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Deo SV, Sundaram V, Sahadevan J, Selvaganesan P, Mohan SM, Rubelowsky J, Josephson R, Elgudin Y, Kilic A, Cmolik B. Outcomes of coronary artery bypass grafting in patients with heart failure with a midrange ejection fraction. J Thorac Cardiovasc Surg 2023; 165:149-158.e4. [PMID: 33618872 DOI: 10.1016/j.jtcvs.2021.01.035] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/15/2020] [Revised: 01/08/2021] [Accepted: 01/08/2021] [Indexed: 12/16/2022]
Abstract
BACKGROUND Coronary artery bypass grafting (CABG) improves survival in patients with heart failure and severely reduced left ventricular systolic function (LVEF). Limited data exist regarding adverse cardiovascular event rates after CABG in patients with heart failure with midrange ejection fraction (HFmrEF; LVEF > 40% and < 55%). METHODS We analyzed data on isolated CABG patients from the Veterans Affairs national database (2010-2019). We stratified patients into control (normal LVEF and no heart failure), HFmrEF, and heart failure with reduced LVEF (HFrEF) groups. We compared all-cause mortality and heart failure hospitalization rates between groups with a Cox model and recurrent events analysis, respectively. RESULTS In 6533 veterans, HFmrEF and HFrEF was present in 1715 (26.3%) and 566 (8.6%) respectively; the control group had 4252 (65.1%) patients. HFrEF patients were more likely to have diabetes mellitus (59%), insulin therapy (36%), and previous myocardial infarction (31%). Anemia was more prevalent in patients with HFrEF (49%) as was a lower serum albumin (mean, 3.6 mg/dL). Compared with the control group, a higher risk of death was observed in the HFmrEF (hazard ratio [HR], 1.3 [1.2-1.5)] and HFrEF (HR, 1.5 [1.2-1.7]) groups. HFmrEF patients had the higher risk of myocardial infarction (subdistribution HR, 1.2 [1-1.6]; P = .04). Risk of heart failure hospitalization was higher in patients with HFmrEF (HR, 4.1 [3.5-4.7]) and patients with HFrEF (HR, 7.2 [6.2-8.5]). CONCLUSIONS Heart failure with midrange ejection fraction negatively affects survival after CABG. These patients also experience higher rates myocardial infarction and heart failure hospitalization.
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Affiliation(s)
- Salil V Deo
- Surgical Services, Louis Stokes Cleveland VA Medical Center, Cleveland, Ohio; Cleveland VA CV Research Group, Cleveland, Ohio.
| | - Varun Sundaram
- Cleveland VA CV Research Group, Cleveland, Ohio; Department of Cardiovascular Medicine, Louis Stokes Cleveland VA Medical Center, Cleveland, Ohio
| | - Jayakumar Sahadevan
- Cleveland VA CV Research Group, Cleveland, Ohio; Department of Cardiovascular Medicine, Louis Stokes Cleveland VA Medical Center, Cleveland, Ohio
| | - Padmini Selvaganesan
- Department of Cardiovascular Medicine, Louis Stokes Cleveland VA Medical Center, Cleveland, Ohio
| | | | - Joseph Rubelowsky
- Surgical Services, Louis Stokes Cleveland VA Medical Center, Cleveland, Ohio
| | - Richard Josephson
- Cleveland VA CV Research Group, Cleveland, Ohio; Department of Cardiovascular Medicine, Harrington Heart and Vascular Institute, Cleveland Medical Center, Cleveland, Ohio
| | - Yakov Elgudin
- Surgical Services, Louis Stokes Cleveland VA Medical Center, Cleveland, Ohio
| | - Ahmet Kilic
- Department of Cardiac Surgery, John Hopkins School of Medicine, Baltimore, Md
| | - Brian Cmolik
- Surgical Services, Louis Stokes Cleveland VA Medical Center, Cleveland, Ohio
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Selvaganesan P, Russell A, Milo T, Mahajan A. A seamless healthcare platform for total connectivity throughout the patient's medical journey. IJBET 2023. [DOI: 10.1504/ijbet.2023.129196] [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] [Subscribe] [Scholar Register] [Indexed: 03/06/2023]
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Selvaganesan P, Russell A, Milo T, Mahajan A. A seamless healthcare platform for total connectivity throughout the patient's medical journey. IJBET 2023. [DOI: 10.1504/ijbet.2023.10054326] [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] [Subscribe] [Scholar Register] [Indexed: 02/24/2023]
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Sundaram V, Selvaganesan P, Deo S, Karnib M. The importance of randomization in clinical research. Indian J Thorac Cardiovasc Surg 2022; 38:562-565. [PMID: 36050978 PMCID: PMC9424468 DOI: 10.1007/s12055-022-01401-7] [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: 04/04/2022] [Revised: 07/01/2022] [Accepted: 07/21/2022] [Indexed: 11/28/2022] Open
Abstract
Studies evaluating average treatment effects (ATE) of an intervention could broadly be classified into those with observational and randomized designs. Observational studies are limited by confounding, in addition to selection and information bias, making the evaluation of ATE hypothesis generating and not hypothesis testing. Randomization attempts to reduce the systemic error introduced by observational studies by ensuring equal distribution of prognostic factors between the treatment and control groups, thereby confirming that any difference in outcomes observed between the two groups is attributable to the treatment. While randomized controlled trials (RCT) remain the gold standard in estimating ATE of therapeutic interventions, they do have inherent limitations due to uncertain external validity. Observational studies can have a complementary role in enhancing RCTs' ability to inform routine clinical practice. In this review, we focus on the limitations of observational studies, the need for randomization, interpretation, and the limitations of RCTs.
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Affiliation(s)
- Varun Sundaram
- Louis Stokes Veteran Affairs Medical Center, Cleveland, OH 44106 USA
- Harrington Heart and Vascular Institute, University Hospitals Cleveland Medical Center, Cleveland, OH USA
- Case Western Reserve University, Cleveland, OH USA
| | - Padmini Selvaganesan
- Louis Stokes Veteran Affairs Medical Center, Cleveland, OH 44106 USA
- Case Western Reserve University, Cleveland, OH USA
| | - Salil Deo
- Louis Stokes Veteran Affairs Medical Center, Cleveland, OH 44106 USA
- Case Western Reserve University, Cleveland, OH USA
| | - Mohamad Karnib
- Louis Stokes Veteran Affairs Medical Center, Cleveland, OH 44106 USA
- Harrington Heart and Vascular Institute, University Hospitals Cleveland Medical Center, Cleveland, OH USA
- Case Western Reserve University, Cleveland, OH USA
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Deo SV, Reddy YN, Zakeri R, Karnib M, Selvaganesan P, Elgudin Y, Kilic A, Rubelowsky J, Altarabsheh SE, Osman MN, Josephson RA, Mohan SKM, Cmolik B, Simon DI, Rajagopalan S, Cleland JG, Sahadevan J, Sundaram V. Revascularization in Ischemic Heart Failure with Preserved Ejection Fraction: A Nationwide Cohort Study. Eur J Heart Fail 2022; 24:1427-1438. [PMID: 35119162 DOI: 10.1002/ejhf.2446] [Citation(s) in RCA: 2] [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: 05/16/2021] [Revised: 01/27/2022] [Accepted: 01/31/2022] [Indexed: 11/09/2022] Open
Affiliation(s)
- Salil V Deo
- Louis Stokes Veteran Affairs Medical Center, Cleveland, OH, USA.,Case Western Reserve University School of Medicine, Cleveland, OH, USA
| | | | | | - Mohamad Karnib
- Louis Stokes Veteran Affairs Medical Center, Cleveland, OH, USA.,Case Western Reserve University School of Medicine, Cleveland, OH, USA.,Harrington Heart and Vascular Institute, University Hospitals Cleveland Medical Center, Cleveland, OH
| | - Padmini Selvaganesan
- Louis Stokes Veteran Affairs Medical Center, Cleveland, OH, USA.,Case Western Reserve University School of Medicine, Cleveland, OH, USA
| | - Yakov Elgudin
- Louis Stokes Veteran Affairs Medical Center, Cleveland, OH, USA.,Case Western Reserve University School of Medicine, Cleveland, OH, USA
| | - Ahmet Kilic
- Johns Hopkins University School of Medicine, Baltimore, MD
| | | | | | - Mohammed N Osman
- Louis Stokes Veteran Affairs Medical Center, Cleveland, OH, USA.,Case Western Reserve University School of Medicine, Cleveland, OH, USA.,Harrington Heart and Vascular Institute, University Hospitals Cleveland Medical Center, Cleveland, OH
| | - Richard A Josephson
- Case Western Reserve University School of Medicine, Cleveland, OH, USA.,Harrington Heart and Vascular Institute, University Hospitals Cleveland Medical Center, Cleveland, OH
| | | | - Brian Cmolik
- Louis Stokes Veteran Affairs Medical Center, Cleveland, OH, USA.,Case Western Reserve University School of Medicine, Cleveland, OH, USA
| | - Daniel I Simon
- Case Western Reserve University School of Medicine, Cleveland, OH, USA.,Harrington Heart and Vascular Institute, University Hospitals Cleveland Medical Center, Cleveland, OH
| | - Sanjay Rajagopalan
- Case Western Reserve University School of Medicine, Cleveland, OH, USA.,Harrington Heart and Vascular Institute, University Hospitals Cleveland Medical Center, Cleveland, OH
| | - John Gf Cleland
- Robertson Center for Biostatistics, University of Glasgow, Glasgow, UK
| | - Jayakumar Sahadevan
- Louis Stokes Veteran Affairs Medical Center, Cleveland, OH, USA.,Case Western Reserve University School of Medicine, Cleveland, OH, USA
| | - Varun Sundaram
- Louis Stokes Veteran Affairs Medical Center, Cleveland, OH, USA.,Case Western Reserve University School of Medicine, Cleveland, OH, USA.,Harrington Heart and Vascular Institute, University Hospitals Cleveland Medical Center, Cleveland, OH
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Deo S, Sundaram V, Sheikh MA, Sahadevan J, Selvaganesan P, Madan Mohan SK, Rubelowsky J, Elgudin Y, Josephson R, Davierwala PM, Cmolik B. Pre-operative glycaemic control and long-term survival in diabetic patients after coronary artery bypass grafting. Eur J Cardiothorac Surg 2021; 60:1169-1177. [PMID: 33970210 DOI: 10.1093/ejcts/ezab180] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/09/2020] [Revised: 02/12/2021] [Accepted: 03/19/2021] [Indexed: 01/04/2023] Open
Abstract
OBJECTIVES We analysed the Veteran Affairs data to evaluate the association of pre-operative glycated haemoglobin (HbA1c) and long-term outcome after isolated coronary artery bypass grafting (CABG). METHODS Veterans with diabetes mellitus and isolated CABG (2006-2018) were divided into 4 groups (I: HbA1c <6.5%, II: HbA1c 6.5-8, III 8-10% and IV: HbA1c >10%). The relationship of pre-operative HbA1c and long-term survival was evaluated with a multivariable Cox proportional hazards model and reported as hazard ratios (HR). The cumulative incidence of secondary end-points [myocardial infarction (MI) and repeat revascularization (percutaneous intervention)] for each group was modelled as competing events with cause-specific Cox proportional hazards models. RESULTS Overall, 16 190 patients (mean age 64.9 years, male 98%; insulin dependent 53%) with diabetes mellitus underwent isolated CABG. We observed 19.4%, 45.4%, 27% and 8.2% patients in groups I, II, III and IV, respectively. Patients with HbA1c >10% were the youngest (mean age 60.9 years) and had high rates of Insulin dependence (78%). In patients with HbA1c >10%, improvement in levels was observed in 76%. The median follow-up observed was 5.8 (3.2-8.8) years. Compared to the study mean HbA1c (7.3%), mortality rate increased with HbA1c levels >8%, and especially with pre-operative HbA1c levels >9%. Compared to patients with HbA1c <8%, HbA1c 8-10% and >10% were associated with increased MI (HR 1.24 and HR 1.39, respectively) and need for reintervention (HR 1.20 and HR 1.24, respectively). CONCLUSIONS In patients undergoing CABG, pre-operative HbA1c >8% is associated with the increased risk of mortality and adverse cardiac events.
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Affiliation(s)
- Salil Deo
- Surgical Services, Louis Stokes Cleveland VA Medical Center, VA Northeast Ohio Healthcare System, Cleveland, OH, USA
| | - Varun Sundaram
- Department of Cardiology, Harrington Heart and Vascular Institute, Cleveland Medical Center, University Hospitals, Cleveland, OH, USA.,Division of Cardiology, Louis Stokes Cleveland VA Medical Center, Cleveland, OH, USA
| | - Muhammad Adil Sheikh
- Division of Hospital Medicine, Department of Internal Medicine, University of Michigan School of Medicine, Ann Arbor, MI, USA
| | - Jayakumar Sahadevan
- Division of Cardiology, Louis Stokes Cleveland VA Medical Center, Cleveland, OH, USA
| | - Padmini Selvaganesan
- Division of Cardiology, Louis Stokes Cleveland VA Medical Center, Cleveland, OH, USA
| | | | - Joseph Rubelowsky
- Surgical Services, Louis Stokes Cleveland VA Medical Center, VA Northeast Ohio Healthcare System, Cleveland, OH, USA
| | - Yakov Elgudin
- Surgical Services, Louis Stokes Cleveland VA Medical Center, VA Northeast Ohio Healthcare System, Cleveland, OH, USA
| | - Richard Josephson
- Department of Cardiology, Harrington Heart and Vascular Institute, Cleveland Medical Center, University Hospitals, Cleveland, OH, USA
| | | | - Brian Cmolik
- Surgical Services, Louis Stokes Cleveland VA Medical Center, VA Northeast Ohio Healthcare System, Cleveland, OH, USA
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Sundaram V, Deo S, Rana M, Selvaganesan P, Rubelowsky J, Elgudin Y, Mohan SKM, Josephson R, Sahadevan J, Reddy Y. RISING PREVALENCE OF OBESE HEART FAILURE WITH PRESERVED EJECTION FRACTION IN THE UNITED STATES. J Am Coll Cardiol 2021. [DOI: 10.1016/s0735-1097(21)02039-8] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
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Deo S, Sundaram V, Selvaganesan P, Rubelowsky J, Elgudin Y, Mohan SKM, Josephson R, Altarabsheh S, Cmolik B, Davierwala P, Sahadevan J. CHA2DS2-VASC SCORE RATHER THAN NEW-ONSET ATRIAL FIBRILLATION INFLUENCES STROKE RISK AFTER ISOLATED CORONARY ARTERY BYPASS GRAFTING - A NATIONWIDE STUDY. J Am Coll Cardiol 2021. [DOI: 10.1016/s0735-1097(21)01722-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
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Deo S, Reddy Y, Selvaganesan P, Rubelowsky J, Elgudin Y, Mohan SKM, Josephson R, Cmolik B, Kilic A, Sahadevan J, Sundaram V. CORONARY ARTERY BYPASS GRAFTING IMPROVES 10 YEAR OUTCOMES IN HEART FAILURE AND PRESERVED EJECTION FRACTION - A NATIONWIDE STUDY. J Am Coll Cardiol 2021. [DOI: 10.1016/s0735-1097(21)02091-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
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Deo S, Sahadevan J, Sheikh MA, Selvaganesan P, Mohan SM, Josephson R, Rubelowsky J, Elgudin Y, Cmolik B, Altarabsheh S, Davierwala P, Sundaram V. A NATIONWIDE ANALYSIS OF THE EXTERNAL APPLICABILITY OF THE COMPASS TRIAL IN PATIENTS UNDERGOING CORONARY ARTERY BYPASS SURGERY. J Am Coll Cardiol 2021. [DOI: 10.1016/s0735-1097(21)01513-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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