese EA, Secemsky EA, Parikh SA, Nathan AS, Kohi MP, Weinberg MD, Jaff MR, Groeneveld PW, Giri JS. Association Between Diagnosis-to-Limb Revascularization Time and Clinical Outcomes in Outpatients With Chronic Limb-Threatening Ischemia: Insights From the CLIPPER Cohort. J Am Heart Assoc 2024; 13:e033898. [PMID: 38639376 DOI: 10.1161/jaha.123.033898] [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: 01/05/2024] [Accepted: 03/18/2024] [Indexed: 04/20/2024]
Abstract
BACKGROUND The extent and consequences of ischemia in patients with chronic limb-threatening ischemia (CLTI) may change rapidly, and delays from diagnosis to revascularization may worsen outcomes. We sought to describe the association between time from diagnosis to endovascular lower extremity revascularization (diagnosis-to-limb revascularization [D2L] time) and clinical outcomes in outpatients with CLTI. METHODS AND RESULTS In the CLIPPER cohort, comprising patients between 66 and 86 years old diagnosed with CLTI betweeen 2010 and 2019, we used Medicare claims data to identify patients who underwent outpatient endovascular revascularization within 180 days of diagnosis. We described the risk-adjusted association between D2L time and clinical outcomes. Among 1 130 065 patients aged between 66 and 86 years with CLTI, 99 221 (8.8%) underwent outpatient endovascular lower extremity revascularization within 180 days of their CLTI diagnosis. Among patients with D2L time <30 days, there was no association between D2L time and all-cause death or major lower extremity amputation. However, among patients with D2L time >30 days, each additional 10-day increase in D2L time was associated with a 2.5% greater risk of major amputation (hazard ratio, 1.025 [95% CI, 1.014-1.036]). There was no association between D2L time and all-cause death. CONCLUSIONS A delay of >30 days from CLTI diagnosis to lower extremity endovascular revascularization was associated with an increased risk of major lower extremity amputation among patients undergoing outpatient endovascular revascularization. Improving systems of care to reduce D2L time could reduce amputations.
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Affiliation(s)
- Alexander C Fanaroff
- Cardiovascular Medicine Division, Perelman School of Medicine University of Pennsylvania Philadelphia PA
- Penn Cardiovascular Outcomes, Quality, and Evaluative Research Center University of Pennsylvania Philadelphia PA
- Leonard Davis Institute for Health Economics Philadelphia PA
- Penn Center for Health Incentives and Behavioral Economics University of Pennsylvania Philadelphia PA
| | - Elias J Dayoub
- Cardiovascular Medicine Division, Perelman School of Medicine University of Pennsylvania Philadelphia PA
- Penn Cardiovascular Outcomes, Quality, and Evaluative Research Center University of Pennsylvania Philadelphia PA
- Leonard Davis Institute for Health Economics Philadelphia PA
| | - Lin Yang
- Penn Cardiovascular Outcomes, Quality, and Evaluative Research Center University of Pennsylvania Philadelphia PA
- Leonard Davis Institute for Health Economics Philadelphia PA
| | - Kaitlyn Schultz
- Penn Cardiovascular Outcomes, Quality, and Evaluative Research Center University of Pennsylvania Philadelphia PA
- Leonard Davis Institute for Health Economics Philadelphia PA
| | - Omar I Ramadan
- Penn Cardiovascular Outcomes, Quality, and Evaluative Research Center University of Pennsylvania Philadelphia PA
- Leonard Davis Institute for Health Economics Philadelphia PA
- Division of Vascular Surgery and Endovascular Therapy, Perelman School of Medicine University of Pennsylvania Philadelphia PA
| | - Grace J Wang
- Penn Cardiovascular Outcomes, Quality, and Evaluative Research Center University of Pennsylvania Philadelphia PA
- Leonard Davis Institute for Health Economics Philadelphia PA
- Division of Vascular Surgery and Endovascular Therapy, Perelman School of Medicine University of Pennsylvania Philadelphia PA
| | - Scott M Damrauer
- Penn Cardiovascular Outcomes, Quality, and Evaluative Research Center University of Pennsylvania Philadelphia PA
- Leonard Davis Institute for Health Economics Philadelphia PA
- Division of Vascular Surgery and Endovascular Therapy, Perelman School of Medicine University of Pennsylvania Philadelphia PA
- Department of Genetics, Perelman School of Medicine University of Pennsylvania Philadelphia PA
- Corporal Michael J. Crescenz Veterans Affairs Medical Center Philadelphia PA
| | - Elizabeth A Genovese
- Penn Cardiovascular Outcomes, Quality, and Evaluative Research Center University of Pennsylvania Philadelphia PA
- Leonard Davis Institute for Health Economics Philadelphia PA
- Division of Vascular Surgery and Endovascular Therapy, Perelman School of Medicine University of Pennsylvania Philadelphia PA
| | - Eric A Secemsky
- Smith Center for Cardiovascular Outcomes Research, Beth Israel Deaconess Medical Center, Harvard Medical School Harvard University Boston MA
| | - Sahil A Parikh
- Division of Cardiology, Vagelos College of Physicians and Surgeons Columbia University New York NY
| | - Ashwin S Nathan
- Cardiovascular Medicine Division, Perelman School of Medicine University of Pennsylvania Philadelphia PA
- Penn Cardiovascular Outcomes, Quality, and Evaluative Research Center University of Pennsylvania Philadelphia PA
- Leonard Davis Institute for Health Economics Philadelphia PA
- Corporal Michael J. Crescenz Veterans Affairs Medical Center Philadelphia PA
| | - Maureen P Kohi
- Department of Radiology University of North Carolina Chapel Hill NC
| | | | | | - Peter W Groeneveld
- Penn Cardiovascular Outcomes, Quality, and Evaluative Research Center University of Pennsylvania Philadelphia PA
- Leonard Davis Institute for Health Economics Philadelphia PA
- Corporal Michael J. Crescenz Veterans Affairs Medical Center Philadelphia PA
- General Internal Medicine Division, Perelman School of Medicine University of Pennsylvania Philadelphia PA
| | - Jay S Giri
- Cardiovascular Medicine Division, Perelman School of Medicine University of Pennsylvania Philadelphia PA
- Penn Cardiovascular Outcomes, Quality, and Evaluative Research Center University of Pennsylvania Philadelphia PA
- Leonard Davis Institute for Health Economics Philadelphia PA
- Corporal Michael J. Crescenz Veterans Affairs Medical Center Philadelphia PA
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Asmar S, Michael G, Gallo V, Weinberg MD. The Role of IVC Filters in the Management of Acute Pulmonary Embolism. J Clin Med 2024; 13:1494. [PMID: 38592401 PMCID: PMC10935447 DOI: 10.3390/jcm13051494] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/18/2024] [Revised: 02/21/2024] [Accepted: 03/04/2024] [Indexed: 04/10/2024] Open
Abstract
Venous thromboembolism (VTE), comprising deep venous thrombosis (DVT) and pulmonary embolism (PE), is a prevalent cardiovascular condition, ranking third globally after myocardial infarction and stroke. The risk of VTE rises with age, posing a growing concern in aging populations. Acute PE, with its high morbidity and mortality, emphasizes the need for early diagnosis and intervention. This review explores prognostic factors for acute PE, categorizing it into low-risk, intermediate-risk, and high-risk based on hemodynamic stability and right ventricular strain. Timely classification is crucial for triage and treatment decisions. In the contemporary landscape, low-risk PE patients are often treated with Direct Oral Anticoagulants (DOACS) and rapidly discharged for outpatient follow-up. Intermediate- and high-risk patients may require advanced therapies, such as systemic thrombolysis, catheter-directed thrombolysis, mechanical thrombectomy, and IVC filter placement. The latter, particularly IVC filters, has witnessed increased usage, with evolving types like retrievable and convertible filters. However, concerns arise regarding complications and the need for timely retrieval. This review delves into the role of IVC filters in acute PE management, addressing their indications, types, complications, and retrieval considerations. The ongoing debate surrounding IVC filter use, especially in patients with less conventional indications, reflects the need for further research and data. Despite complications, recent studies suggest that clinically significant issues are rare, sparking discussions on the appropriate and safe utilization of IVC filters in select PE cases. The review concludes by highlighting current trends, gaps in knowledge, and potential avenues for advancing the role of IVC filters in future acute PE management.
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Affiliation(s)
- Samer Asmar
- Division of Cardiology, Department of Internal Medicine, Staten Island University Hospital, Staten Island, NY 10305, USA;
| | - George Michael
- Division of Vascular & Interventional Radiology, Department of Radiology, Staten Island University Hospital—Northwell Health, Staten Island, NY 10305, USA; (G.M.); (V.G.)
| | - Vincent Gallo
- Division of Vascular & Interventional Radiology, Department of Radiology, Staten Island University Hospital—Northwell Health, Staten Island, NY 10305, USA; (G.M.); (V.G.)
| | - Mitchell D. Weinberg
- Division of Cardiology, Department of Internal Medicine, Staten Island University Hospital, Staten Island, NY 10305, USA;
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Fulton B, Bashir R, Weinberg MD, Lakhter V, Rali P, Pugliese S, Giri J, Kobayashi T. Advanced Treatment of Hemodynamically Unstable Acute Pulmonary Embolism and Clinical Follow-up. Semin Thromb Hemost 2023; 49:785-796. [PMID: 37696292 DOI: 10.1055/s-0043-1772840] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/13/2023]
Abstract
High-risk acute pulmonary embolism (PE), defined as acute PE associated with hemodynamic instability, remains a significant contributor to cardiovascular morbidity and mortality in the United States and worldwide. Historically, anticoagulant therapy in addition to systemic thrombolysis has been the mainstays of medical therapy for the majority of patients with high-risk PE. In efforts to reduce the morbidity and mortality, a wide array of interventional and surgical therapies has been developed and employed in the management of these patients. However, the most recent guidelines for the management of PE have reserved the use of these advanced therapies in scenarios where thrombolytic therapy plus anticoagulation are unsuccessful. This is due largely to the lack of prospective, randomized studies in this population. Stemming from this, the approach to treatment of these patients varies widely depending on institutional experience and resources. Furthermore, morbidity and mortality remain unacceptably high in this population, with estimated 30-day mortality of at least 30%. As such, development of a standardized approach to treatment of these patients is paramount to improving outcomes. Early and accurate risk stratification in conjunction with a multidisciplinary team approach in the form of a PE response team is crucial. With the advent of novel therapies for the treatment of acute PE, in addition to the growing availability of and familiarity with mechanical circulatory support systems, such a standardized approach may now be within reach.
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Affiliation(s)
- Brian Fulton
- Division of Cardiovascular Medicine, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Riyaz Bashir
- Division of Cardiovascular Disease, Lewis Katz School of Medicine at Temple University, Philadelphia, Pennsylvania
| | - Mitchell D Weinberg
- Zucker School of Medicine at Hofstra/Northwell, Staten Island University Hospital, Staten Island, New York
| | - Vladimir Lakhter
- Division of Cardiovascular Disease, Lewis Katz School of Medicine at Temple University, Philadelphia, Pennsylvania
| | - Parth Rali
- Department of Thoracic Medicine and Surgery, Lewis Katz School of Medicine at Temple University, Philadelphia, Pennsylvania
| | - Steve Pugliese
- Division of Pulmonary and Critical Care Medicine, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Jay Giri
- Division of Cardiovascular Medicine, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania
- Cardiovascular Outcomes, Quality and Evaluative Research Center, Philadelphia, Pennsylvania
| | - Taisei Kobayashi
- Division of Cardiovascular Medicine, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania
- Cardiovascular Outcomes, Quality and Evaluative Research Center, Philadelphia, Pennsylvania
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Dicks AB, Lakhter V, Elgendy IY, Schainfeld RM, Mohapatra A, Giri J, Weinberg MD, Weinberg I, Parmar G. Mortality differences by race over 20 years in individuals with peripheral artery disease. Vasc Med 2023; 28:214-221. [PMID: 37010137 DOI: 10.1177/1358863x231159947] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/04/2023]
Abstract
INTRODUCTION Racial disparities exist in patients with peripheral artery disease (PAD), with Black individuals having worse PAD-specific outcomes. However, mortality risk in this population has been mixed. As such, we sought to evaluate all-cause mortality by race among individuals with PAD. METHODS We analyzed data from the National Health and Nutrition Examination Survey (NHANES). Baseline data were obtained from 1999 to 2004. Patients with PAD were grouped according to self-reported race. Multivariable Cox proportional hazards regression was performed to calculate adjusted hazard ratios (HR) by race. A separate analysis was performed to study the effect of burden of social determinants of health (SDoH) on all-cause mortality. RESULTS Of 647 individuals identified, 130 were Black and 323 were White. Black individuals had more premature PAD (30% vs 20%, p < 0.001) and a higher burden of SDoH compared to White individuals. Crude mortality rates were higher in Black individuals in the 40-49-year and 50-69-year age groups compared to White individuals (6.7% vs 6.1% and 8.8% vs 7.8%, respectively). Multivariable analysis demonstrated that Black individuals with both PAD and coronary artery disease (CAD) had a 30% higher hazard of death over 20 years compared to White individuals (HR = 1.3, 95% CI: 1.0-2.1). The cumulative burden of SDoH marginally (10-20%) increased the risk of all-cause mortality. CONCLUSIONS In a nationally representative sample, Black individuals with PAD and CAD had higher rates of mortality compared to their White counterparts. These findings add further proof to the ongoing racial disparities among Black individuals with PAD and highlight the necessity to identify ways to mitigate these differences.
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Affiliation(s)
- Andrew B Dicks
- Department of Vascular Surgery, Prisma Health, University of South Carolina School of Medicine - Greenville, Greenville, SC, USA
| | - Vladimir Lakhter
- Division of Cardiovascular Medicine, Temple University Hospital, Philadelphia, PA, USA
| | - Islam Y Elgendy
- Division of Cardiovascular Medicine, Gill Heart Institute, University of Kentucky, Lexington, KY, USA
| | - Robert M Schainfeld
- Section of Vascular Medicine, Massachusetts General Hospital, Harvard Medical School Teaching Hospital, Boston, MA, USA
| | - Abhisekh Mohapatra
- Division of Vascular Surgery, Massachusetts General Hospital, Harvard Medical School Teaching Hospital, Boston, MA, USA
| | - Jay Giri
- Division of Cardiovascular Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Mitchell D Weinberg
- Department of Cardiology, Northwell Health, Zucker School of Medicine at Hosftra/Northwell, Staten Island University Hospital, Staten Island, NY, USA
| | - Ido Weinberg
- Section of Vascular Medicine, Massachusetts General Hospital, Harvard Medical School Teaching Hospital, Boston, MA, USA
| | - Gaurav Parmar
- Section of Vascular Medicine, Massachusetts General Hospital, Harvard Medical School Teaching Hospital, Boston, MA, USA
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Bangalore S, Horowitz JM, Beam D, Jaber WA, Khandhar S, Toma C, Weinberg MD, Mina B. Prevalence and Predictors of Cardiogenic Shock in Intermediate-Risk Pulmonary Embolism: Insights From the FLASH Registry. JACC Cardiovasc Interv 2023; 16:958-972. [PMID: 37100559 DOI: 10.1016/j.jcin.2023.02.004] [Citation(s) in RCA: 9] [Impact Index Per Article: 9.0] [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: 09/27/2022] [Revised: 01/31/2023] [Accepted: 02/07/2023] [Indexed: 04/28/2023]
Abstract
BACKGROUND Patients with acute pulmonary embolism (PE) and hypotension (high-risk PE) have high mortality. Cardiogenic shock can also occur in nonhypotensive or normotensive patients (intermediate-risk PE) but is less well characterized. OBJECTIVES The authors sought to evaluate the prevalence and predictors of normotensive shock in intermediate-risk PE. METHODS Intermediate-risk PE patients in the FLASH (FlowTriever All-Comer Registry for Patient Safety and Hemodynamics) registry undergoing mechanical thrombectomy with the FlowTriever System (Inari Medical) were included. The prevalence of normotensive shock (systolic blood pressure ≥90 mm Hg but cardiac index ≤2.2 L/min/m2) was assessed. A composite shock score consisting of markers of right ventricular function and ischemia (elevated troponin, elevated B-type natriuretic peptide, moderately/severely reduced right ventricular function), central thrombus burden (saddle PE), potential additional embolization (concomitant deep vein thrombosis), and cardiovascular compensation (tachycardia) was prespecified and assessed for its ability to identify normotensive shock patients. RESULTS Over one-third of intermediate-risk PE patients in FLASH (131/384, 34.1%) were in normotensive shock. The normotensive shock prevalence was 0% in patients with a composite shock score of 0 and 58.3% in those with a score of 6 (highest score). A score of 6 was a significant predictor of normotensive shock (odds ratio: 5.84; 95% CI: 2.00-17.04). Patients showed significant on-table improvements in hemodynamics post-thrombectomy, including normalization of the cardiac index in 30.5% of normotensive shock patients. Right ventricular size, function, dyspnea, and quality of life significantly improved at the 30-day follow-up. CONCLUSIONS Although hemodynamically stable, over one-third of intermediate-risk FLASH patients were in normotensive shock with a depressed cardiac index. A composite shock score effectively further risk stratified these patients. Mechanical thrombectomy improved hemodynamics and functional outcomes at the 30-day follow-up.
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Affiliation(s)
- Sripal Bangalore
- Department of Medicine, New York University Grossman School of Medicine, New York, New York, USA.
| | - James M Horowitz
- Division of Cardiology, New York University Grossman School of Medicine, New York, New York, USA
| | - Daren Beam
- Department of Emergency Medicine, Indiana University School of Medicine, Indianapolis, Indiana
| | - Wissam A Jaber
- Division of Cardiology, Emory University Hospital, Atlanta, Georgia
| | - Sameer Khandhar
- Division of Cardiology at Penn Presbyterian Medical Center, Perelman School of Medicine at University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Catalin Toma
- Heart and Vascular Institute, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
| | - Mitchell D Weinberg
- Department of Cardiology, Northwell Health, Zucker School of Medicine at Hofstra/Northwell Health, Staten Island University Hospital, Staten Island, New York, USA
| | - Bushra Mina
- Department of Pulmonary and Critical Care Medicine, Lenox Hill Hospital, Northwell Health, New York, New York, USA
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Mustafa A, Makhoul GW, Wei C, Grovu R, Khan S, Rizvi T, Ling J, Asogwa N, Khan D, Elhosseiny S, Basman C, Weinberg MD, Lafferty JC. HEART FAILURE - AN UNEXPLORED RISK FACTOR FOR INFECTIVE ENDOCARDITIS AFTER PACEMAKER IMPLANTATION. J Am Coll Cardiol 2023. [DOI: 10.1016/s0735-1097(23)00541-7] [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: 03/06/2023]
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Mustafa A, Wei C, Grovu R, Basman C, Pirelli L, Lafferty JC, Weinberg MD, Kliger C. PREDICTING EARLY HOSPITAL DISCHARGE AFTER TRANSCATHETER MITRAL VALVE REPLACEMENT USING DEEP NEURAL NETWORK. J Am Coll Cardiol 2023. [DOI: 10.1016/s0735-1097(23)01533-4] [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: 03/06/2023]
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Mustafa A, Wei C, Grovu R, Kliger C, Rutkin B, Kodra A, Lafferty JC, Weinberg MD, Basman C. UTILIZATION OF DEEP NEURAL NETWORK FOR PREDICTING EARLY HOSPITAL DISCHARGE AFTER TRANSCATHETER AORTIC VALVE REPLACEMENT. J Am Coll Cardiol 2023. [DOI: 10.1016/s0735-1097(23)01520-6] [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: 03/07/2023]
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9
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Mustafa A, Wei C, Grovu R, Ling J, Jdaidani J, Khan S, Makhoul GW, Asogwa N, Medina Y, Elhosseiny S, Weinberg MD, Lafferty JC. CARDIOVASCULAR COMPLICATIONS OF TRADITIONAL VS SURROGATE PREGNANCY. J Am Coll Cardiol 2023. [DOI: 10.1016/s0735-1097(23)02739-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 03/06/2023]
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Toma C, Jaber WA, Weinberg MD, Bunte MC, Khandhar S, Stegman B, Gondi S, Chambers J, Amin R, Leung DA, Kado H, Brown MA, Sarosi MG, Bhat AP, Castle J, Savin M, Siskin G, Rosenberg M, Fanola C, Horowitz JM, Pollak JS. Acute outcomes for the full US cohort of the FLASH mechanical thrombectomy registry in pulmonary embolism. EUROINTERVENTION 2023; 18:1201-1212. [PMID: 36349702 PMCID: PMC9936254 DOI: 10.4244/eij-d-22-00732] [Citation(s) in RCA: 33] [Impact Index Per Article: 33.0] [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: 08/21/2022] [Accepted: 09/09/2022] [Indexed: 02/19/2023]
Abstract
BACKGROUND Evidence supporting interventional pulmonary embolism (PE) treatment is needed. AIMS We aimed to evaluate the acute safety and effectiveness of mechanical thrombectomy for intermediate- and high-risk PE in a large real-world population. METHODS FLASH is a multicentre, prospective registry enrolling up to 1,000 US and European PE patients treated with mechanical thrombectomy using the FlowTriever System. The primary safety endpoint is a major adverse event composite including device-related death and major bleeding at 48 hours, and intraprocedural adverse events. Acute mortality and 48-hour outcomes are reported. Multivariate regression analysed characteristics associated with pulmonary artery pressure and dyspnoea improvement. RESULTS Among 800 patients in the full US cohort, 76.7% had intermediate-high risk PE, 7.9% had high-risk PE, and 32.1% had thrombolytic contraindications. Major adverse events occurred in 1.8% of patients. All-cause mortality was 0.3% at 48-hour follow-up and 0.8% at 30-day follow-up, with no device-related deaths. Immediate haemodynamic improvements included a 7.6 mmHg mean drop in mean pulmonary artery pressure (-23.0%; p<0.0001) and a 0.3 L/min/m2 mean increase in cardiac index (18.9%; p<0.0001) in patients with depressed baseline values. Most patients (62.6%) had no overnight intensive care unit stay post-procedure. At 48 hours, the echocardiographic right ventricle/left ventricle ratio decreased from 1.23±0.36 to 0.98±0.31 (p<0.0001 for paired values) and patients with severe dyspnoea decreased from 66.5% to 15.6% (p<0.0001). Conclusions: Mechanical thrombectomy with the FlowTriever System demonstrates a favourable safety profile, improvements in haemodynamics and functional outcomes, and low 30-day mortality for intermediate- and high-risk PE.
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Affiliation(s)
- Catalin Toma
- University of Pittsburgh Medical Center Heart and Vascular Institute, Pittsburgh, PA, USA
| | | | - Mitchell D Weinberg
- Department of Cardiology, Northwell Health, Zucker School of Medicine at Hofstra/Northwell, Staten Island University Hospital, Staten Island, NY, USA
| | - Matthew C Bunte
- Saint Luke's Mid America Heart Institute, Kansas City, MO, USA
| | - Sameer Khandhar
- Division of Cardiology, Penn Presbyterian Medical Center, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, USA
| | - Brian Stegman
- CentraCare Heart and Vascular Center, St. Cloud, MN, USA
| | | | - Jeffrey Chambers
- Interventional Cardiology, Metropolitan Heart and Vascular Institute, Minneapolis, MN, USA
| | - Rohit Amin
- Ascension Sacred Heart Hospital Pensacola, Pensacola, FL, USA
| | | | - Herman Kado
- Ascension Providence Hospital, Southfield, MI, USA
| | | | | | - Ambarish P Bhat
- Department of Radiology, Section of Vascular and Interventional Radiology, University of Missouri, Columbia, MO, USA
| | - Jordan Castle
- Inland Imaging, Providence Sacred Heart, Spokane, WA, USA
| | - Michael Savin
- Department of Radiology, Oakland University William Beaumont School of Medicine, Royal Oak, MI, USA
| | - Gary Siskin
- Department of Radiology, Albany Medical Center, Albany, NY, USA
| | - Michael Rosenberg
- Department of Radiology, University of Minnesota, Minneapolis, MN, USA
| | - Christina Fanola
- Department of Cardiology, University of Minnesota, Minneapolis, MN, USA
| | - James M Horowitz
- Division of Cardiology, Department of Medicine, New York University Grossman School of Medicine, New York, NY, USA
| | - Jeffrey S Pollak
- Department of Radiology and Biomedical Imaging, Yale University School of Medicine, New Haven, CT, USA
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Saouma S, Akhrass P, Kowalski M, Shah R, Kandov R, Patel R, Lafferty JC, Parikh V, Weinberg MD, Yacoub H. PROXIMITY OF CORONARY ARTERIES TO RVOT AS DETERMINED BY COMPUTED TOMOGRAPHY. J Am Coll Cardiol 2022. [DOI: 10.1016/s0735-1097(22)01128-7] [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: 10/18/2022]
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Lakhter V, Weinberg MD, Galmer A, Mishra S, Dalsania R, Das S, Geraghty PJ, Jaff MR, Schneider PA, Weinberg I. Objective Outcome Measures for Trials in Patients With Chronic Limb-Threatening Ischemia Across 2 Decades: Analysis and Recommendations. JACC Cardiovasc Interv 2021; 14:2584-2597. [PMID: 34887050 DOI: 10.1016/j.jcin.2021.08.079] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/23/2021] [Revised: 08/13/2021] [Accepted: 08/17/2021] [Indexed: 11/30/2022]
Abstract
Chronic limb-threatening ischemia (CLTI) is prevalent and associated with morbidity and mortality. The published research concerning CLTI therapeutics is evolving. The goals of this review are to: 1) summarize the endpoints that are being used in trials assessing interventions for patients with CLTI; and 2) review gaps and discrepancies in current outcome definitions. A search was conducted of the PubMed database and ClinicalTrials.gov to identify studies published between January 2000 and March 2020 that evaluated treatment options for patients with CLTI. Meta-analyses, case series, case reports, abstracts, and expert opinion were excluded. Forty-nine studies (n = 11,667) were identified that fulfilled the inclusion criteria. Most trials reported clinical outcomes (mortality, 69.4%; limb events, 87.8%; target lesion revascularization, 83.7%). Mean follow-up duration was 23.7 months. In investigational device exemption trials, total follow-up and follow-up to primary outcomes were discordant (12 months vs 6 months; P = 0.0018). Hemodynamic testing was reported in 71.4%, usually ankle-brachial index. Patency was assessed in 89.8% of trials; ultrasound was used in 65.3% and invasive angiography in 85.7%, at baseline and/or during follow-up. Wound assessment was performed in 49.0% of studies, qualitative in 28.6% and quantitative in 20.4%. Finally, quality of life assessment was performed in 55% of studies. Definitions for many outcomes varied across studies. Consensus regarding which outcomes to study, uniform definitions, and optimal methods to measure some of these outcomes are yet to be established. A comprehensive effort by all stakeholders is needed to move the field of CLTI forward.
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Affiliation(s)
- Vladimir Lakhter
- Cardiology Division, Department of Internal Medicine, Temple University Hospital, Philadelphia, Pennsylvania, USA
| | - Mitchell D Weinberg
- Department of Cardiology, Northwell Health, Zucker School of Medicine at Hofstra/Northwell, Staten Island University Hospital, New York, USA
| | - Andrew Galmer
- Department of Cardiology, North Shore University Hospital, Northwell Health, Manhasset, New York, USA
| | - Suraj Mishra
- Department of Internal Medicine, Temple University Hospital, Philadelphia, Pennsylvania, USA
| | - Raj Dalsania
- Department of Internal Medicine, Temple University Hospital, Philadelphia, Pennsylvania, USA
| | - Shinjita Das
- VASCORE, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Patrick J Geraghty
- Department of Surgery, Washington University Medical School, St. Louis, Missouri, USA
| | - Michael R Jaff
- Boston Scientific, Marlboro, Massachusetts, USA; Department of Surgery, Division of Vascular and Endovascular Surgery, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Peter A Schneider
- Division of Vascular and Endovascular Surgery, University of California, San Francisco, San Francisco, California, USA
| | - Ido Weinberg
- VASCORE, Massachusetts General Hospital, Boston, Massachusetts, USA.
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Jamil A, Johnston-Cox H, Pugliese S, Nathan AS, Fiorilli P, Khandhar S, Weinberg MD, Giri J, Kobayashi T. Current interventional therapies in acute pulmonary embolism. Prog Cardiovasc Dis 2021; 69:54-61. [PMID: 34822807 DOI: 10.1016/j.pcad.2021.11.009] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/14/2021] [Accepted: 11/14/2021] [Indexed: 11/26/2022]
Abstract
Pulmonary embolism (PE) is the third leading cause of cardiovascular mortality. The management of PE is currently evolving given the development of new technologies and team-based approaches. This document will focus on risk stratification of PEs, review of the current interventional therapies, the role of clinical endpoints to assess the effectiveness of different interventional therapies, and the role for mechanical circulatory support in the complex management of this disease.
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Affiliation(s)
- Alisha Jamil
- Department of Medicine, Hospital of the University of Pennsylvania, Philadelphia, PA 19104, United States of America
| | - Hillary Johnston-Cox
- Department of Medicine, Hospital of the University of Pennsylvania, Philadelphia, PA 19104, United States of America; Division of Cardiovascular Medicine, Hospital of the University of Pennsylvania, Philadelphia, PA 19104, United States of America
| | - Steven Pugliese
- Division of Pulmonary and Critical Care Medicine, Hospital of the University of Pennsylvania, Philadelphia, PA 19104, United States of America
| | - Ashwin S Nathan
- Department of Medicine, Hospital of the University of Pennsylvania, Philadelphia, PA 19104, United States of America; Division of Cardiovascular Medicine, Hospital of the University of Pennsylvania, Philadelphia, PA 19104, United States of America; Center for Cardiovascular Outcomes, Quality, and Evaluative Research, United States of America
| | - Paul Fiorilli
- Department of Medicine, Hospital of the University of Pennsylvania, Philadelphia, PA 19104, United States of America; Division of Cardiovascular Medicine, Hospital of the University of Pennsylvania, Philadelphia, PA 19104, United States of America; Center for Cardiovascular Outcomes, Quality, and Evaluative Research, United States of America
| | - Sameer Khandhar
- Division of Cardiovascular Medicine, Penn Presbyterian Medical Center, Philadelphia, PA 19104, United States of America
| | - Mitchell D Weinberg
- Zucker School of Medicine at Hofstra/Northwell, Staten Island University Hospital, Staten Island, NY 10305, United States of America
| | - Jay Giri
- Department of Medicine, Hospital of the University of Pennsylvania, Philadelphia, PA 19104, United States of America; Division of Cardiovascular Medicine, Hospital of the University of Pennsylvania, Philadelphia, PA 19104, United States of America; Center for Cardiovascular Outcomes, Quality, and Evaluative Research, United States of America
| | - Taisei Kobayashi
- Department of Medicine, Hospital of the University of Pennsylvania, Philadelphia, PA 19104, United States of America; Division of Cardiovascular Medicine, Hospital of the University of Pennsylvania, Philadelphia, PA 19104, United States of America; Center for Cardiovascular Outcomes, Quality, and Evaluative Research, United States of America.
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Rao G, Xu H, Wang JJ, Galmer A, Giri J, Jaff MR, Kolluri R, Lau JF, Selim S, Weinberg I, Weinberg MD. Ultrasound-assisted versus conventional catheter-directed thrombolysis for acute pulmonary embolism: A multicenter comparison of patient-centered outcomes. Vasc Med 2019; 24:241-247. [DOI: 10.1177/1358863x19838334] [Citation(s) in RCA: 26] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Both catheter-directed thrombolysis (CDT) and ultrasound-assisted thrombolysis (USAT) are novel treatment modalities for patients presenting with acute pulmonary embolism (PE). The objective of this study was to compare clinical and quality-of-life (QOL) outcomes for patients undergoing either treatment modality. We retrospectively studied 70 consecutive patients treated with either CDT or USAT over 3 years at a multicenter health system. The primary clinical efficacy endpoint was right ventricular systolic pressure (RVSP) reduction post-procedurally. Safety endpoints were mortality and bleeding incidents based on Global Utilization of Streptokinase and Tissue Plasminogen Activator for Occluded Arteries (GUSTO) criteria. Long-term QOL was assessed using the 36-Item Short-Form Health Survey (SF-36) via phone interview. Thirty-seven patients (53%) in our study underwent USAT and 33 (47%) patients were treated with conventional CDT. Among all patients studied, 96% had echocardiographic evidence for right ventricular strain on admission. Mean RVSP decreased by 18 ± 13 mmHg in the USAT group post-procedurally as compared to 14 ± 16 mmHg in the CDT group, without significant difference between groups ( p = 0.31). Rates of moderate and severe bleeding were largely identical between USAT and CDT groups (USAT: 3%; CDT: 0%; p = 0.09). There was no death in either group during admission. At long-term follow-up, there was no significant difference in QOL between both treatment modalities in all eight functional domains of SF-36. Our retrospective study demonstrated using USAT over conventional CDT for acute submassive or massive PE did not yield additional clinical, safety, or long-term QOL benefit.
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Affiliation(s)
- Gaurav Rao
- Department of Cardiology, Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Manhasset, NY, USA
| | - Hai Xu
- Department of Medicine, Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Manhasset, NY, USA
| | - Jason J Wang
- Department of Medicine, Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Manhasset, NY, USA
| | - Andrew Galmer
- Department of Cardiology, Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Manhasset, NY, USA
| | - Jay Giri
- Department of Medicine, Hospital of the University of Pennsylvania, Philadelphia, PA, USA
| | - Michael R Jaff
- Department of Medicine, Harvard Medical School, Boston, MA, USA
| | - Raghu Kolluri
- Vascular Medicine Department, OhioHealth, Columbus, OH, USA
| | - Joe F Lau
- Department of Cardiology, Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Manhasset, NY, USA
| | - Samy Selim
- Department of Cardiology, Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Manhasset, NY, USA
| | - Ido Weinberg
- Department of Cardiology, Massachusetts General Hospital, Boston, MA, USA
| | - Mitchell D Weinberg
- Department of Cardiology, Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Manhasset, NY, USA
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Devanabanda AR, Tummala R, Galmer A, Grines C, Weinberg MD. Peripheral vascular interventional advances in 2017. J Interv Cardiol 2018; 31:553-561. [PMID: 29926509 DOI: 10.1111/joic.12530] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/29/2018] [Accepted: 05/31/2018] [Indexed: 12/24/2022] Open
Abstract
Aim of this review is to inform major clinical trials in peripheral vascular interventions in the year of 2017.
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Affiliation(s)
- Arvind R Devanabanda
- Department of Cardiology, Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Manhasset, New York
| | - Ramyashree Tummala
- St. Vincent Charity Medical Center, An Affiliate of Case Western Reserve University, Cleveland, Ohio
| | - Andrew Galmer
- Department of Cardiology, Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Manhasset, New York
| | - Cindy Grines
- Department of Cardiology, Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Manhasset, New York
| | - Mitchell D Weinberg
- Department of Cardiology, Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Manhasset, New York
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16
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Chatterjee S, Weinberg I, Yeh RW, Chakraborty A, Sardar P, Weinberg MD, Kabrhel C, Barnes GD, Mukherjee D, Kumbhani D, Bashir R, Vaidya A, Smith A, Fuchs B, Groeneveld P, Giri J. Risk factors for intracranial haemorrhage in patients with pulmonary embolism treated with thrombolytic therapy Development of the PE-CH Score. Thromb Haemost 2017; 117:246-251. [DOI: 10.1160/th16-07-0588] [Citation(s) in RCA: 37] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/29/2016] [Accepted: 10/19/2016] [Indexed: 11/05/2022]
Abstract
SummaryPulmonary embolism (PE) is a major cause of morbidity and mortality world-wide, and the use of thrombolytic therapy has been associated with favourable clinical outcomes in certain patient subsets. These potential benefits are counterbalanced by the risk of bleeding complications, the most devastating of which is intracranial haemorrhage (ICH). We retrospectively evaluated 9703 patients from the 2003–2012 nationwide in-patient sample database (NIS) who received thrombolytics for PE. All patients with ICH during the PE hospitalisation were identified and a clinical risk score model was developed utilizing demographics and comorbidities. The dataset was divided 1:1 into derivation and validation cohorts. During 2003–2012, 176/9705 (1.8 %) patients with PE experienced ICH after thrombolytic use. Four independent prognostic factors were identified in a backward logistic regression model, and each was assigned a number of points proportional to its regression coefficient: pre-existing Peripheral vascular disease (1 point), age greater than 65 years (Elderly) (1 point), prior Cerebrovascular accident with residual deficit (5 points), and prior myocardial infarction (Heart attack) (1 point). In the derivation cohort, scores of 0, 1, 2 and ≥ 5 points were associated with ICH risks of 1.2 %, 1.9 %, 2.4 % and 17.8 %, respectively. Rates of ICH were similar in the validation cohort. The C-statistic for the risk score was 0.65 (0.61–0.70) in the derivation cohort and 0.66 (0.60–0.72) in the validation cohort. A novel risk score, derived from simple clinical historical elements was developed to predict ICH in PE patients treated with thrombolytics.Supplementary Material to this article is available online at www.thrombosis-online.com.
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Abstract
OPINION STATEMENT The need to develop highly qualified, multidisciplinary critical limb ischemia (CLI) programs has gained significant momentum. Due to the systemic nature of the disease, patients with CLI are inherently medically complex and often present with multiple comorbidities. Successful care for these patients depends on community screening, early referral, accurate diagnosis, risk stratification, risk factor modification, invasive and non-invasive treatment strategies, and appropriate surveillance. Patients with CLI are often treated by multiple subspecialists-often lacking a unified team which could lead to inefficiencies and redundancy. Establishing an effective critical limb ischemia program relies on the joint efforts of multiple physician specialists, nurses, technicians, wound care specialists, researchers, and administrators who together form an integrated network that is easily accessible to the patient. This article will focus on the various modalities needed to build an advanced critical limb ischemia program, while addressing the challenges facing the medical community in caring for this population.
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Affiliation(s)
- Andrew M Galmer
- Department of Cardiology:Vascular Medicine and Peripheral Vascular Intervention Program, Northwell Health, 300 Community Drive, Manhasset, NY, USA
| | - Samy M Selim
- Department of Cardiology:Vascular Medicine and Peripheral Vascular Intervention Program, Northwell Health, 300 Community Drive, Manhasset, NY, USA
| | - Jay Giri
- Hospital of the University of Pennsylvania, 3400 Spruce St, Philadelphia, PA, 19104, USA
| | - Joe F Lau
- Department of Cardiology:Vascular Medicine and Peripheral Vascular Intervention Program, Northwell Health, 27005 76th Ave, New Hyde Park, NY, 11040, USA
| | - Mitchell D Weinberg
- Department of Cardiology:Vascular Medicine and Peripheral Vascular Intervention Program, Northwell Health, 300 Community Drive, Manhasset, NY, USA.
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Giri J, Yeh RW, Kennedy KF, Hawkins BM, Weinberg I, Weinberg MD, Parikh SA, Garasic J, Jaff MR, White CJ, Rosenfield K. Unprotected carotid artery stenting in modern practice. Catheter Cardiovasc Interv 2013; 83:595-602. [DOI: 10.1002/ccd.25090] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/14/2013] [Revised: 06/04/2013] [Accepted: 06/16/2013] [Indexed: 11/05/2022]
Affiliation(s)
- Jay Giri
- Cardiovascular Medicine Division; Hospital of the University of Pennsylvania; Philadelphia Pennsylvania
| | - Robert W. Yeh
- Division of Cardiology; Massachusetts General Hospital, Harvard Medical School; Boston Massachusetts
| | - Kevin F. Kennedy
- St. Luke's Mid-America Heart Institute; University of Missouri - Kansas City; Kansas City Missouri
| | - Beau M. Hawkins
- Division of Cardiology; Massachusetts General Hospital, Harvard Medical School; Boston Massachusetts
| | - Ido Weinberg
- Division of Cardiology; Massachusetts General Hospital, Harvard Medical School; Boston Massachusetts
| | - Mitchell D. Weinberg
- Division of Cardiology; Massachusetts General Hospital, Harvard Medical School; Boston Massachusetts
| | - Sahil A. Parikh
- University Hospitals Harrington Heart and Vascular Institute and Case Western Reserve University School of Medicine; Cleveland Ohio
| | - Joseph Garasic
- Division of Cardiology; Massachusetts General Hospital, Harvard Medical School; Boston Massachusetts
| | - Michael R. Jaff
- Division of Cardiology; Massachusetts General Hospital, Harvard Medical School; Boston Massachusetts
| | - Christopher J. White
- John Ochsner Heart and Vascular Institute; Ochsner Medical Center; New Orleans Louisiana
| | - Kenneth Rosenfield
- Division of Cardiology; Massachusetts General Hospital, Harvard Medical School; Boston Massachusetts
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Weinberg I, Giri J, Calfon MA, Hawkins BM, Weinberg MD, Margey R, Hannon K, Schainfeld RM, Jaff MR. Anatomic correlates of supra-normal ankle brachial indices. Catheter Cardiovasc Interv 2013; 81:1025-30. [DOI: 10.1002/ccd.24604] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/23/2012] [Accepted: 08/09/2012] [Indexed: 11/08/2022]
Affiliation(s)
- Ido Weinberg
- Section of Vascular Medicine; Division of Cardiovascular Medicine; The Massachusetts General Hospital Vascular Center; Boston; Massachusetts
| | - Jay Giri
- Section of Vascular Medicine; Division of Cardiovascular Medicine; The Massachusetts General Hospital Vascular Center; Boston; Massachusetts
| | - Marcella A. Calfon
- Section of Vascular Medicine; Division of Cardiovascular Medicine; The Massachusetts General Hospital Vascular Center; Boston; Massachusetts
| | - Beau M. Hawkins
- Section of Vascular Medicine; Division of Cardiovascular Medicine; The Massachusetts General Hospital Vascular Center; Boston; Massachusetts
| | - Mitchell D. Weinberg
- Section of Vascular Medicine; Division of Cardiovascular Medicine; The Massachusetts General Hospital Vascular Center; Boston; Massachusetts
| | - Ronan Margey
- Section of Vascular Medicine; Division of Cardiovascular Medicine; The Massachusetts General Hospital Vascular Center; Boston; Massachusetts
| | - Kathleen Hannon
- Section of Vascular Medicine; Division of Cardiovascular Medicine; The Massachusetts General Hospital Vascular Center; Boston; Massachusetts
| | - Robert M. Schainfeld
- Section of Vascular Medicine; Division of Cardiovascular Medicine; The Massachusetts General Hospital Vascular Center; Boston; Massachusetts
| | - Michael R. Jaff
- Section of Vascular Medicine; Division of Cardiovascular Medicine; The Massachusetts General Hospital Vascular Center; Boston; Massachusetts
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Abstract
Peripheral artery disease (PAD) is a marker of systemic atherosclerosis. Most patients with PAD also have concomitant coronary artery disease (CAD), and a large burden of morbidity and mortality in patients with PAD is related to myocardial infarction, ischemic stroke, and cardiovascular death. PAD patients without clinical evidence of CAD have the same relative risk of death from cardiac or cerebrovascular causes as those diagnosed with prior CAD, consistent with the systemic nature of the disease. The same risk factors that contribute to CAD and cerebrovascular disease also lead to the development of PAD. Because of the high prevalence of asymptomatic disease and because only a small percentage of PAD patients present with classic claudication, PAD is frequently underdiagnosed and thus undertreated. Health care providers may have difficulty differentiating PAD from other diseases affecting the limb, such as arthritis, spinal stenosis or venous disease. In Part 1 of this Review, we explain the epidemiology of and risk factors for PAD, and discuss the clinical presentation and diagnostic evaluation of patients with this condition.
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Affiliation(s)
- Joe F Lau
- The Zena and Michael A. Wiener Cardiovascular Institute, Mount Sinai School of Medicine, One Gustave L. Levy Place, Box 1033, New York, NY 10029-6574, USA
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22
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Dangas G, Stone GW, Weinberg MD, Webb J, Cox DA, Brodie BR, Krucoff MW, Gibbons RJ, Lansky AJ, Mehran R. Contemporary outcomes of rescue percutaneous coronary intervention for acute myocardial infarction: comparison with primary angioplasty and the role of distal protection devices (EMERALD trial). Am Heart J 2008; 155:1090-6. [PMID: 18513524 DOI: 10.1016/j.ahj.2007.12.003] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/21/2006] [Accepted: 12/05/2007] [Indexed: 11/25/2022]
Abstract
BACKGROUND The value of distal protection devices during rescue PCI has not been studied. METHODS The population enrolled in a prospective, randomized multicenter trial of distal microcirculatory protection in ST-elevation MI, was stratified for those undergoing rescue (n = 93) or primary (n = 408) PCI; we performed the prespecified comparisons of distal protection in rescue and primary PCI. RESULTS Compared to primary PCI, rescue patients had higher baseline rates of TIMI-3 flow, but lower rates of post PCI TIMI-3 flow. However, no differences in the primary endpoints of complete ST-segment resolution (STR) at 30 minutes or infarct size, or 6 month mortality were present. In rescue PCI patients, randomization to distal protection did not significantly affect infarct size, STR, mortality or other clinical events. CONCLUSION Despite reduced rates of post-procedural TIMI-3 flow, patients undergoing rescue PCI compared to primary PCI have similar myocardial perfusion, infarct size and clinical outcomes. Distal protection did not offer any detectable benefit in this patient population.
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Abstract
Inflammation has been implicated in all stages of cardiovascular disease. This has driven a very fruitful search for new biomarkers, which potentially can be used as tools in the diagnosis and prognosis of atherothrombotic disease. While these new markers might prove useful in predicting the onset of atherosclerosis in healthy individuals, the utility of biomarkers in risk assessment for events in those patients with established disease and/or those with acute coronary syndrome requires further work. Effective biomarkers must be standardized, logistically simple to analyze, and clinically useful. Understanding what impact sex, age, ethnicity, and comorbid conditions may have on biomarkers is also of importance. Unfortunately, many of the candidate markers have yet to satisfy these requirements.
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Affiliation(s)
- M D Weinberg
- Columbia University Medical Center, New York, NY 10032, USA
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Neugut AI, Weinberg MD, Ahsan H, Rescigno J. Carcinogenic effects of radiotherapy for breast cancer. Oncology (Williston Park) 1999; 13:1245-56; discussion 1257, 1261-5. [PMID: 10509322] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 02/14/2023]
Abstract
As increasing numbers of women with breast cancer survive their illness, it is critical to ascertain the long-term consequences of breast cancer treatment. One important effect is the occurrence of second malignancies, particularly in women treated with radiation therapy. Methodologic considerations raised in studying this issue include the effects of postmastectomy radiotherapy vs whole-breast irradiation, as currently employed following breast-conserving surgery; particularly germane are differences in the fields irradiated and the relative dosages to which various organs are exposed. Breast cancer radiotherapy does not appear to be a major factor in the occurrence of subsequent contralateral breast cancer. Such therapy may raise the risk of leukemia, particularly in association with certain types of adjuvant chemotherapy. Lung cancer risk is also increased, especially in cigarette smokers, and there are some indications that the risks of esophageal cancer and sarcomas may be elevated as well. Clinicians should be aware of these risks when trying to distinguish breast cancer recurrences from new primary malignancies. However, it should also be remembered that a high relative risk may represent only a slight increase in absolute risk. The benefits of breast cancer radiotherapy in improving survival or quality of life remain the principal factors to be weighed when deciding whether to treat patients with radiation.
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Affiliation(s)
- A I Neugut
- Herbert Irving Comprehensive Cancer Center, College of Physicians and Surgeons, Columbia University, New York, New York, USA
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