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Scierka LE, Jelani QUA, Smolderen KG, Gosch K, Spertus JA, Mena-Hurtado C, Jones P, Dreyer RP. Patient representativeness of a peripheral artery disease cohort in a randomized control trial versus a real-world cohort: The CLEVER trial versus the PORTRAIT registry. Contemp Clin Trials 2021; 112:106624. [PMID: 34793986 DOI: 10.1016/j.cct.2021.106624] [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] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/09/2021] [Revised: 09/23/2021] [Accepted: 11/11/2021] [Indexed: 11/03/2022]
Abstract
INTRODUCTION Peripheral artery disease (PAD) is a burdensome disease. It is unclear whether PAD cohorts enrolled in contemporary randomized control trials (RCT) are representative of the real-world PAD populations in terms of their patient characteristics. METHODS We compared baseline patient characteristics and health status (as measured by the Peripheral Artery Questionnaire [PAQ]) between the randomized CLEVER study, and the real-world PORTRAIT registry. CLEVER was an RCT of PAD patients enrolled from 29 centers across the US and Canada comparing revascularization with stenting versus optimal medical therapy (OMT) and supervised exercise therapy (SET) plus OMT. PORTRAIT was a multicenter, prospective study of patients with new or worsening PAD symptoms across ten sites in the US. RESULTS The final cohort consisted of 879 patients (n = 119 from CLEVER, n = 760 from PORTRAIT (24.5% black, 41.4% women). While CLEVER enrolled patients with aortoiliac disease, only 16.0% of the PORTRAIT cohort had isolated aortoiliac disease. Compared with CLEVER, patients from PORTRAIT were older (64.0 ± 9.5 versus 68.9 ± 9.5 yrs., p ≤0.001), had more severe disease as measured by the ankle brachial index (0.7 ± 0.2 versus 0.9 ± 0.2, p ≤0.001) and a higher prevalence of cardiovascular risk factors including hyperlipidemia and diabetes (all p values<0.05). Both cohorts had similar disease-specific health status as measured by the PAQ summary score (47.4 ± 21.9 versus 43.6 ± 18.4, p = 0.07). CONCLUSION In this comparative study, real-world patients with PAD were older and sicker when compared to an RCT with similar indications. This gap may be bridged by improving enrollment of underrepresented high-risk patients in PAD trials testing strategies for PAD symptom relief. CLINICAL TRIAL REGISTRATION https://clinicaltrials.gov/ct2/show/NCT01419080?term=portrait&rank=1NCT01419080.
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Affiliation(s)
- Lindsey E Scierka
- Vascular Medicine Outcomes Program, Section of Cardiovascular Medicine, Department of Internal Medicine, Yale University, New Haven, CT, USA
| | - Qurat-Ul-Ain Jelani
- Vascular Medicine Outcomes Program, Section of Cardiovascular Medicine, Department of Internal Medicine, Yale University, New Haven, CT, USA
| | - Kim G Smolderen
- Vascular Medicine Outcomes Program, Section of Cardiovascular Medicine, Department of Internal Medicine, Yale University, New Haven, CT, USA
| | - Kensey Gosch
- Saint Luke's Mid America Heart Institute, Kansas City, MO, USA
| | - John A Spertus
- Saint Luke's Mid America Heart Institute, Kansas City, MO, USA; University of Missouri-, Kansas City, MO, USA
| | - Carlos Mena-Hurtado
- Vascular Medicine Outcomes Program, Section of Cardiovascular Medicine, Department of Internal Medicine, Yale University, New Haven, CT, USA
| | - Philip Jones
- Saint Luke's Mid America Heart Institute, Kansas City, MO, USA
| | - Rachel P Dreyer
- Department of Emergency Medicine, Yale School of Medicine, New Haven, CT, USA; Center for Outcomes Research and Evaluation (CORE), Yale New Haven Hospital, New Haven, CT, USA.
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Jelani QUA, Llanos-Chea F, Bogra P, Trejo-Paredes C, Huang J, Provance JB, Turner J, Anantha-Narayanan M, Sheikh AB, Smolderen KG, Mena-Hurtado C. Guideline-Directed Medical Therapy in Patients with Chronic Kidney Disease Undergoing Peripheral Vascular Intervention. Am J Nephrol 2021; 52:845-853. [PMID: 34706363 DOI: 10.1159/000519484] [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] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/09/2021] [Accepted: 09/03/2021] [Indexed: 11/19/2022]
Abstract
INTRODUCTION Guideline-directed medical therapy (GDMT) is imperative to improve cardiovascular and limb outcomes for patients with critical limb ischemia (CLI), especially amongst those at highest risk for poor outcomes, including those with comorbid chronic kidney disease (CKD). Our objective was to examine GDMT prescription rates and their variation across individual sites for patients with CLI undergoing peripheral vascular interventions (PVIs), by their comorbid CKD status. METHODS Patients with CLI who underwent PVI (October 2016-April 2019) were included from the Vascular Quality Initiative (VQI) database. CKD was defined as GFR <60 mL/min/1.73 m2. GDMT included the composite use of antiplatelet therapy and a statin, as well as an angiotensin-converting enzyme inhibitor or angiotensin receptor blocker if hypertension was present. The use of GDMT before and after the index procedure was summarized in those with and without CKD. Adjusted median odds ratios (MORs) for site variability were calculated. RESULTS The study included 28,652 patients, with a mean age of 69.4 ± 11.7 years, and 40.8% were females. A total of 47.5% had CKD. Patients with CKD versus those without CKD had lower prescription rates both before (31.7% vs. 38.9%) and after (36.5% vs. 48.8%) PVI (p < 0.0001). Significant site variability was observed in the delivery of GDMT in both the non-CKD and CKD groups before and after PVI (adjusted MORs: 1.31-1.41). DISCUSSION/CONCLUSION In patients with CLI undergoing PVI, patients with comorbid CKD were less likely to receive GDMT. Significant variability of GDMT was observed across sites. These findings indicate that significant improvements must be made in the medical management of patients with CLI, particularly in patients at high risk for poor clinical outcomes.
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Affiliation(s)
- Qurat-Ul-Ain Jelani
- Vascular Medicine Outcomes (VAMOS) Program, Section of Cardiovascular Medicine, Department of Internal Medicine, Yale School of Medicine, New Haven, Connecticut, USA
| | - Fiorella Llanos-Chea
- Vascular Medicine Outcomes (VAMOS) Program, Section of Cardiovascular Medicine, Department of Internal Medicine, Yale School of Medicine, New Haven, Connecticut, USA
| | - Pragati Bogra
- Department of Internal Medicine, Griffin Hospital, Derby, Connecticut, USA
| | - Camila Trejo-Paredes
- Department of Internal Medicine, University of Connecticut, Farmington, Connecticut, USA
| | - Jiaming Huang
- Department of Data Science, Dana-Farber Cancer Institute, Boston, Massachusetts, USA
| | - Jeremy B Provance
- Vascular Medicine Outcomes (VAMOS) Program, Section of Cardiovascular Medicine, Department of Internal Medicine, Yale School of Medicine, New Haven, Connecticut, USA
| | - Jeffrey Turner
- Section of Nephrology, Department of Internal Medicine, Yale School of Medicine, New Haven, Connecticut, USA
| | | | - Azfar Bilal Sheikh
- Division of Cardiology, Department of Internal Medicine, University of Texas Health Science Center, Houston, Texas, USA
| | - Kim G Smolderen
- Vascular Medicine Outcomes (VAMOS) Program, Section of Cardiovascular Medicine, Department of Internal Medicine, Yale School of Medicine, New Haven, Connecticut, USA
| | - Carlos Mena-Hurtado
- Vascular Medicine Outcomes (VAMOS) Program, Section of Cardiovascular Medicine, Department of Internal Medicine, Yale School of Medicine, New Haven, Connecticut, USA
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Pichert MD, Smolderen KG, Castro-Dominguez Y, Jelani QUA, Nagpal S, Provance JB, Huang J, Malik AO, Secemsky EA, Derbas LA, Mena-Hurtado CI. Trends in drug-coated device use for peripheral artery disease: Insights from the Vascular Quality Initiative (VQI). Vasc Med 2021; 27:73-74. [PMID: 34610776 DOI: 10.1177/1358863x211043567] [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] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Affiliation(s)
- Matthew D Pichert
- Vascular Medicine Outcomes Program at Yale University, Department of Internal Medicine, Section of Cardiovascular Medicine, Yale University School of Medicine, New Haven, CT, USA
| | - Kim G Smolderen
- Vascular Medicine Outcomes Program at Yale University, Department of Internal Medicine, Section of Cardiovascular Medicine, Yale University School of Medicine, New Haven, CT, USA.,Yale University, Department of Psychiatry, Yale University School of Medicine, New Haven, CT
| | | | - Qurat-Ul-Ain Jelani
- Vascular Medicine Outcomes Program at Yale University, Department of Internal Medicine, Section of Cardiovascular Medicine, Yale University School of Medicine, New Haven, CT, USA
| | - Sameer Nagpal
- Vascular Medicine Outcomes Program at Yale University, Department of Internal Medicine, Section of Cardiovascular Medicine, Yale University School of Medicine, New Haven, CT, USA
| | - Jeremy B Provance
- Vascular Medicine Outcomes Program at Yale University, Department of Internal Medicine, Section of Cardiovascular Medicine, Yale University School of Medicine, New Haven, CT, USA
| | | | - Ali O Malik
- Saint Luke's Mid America Heart Institute, Kansas City, MI, USA.,Department of Biomedical and Health Informatics, University of Missouri-Kansas City, Kansas City, MI, USA
| | - Eric A Secemsky
- Smith Center for Outcomes Research in Cardiology, Department of Medicine, Division of Cardiology, Beth Israel Deaconess Medical Center, Boston, MA, USA
| | - Laith A Derbas
- Division of Cardiology, Rush University, Chicago, IL, USA
| | - Carlos I Mena-Hurtado
- Vascular Medicine Outcomes Program at Yale University, Department of Internal Medicine, Section of Cardiovascular Medicine, Yale University School of Medicine, New Haven, CT, USA
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Jelani QUA, Smolderen KG, Halpin D, Gosch K, Spertus JA, Iyad Ochoa Chaar C, Tutein Nolthenius RP, Heyligers J, De Vries JP, Mena-Hurtado C. Patient profiles and health status outcomes for peripheral artery disease in high-income countries: a comparison between the USA and The Netherlands. Eur Heart J Qual Care Clin Outcomes 2021; 7:505-512. [PMID: 32539108 DOI: 10.1093/ehjqcco/qcaa052] [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] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/23/2020] [Revised: 05/29/2020] [Accepted: 06/08/2020] [Indexed: 12/24/2022]
Abstract
AIMS Peripheral artery disease (PAD) is a global disease. Understanding variability in patient profiles and PAD-specific health status outcomes across health system countries can provide insights into improving PAD care. We compared these features between two high-income countries, the USA and The Netherlands. METHODS AND RESULTS Patients were identified from the patient-centred outcomes related to treatment practices in peripheral arterial disease: investigating trajectories study-a prospective, international registry of patients presenting to vascular specialty clinics for new onset, or exacerbation of PAD symptoms. PAD-specific health status was measured with the peripheral artery questionnaire. General linear mixed models for repeated measures were used to study baseline, 3, 6, and 12-month PAD-specific health status outcomes (peripheral artery questionnaire summary score) between the USA and The Netherlands. Out of a total of 1114 patients, 748 patients (67.1%) were from the USA and 366 (32.9%) from The Netherlands. US patients with PAD were older, with more financial barriers, higher cardiovascular risk factor burden, and lower referral rates for exercise treatment (P < 0.001). They had significantly worse PAD-specific adjusted health status scores at presentation, 3, 6, and 12 months of follow-up (all P < 0.0001). Magnitude of change in 1-year health status scores was smaller in the US cohort when compared with The Netherlands. CONCLUSION Compared with the Dutch cohort, US patients had worse adjusted PAD-specific health status scores at all time point, improving less over time, despite treatment. Leveraging inter-country differences in care and outcomes could provide important insights into optimizing PAD outcomes. CLINICAL TRIAL REGISTRATION https://clinicaltrials.gov/ct2/show/NCT01419080? term=portrait&rank=1 NCT01419080.
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Affiliation(s)
- Qurat-Ul-Ain Jelani
- Section of Cardiovascular Medicine, Department of Medicine, Yale University School of Medicine, 20 York St, New Haven 06520, CT, USA
| | - Kim G Smolderen
- Section of Cardiovascular Medicine, Department of Medicine, Yale University School of Medicine, 20 York St, New Haven 06520, CT, USA
| | - David Halpin
- David Halpin: Colorado Heart and Vascular Institute, 030 Mountain View Ave, Ste 300. Longmont, Colorado 80501, USA
| | - Kensey Gosch
- Saint Luke's Mid America Heart Institute/UMKC, 4401 Wornall Rd, Kansas Kansas City, MO 64111, USA
| | - John A Spertus
- Saint Luke's Mid America Heart Institute/UMKC, 4401 Wornall Rd, Kansas Kansas City, MO 64111, USA.,University of Missouri-Kansas City, 5000 Holmes St., Kansas City, MO 64110, USA
| | - Cassius Iyad Ochoa Chaar
- Division of Vascular Surgery, Department of Surgery, Yale University School of Medicine, 20 YorK Street, New Haven, CT 06520, USA
| | - Rudolf P Tutein Nolthenius
- Department of Surgery, Albert Schweitzer Hospital, Albert Schweitzerplaats 25, 3318 AT Dordrecht, The Netherlands
| | - Jan Heyligers
- Department of Vascular Surgery, University Medical Center Utrecht, Heidelberglaan 100, 3584 CX Utrecht, The Netherlands.,Department of Surgery, St Elisabeth Hospital, Hilvarenbeekse Weg 60, 5022 GC Tilburg, The Netherlands
| | - Jean-Paul De Vries
- Department of Surgery, Division of Vascular Surgery, University Medical Centre Groningen, Hanzeplein 1, 9713 GZ Groningen, The Netherlands
| | - Carlos Mena-Hurtado
- Section of Cardiovascular Medicine, Department of Medicine, Yale University School of Medicine, 20 York St, New Haven 06520, CT, USA
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Peri-Okonny PA, Wang J, Gosch KL, Patel MR, Shishehbor MH, Safley DL, Abbott JD, Aronow HD, Mena-Hurtado C, Jelani QUA, Tang Y, Bunte M, Labrosciano C, Beltrame JF, Spertus JA, Smolderen KG. Establishing Thresholds for Minimal Clinically Important Differences for the Peripheral Artery Disease Questionnaire. Circ Cardiovasc Qual Outcomes 2021; 14:e007232. [PMID: 33947205 DOI: 10.1161/circoutcomes.120.007232] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND Understanding minimum clinically important differences (MCID) in patient-reported outcomes is essential in interpreting the magnitude of changes in these measures. No MCID from patients' perspectives has ever been published for peripheral artery disease-specific health status assessment tools. The Peripheral Artery Questionnaire (PAQ) is a commonly used, validated peripheral artery disease-specific health status instrument for which we sought to prospectively establish its MCID from patients' perspectives. METHODS AND RESULTS Patients presenting to vascular clinics with new or worsened claudication in the US cohort of the PORTRAIT (Patient-Centered Outcomes Related to Treatment Practices in Peripheral Arterial Disease: Investigating Trajectories) registry who completed baseline and follow-up PAQ assessments along with the Global Assessment of Functioning scale were included. Mean change in PAQ summary scores from 3- to 6-month follow-up was calculated according to Global Assessment of Functioning category. MCID was defined as the mean difference in scores between those with small improvement or deterioration and those with no change. Multivariable linear regression was used to provide an MCID estimate after adjusting for patients' 3-month PAQ score. Of the 483 patients who completed the Global Assessment of Functioning score at 6 months and who had available 3- and 6-month PAQ assessments, the mean age was 69 years, 42% were female, and 71% were White. The MCIDs for PAQ summary scale improvement and worsening were 8.7 (2.9-14.5) and -11.0 (-18.6 to -3.3), respectively. After multivariable adjustment, these were 8.9 (3.0-14.8) and -11.2 (-18.2 to -4.2), respectively. There was no significant interaction between treatment (invasive versus noninvasive) and Global Assessment of Functioning response (P=0.75). CONCLUSIONS In patients with new or worsened claudication, a 10-point change in PAQ summary score represents an MCID. This estimate needs external validation and may inform the interpretation of PAQ scores when used as outcomes in clinical trials or in routine clinical care. Registration: URL: https://www.clinicaltrials.gov; Unique identifier: NCT01419080.
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Affiliation(s)
- Poghni A Peri-Okonny
- Department of Internal Medicine, University of Missouri, Kansas City (P.A.P.-O., D.A., M.B., J.A.S.).,Department of Cardiovascular Medicine, Saint Luke's Mid America Heart Institute, Kansas City, MO (P.A.P.-O., J.W., J.G., D.S, Y.T., M.B., J.A.S.)
| | - Jingyan Wang
- Department of Cardiovascular Medicine, Saint Luke's Mid America Heart Institute, Kansas City, MO (P.A.P.-O., J.W., J.G., D.S, Y.T., M.B., J.A.S.)
| | | | - Manesh R Patel
- Division of Cardiology, Duke University School of Medicine, Durham, NC (M.P.)
| | - Mehdi H Shishehbor
- Harrington Heart & Vascular Institute and Case Western University School of Medicine, Cleveland, OH (M.H.S.)
| | - David L Safley
- Department of Internal Medicine, University of Missouri, Kansas City (P.A.P.-O., D.A., M.B., J.A.S.).,Department of Cardiovascular Medicine, Saint Luke's Mid America Heart Institute, Kansas City, MO (P.A.P.-O., J.W., J.G., D.S, Y.T., M.B., J.A.S.)
| | - J Dawn Abbott
- Division of Cardiology, Department of Medicine, Brown University, Providence, RI (J.D.A., H.D.A.)
| | - Herbert D Aronow
- Division of Cardiology, Department of Medicine, Brown University, Providence, RI (J.D.A., H.D.A.)
| | - Carlos Mena-Hurtado
- Vascular Medicine Outcomes (VAMOS) Program, Section of Cardiovascular Medicine, Yale University, New Haven, CT (C.M.-H., Q.-U.-A.J., K.G.S.)
| | - Qurat-Ul-Ain Jelani
- Vascular Medicine Outcomes (VAMOS) Program, Section of Cardiovascular Medicine, Yale University, New Haven, CT (C.M.-H., Q.-U.-A.J., K.G.S.)
| | - Yuanyuan Tang
- Department of Cardiovascular Medicine, Saint Luke's Mid America Heart Institute, Kansas City, MO (P.A.P.-O., J.W., J.G., D.S, Y.T., M.B., J.A.S.)
| | - Matthew Bunte
- Department of Internal Medicine, University of Missouri, Kansas City (P.A.P.-O., D.A., M.B., J.A.S.).,Department of Cardiovascular Medicine, Saint Luke's Mid America Heart Institute, Kansas City, MO (P.A.P.-O., J.W., J.G., D.S, Y.T., M.B., J.A.S.)
| | | | - John F Beltrame
- Department of Medicine, Queen Elisabeth Hospital, Adelaide, Australia (C.L., J.F.B.)
| | - John A Spertus
- Department of Internal Medicine, University of Missouri, Kansas City (P.A.P.-O., D.A., M.B., J.A.S.).,Department of Cardiovascular Medicine, Saint Luke's Mid America Heart Institute, Kansas City, MO (P.A.P.-O., J.W., J.G., D.S, Y.T., M.B., J.A.S.)
| | - Kim G Smolderen
- Vascular Medicine Outcomes (VAMOS) Program, Section of Cardiovascular Medicine, Yale University, New Haven, CT (C.M.-H., Q.-U.-A.J., K.G.S.)
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6
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Llanos-Chea F, Jelani QUA, Trejo-Paredes C, Curtis JP, Parzynski CS, Huang J, Faridi KF, Turner J, Smolderen KG, Mena-Hurtado C. Lack of Guideline-Directed Medical Therapy in Patients Undergoing Endovascular Procedures for Critical Limb Ischemia. J Am Coll Cardiol 2021; 77:1374-1375. [PMID: 33706882 DOI: 10.1016/j.jacc.2020.12.063] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/03/2020] [Revised: 12/17/2020] [Accepted: 12/22/2020] [Indexed: 12/28/2022]
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Weissler EH, Annapureddy A, Wang Y, Secemsky EA, Shishehbor MH, Mena-Hurtado C, Jelani QUA, Aronow HD, Tsai TT, Patel MR, Curtis JP, Jones WS. Paclitaxel-coated devices in the treatment of femoropopliteal stenosis among patients ≥65 years old: An ACC PVI Registry Analysis. Am Heart J 2021; 233:59-67. [PMID: 33321119 DOI: 10.1016/j.ahj.2020.12.004] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/06/2020] [Accepted: 12/08/2020] [Indexed: 12/30/2022]
Abstract
BACKGROUND The connection between paclitaxel-coated devices (PCD) use during peripheral vascular interventions (PVI) and mortality is debated. We aimed to analyze patterns of PCD use and the safety and effectiveness of PCD use in the superficial femoral and/or popliteal arteries. METHODS Patients undergoing PVI of femoropopliteal lesions with and without PCD between January 1, 2015 and June 30, 2017 were compared using the American College of Cardiology's National Cardiovascular Data Registry PVI Registry. Outcomes were derived from Centers for Medicare & Medicaid claims data. The primary outcome was all-cause mortality at 6-, 12-, and 24-months following PVI. Inverse probability weighting and frailty models were used to assess the differences between groups. The analysis was IRB-approved. RESULTS In the overall cohort consisting of 6,302 femoropopliteal PVIs, PCD-PVI patients were more likely to be treated for claudication (63.5% vs 51.3%, P< .001), less likely to have a chronic total occlusion (24.6% vs 34.7%, P < .001), and more likely to be treated in certain geographic and practice settings. In the analytic cohort consisting of 1,666 femoropopliteal PVIs with linked claims outcomes (888 PCD-PVI, 53.3%), unadjusted rates of all outcomes were lower in PCD-PVI patients. After adjustment, there were no significant differences in mortality following PCD-PVI versus non-PCD PVI at 1 year (adjusted RR 0.78, 95% CI 0.60-1.01, P= .055) or 2 years (aRR 0.98, 95% CI 0.77-1.24, P= .844). CONCLUSION There were significant differences between the patients in whom and settings in which PCD-PVI was versus was not used. PCD-PVI was not associated with an increased risk of 2-year mortality in real-world use.
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Affiliation(s)
| | - Amarnath Annapureddy
- Section of Cardiovascular Medicine, Department of Internal Medicine, Yale School of Medicine, New Haven, CT
| | - Yongfei Wang
- Section of Cardiovascular Medicine, Department of Internal Medicine, Yale School of Medicine, New Haven, CT
| | - Eric A Secemsky
- Division of Cardiology, Beth Israel Deaconess Medical Center, Boston, MA; Smith Center for Outcomes Research in Cardiology, Boston, MA
| | - Mehdi H Shishehbor
- University Hospitals, Cleveland Medical Center, Case Western Reserve University School of Medicine, Cleveland, OH
| | - Carlos Mena-Hurtado
- Section of Cardiovascular Medicine, Department of Internal Medicine, Yale School of Medicine, New Haven, CT
| | - Qurat-Ul-Ain Jelani
- Section of Cardiovascular Medicine, Department of Internal Medicine, Yale School of Medicine, New Haven, CT
| | - Herbert D Aronow
- Lifespan Cardiovascular Institute/Alpert Medical School at Brown University, Providence, RI
| | - Thomas T Tsai
- University of Colorado and Institute for Health Research, Kaiser Permanente Colorado, Denver, Colorado
| | - Manesh R Patel
- Duke Clinical Research Institute, Durham, NC; Division of Cardiology, Duke University Health System, Durham, NC
| | - Jeptha P Curtis
- Section of Cardiovascular Medicine, Department of Internal Medicine, Yale School of Medicine, New Haven, CT
| | - William Schuyler Jones
- Duke Clinical Research Institute, Durham, NC; Division of Cardiology, Duke University Health System, Durham, NC.
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Smolderen KG, Pacheco C, Provance J, Stone N, Fuss C, Decker C, Bunte M, Jelani QUA, Safley DM, Secemsky E, Sepucha KR, Spatz ES, Mena-Hurtado C, Spertus JA. Treatment decisions for patients with peripheral artery disease and symptoms of claudication: Development process and alpha testing of the SHOW-ME PAD decision aid. Vasc Med 2021; 26:273-280. [PMID: 33627058 DOI: 10.1177/1358863x20988780] [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] [Indexed: 11/17/2022]
Abstract
Patients with peripheral artery disease (PAD) face a range of treatment options to improve survival and quality of life. An evidence-based shared decision-making tool (brochure, website, and recorded patient vignettes) for patients with new or worsening claudication symptoms was created using mixed methods and following the International Patient Decision Aids Standards (IPDAS) criteria. We reviewed literature and collected qualitative input from patients (n = 28) and clinicians (n = 34) to identify decisional needs, barriers, outcomes, knowledge, and preferences related to claudication treatment, along with input on implementation logistics from 59 patients and 27 clinicians. A prototype decision aid was developed and tested through a survey administered to 20 patients with PAD and 23 clinicians. Patients identified invasive treatment options (endovascular or surgical revascularization), non-invasive treatments (supervised exercise therapy, claudication medications), and combinations of these as key decisions. A total of 65% of clinicians thought the brochure would be useful for medical decision-making, an additional 30% with suggested improvements. For patients, those percentages were 75% and 25%, respectively. For the website, 76.5% of clinicians and 85.7% of patients thought it would be useful; an additional 17.6% of clinicians and 14.3% of patients thought it would be useful, with improvements. Suggestions were incorporated in the final version. The first prototype was well-received among patients and clinicians. The next step is to implement the tool in a PAD specialty care setting to evaluate its impact on patient knowledge, engagement, and decisional quality. ClinicalTrials.gov Identifier: NCT03190382.
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Affiliation(s)
- Kim G Smolderen
- Department of Internal Medicine, Vascular Medicine Outcomes (VAMOS) Program, Cardiovascular Medicine Section, Yale University, New Haven, CT, USA
| | - Christina Pacheco
- Saint Luke's Mid America Heart Institute, Kansas City, MO, USA.,School of Medicine, University of Missouri-Kansas City, Kansas City, MO, USA
| | - Jeremy Provance
- School of Medicine, University of Missouri-Kansas City, Kansas City, MO, USA
| | - Nancy Stone
- Saint Luke's Mid America Heart Institute, Kansas City, MO, USA
| | - Christine Fuss
- Saint Luke's Mid America Heart Institute, Kansas City, MO, USA
| | - Carole Decker
- Saint Luke's Mid America Heart Institute, Kansas City, MO, USA.,School of Medicine, University of Missouri-Kansas City, Kansas City, MO, USA
| | - Matthew Bunte
- Saint Luke's Mid America Heart Institute, Kansas City, MO, USA
| | - Qurat-Ul-Ain Jelani
- Department of Internal Medicine, Vascular Medicine Outcomes (VAMOS) Program, Cardiovascular Medicine Section, Yale University, New Haven, CT, USA
| | - David M Safley
- Saint Luke's Mid America Heart Institute, Kansas City, MO, USA.,School of Medicine, University of Missouri-Kansas City, Kansas City, MO, USA
| | - Eric Secemsky
- Beth Israel Deaconess Medical Center, Boston, MA, USA
| | - Karen R Sepucha
- Dana Farber/Harvard Cancer Center, Massachusetts General Hospital, Boston, MA, USA
| | - Erica S Spatz
- Department of Internal Medicine, Cardiovascular Medicine Section Yale University/Center for Outcomes Research and Evaluation, Yale New Haven Health Hospital, New Haven, CT, USA
| | - Carlos Mena-Hurtado
- Department of Internal Medicine, Vascular Medicine Outcomes (VAMOS) Program, Cardiovascular Medicine Section, Yale University, New Haven, CT, USA
| | - John A Spertus
- Saint Luke's Mid America Heart Institute, Kansas City, MO, USA.,School of Medicine, University of Missouri-Kansas City, Kansas City, MO, USA
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Sheikh AB, Llanos-Chea F, Jelani QUA, Anantha-Narayanan M, Attaran R, Schneider M, Ionescu C, Regan C, Nagpal S, Smolderen KG, Mena-Hurtado C. Safety and efficacy outcomes of the Pioneer Plus catheter in endovascular revascularization of lower extremity chronic total occlusions. J Vasc Surg 2021; 74:746-755. [PMID: 33592298 DOI: 10.1016/j.jvs.2021.01.045] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [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: 07/12/2020] [Accepted: 01/05/2021] [Indexed: 11/16/2022]
Abstract
OBJECTIVE Our aim was to evaluate the efficacy and safety outcomes of the Pioneer Plus catheter (Philips, San Diego, Calif) and report the in-hospital and 30-day outcomes of lower extremity chronic total occlusion (CTO) interventions assisted by the Pioneer Plus catheter. In addition, we explored the factors associated with procedural success. METHODS We conducted a retrospective review of 135 consecutive procedures in 116 patients from July 2011 to September 2018 performed by eight operators with various levels of experience at a high-volume center where the Pioneer Plus catheter was used for lower extremity CTO. The patient demographics, preprocedural symptoms, preprocedural testing results, procedural setting, and angiography findings were abstracted. The outcomes were divided into device-related and procedure-related outcomes. Device-related efficacy outcome included procedural success. Device-related safety outcomes included device-related complications. Procedure-related outcomes included procedure-related complications, 30-day major adverse cardiovascular events, and 30-day major adverse limb events. We conducted univariate comparisons of the provider, patient, and procedural characteristics stratified by procedural success. RESULTS Procedural success was observed in 118 procedures overall (87.4%), and success rates ≤95.8% were observed for operators with an experience level of >25 devices deployed. No device-related complications, such as pseudoaneurysm formation, vessel perforation, or arteriovenous fistula formation, were observed. The Pioneer Plus catheter was mostly often used for CTO in the superficial femoral and popliteal arteries. Overall, the procedure-related complications included access site hematoma (5.2%), major bleeding (0.7%), pseudoaneurysm formation (0.7%), distal embolization (1.5%), and acute arterial thrombosis (1.5%). The 30-day major adverse limb events included index limb unplanned amputation (0.7%), index limb reintervention (4.4%), and index limb acute limb ischemia (0.7%) and occurred in 5.9% of the procedures. The only factor associated with procedural success was operator experience (P < .0001). CONCLUSIONS The results from the present study have shown that Pioneer Plus catheter use is safe and effective when used to cross lower extremity CTO. However, further investigation is needed to identify patient- and provider-level factors to optimize patient outcomes.
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Affiliation(s)
- Azfar Bilal Sheikh
- Vascular Outcomes Program, Section of Cardiovascular Medicine, Department of Internal Medicine, Yale New Haven Hospital, Yale School of Medicine, New Haven, Conn.
| | - Fiorella Llanos-Chea
- Vascular Outcomes Program, Section of Cardiovascular Medicine, Department of Internal Medicine, Yale New Haven Hospital, Yale School of Medicine, New Haven, Conn
| | - Qurat-Ul-Ain Jelani
- Vascular Outcomes Program, Section of Cardiovascular Medicine, Department of Internal Medicine, Yale New Haven Hospital, Yale School of Medicine, New Haven, Conn
| | - Mahesh Anantha-Narayanan
- Vascular Outcomes Program, Section of Cardiovascular Medicine, Department of Internal Medicine, Yale New Haven Hospital, Yale School of Medicine, New Haven, Conn
| | - Robert Attaran
- Vascular Outcomes Program, Section of Cardiovascular Medicine, Department of Internal Medicine, Yale New Haven Hospital, Yale School of Medicine, New Haven, Conn
| | - Marabel Schneider
- Vascular Outcomes Program, Section of Cardiovascular Medicine, Department of Internal Medicine, Yale New Haven Hospital, Yale School of Medicine, New Haven, Conn
| | - Costin Ionescu
- Vascular Outcomes Program, Section of Cardiovascular Medicine, Department of Internal Medicine, Yale New Haven Hospital, Yale School of Medicine, New Haven, Conn
| | - Christopher Regan
- Vascular Outcomes Program, Section of Cardiovascular Medicine, Department of Internal Medicine, Yale New Haven Hospital, Yale School of Medicine, New Haven, Conn
| | - Sameer Nagpal
- Vascular Outcomes Program, Section of Cardiovascular Medicine, Department of Internal Medicine, Yale New Haven Hospital, Yale School of Medicine, New Haven, Conn
| | - Kim G Smolderen
- Vascular Outcomes Program, Section of Cardiovascular Medicine, Department of Internal Medicine, Yale New Haven Hospital, Yale School of Medicine, New Haven, Conn
| | - Carlos Mena-Hurtado
- Vascular Outcomes Program, Section of Cardiovascular Medicine, Department of Internal Medicine, Yale New Haven Hospital, Yale School of Medicine, New Haven, Conn
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10
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Anantha-Narayanan M, Sheikh AB, Nagpal S, Jelani QUA, Smolderen KG, Regan C, Ionescu C, Ochoa Chaar CI, Schneider M, Llanos-Chea F, Mena-Hurtado C. Systematic review and meta-analysis of outcomes of lower extremity peripheral arterial interventions in patients with and without chronic kidney disease or end-stage renal disease. J Vasc Surg 2020; 73:331-340.e4. [PMID: 32889074 DOI: 10.1016/j.jvs.2020.08.032] [Citation(s) in RCA: 18] [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] [Subscribe] [Scholar Register] [Received: 03/02/2020] [Accepted: 08/04/2020] [Indexed: 10/23/2022]
Abstract
OBJECTIVE Patients with chronic kidney disease (CKD) have a greater risk of peripheral arterial disease (PAD). Although individual studies have documented an association between CKD and/or end-stage renal disease (ESRD) and adverse outcomes in patients undergoing PAD interventions in an era of technological advances in peripheral revascularization, the magnitude of the effect size is unknown. Therefore, we performed a meta-analysis to compare the outcomes of PAD interventions for patients with CKD/ESRD with those patients with normal renal function, stratified by intervention type (endovascular vs surgical), reflecting contemporary practice. METHODS Five databases were analyzed from January 2000 to June 2019 for studies that had compared the outcomes of lower extremity PAD interventions for patients with CKD/ESRD vs normal renal function. We included both endovascular and open interventions, with an indication of either claudication or critical limb ischemia. We analyzed the pooled odds ratios (ORs) across studies with 95% confidence intervals (CIs) using a random effects model. Funnel plot and exclusion sensitivity analyses were used for bias assessment. RESULTS Seventeen observational studies with 13,140 patients were included. All included studies, except for two, had accounted for unmeasured confounding using either multivariable regression analysis or case-control matching. The maximum follow-up period was 114 months (range, 0.5-114 months). The incidence of target lesion revascularization (TLR) was greater in those with CKD/ESRD than in those with normal renal function (OR, 1.68; 95% CI, 1.25-2.27; P = .001). The incidence of major amputations (OR, 1.97; 95% CI, 1.37-2.83; P < .001) and long-term mortality (OR, 2.28; 95% CI, 1.45-3.58; P < .001) was greater in those with CKD/ESRD. The greater TLR rates with CKD/ESRD vs normal renal function were only seen with endovascular interventions, with no differences for surgical interventions. The differences in rates of major amputations and long-term mortality between the CKD/ESRD and normal renal function groups were statistically significant, regardless of the intervention type. CONCLUSIONS Patients with CKD/ESRD who have undergone lower extremity PAD interventions had worse outcomes than those of patients with normal renal function. When stratifying our results by intervention (endovascular vs open surgery), greater rates of TLR for CKD/ESRD were only seen with endovascular and not with open surgical approaches. Major amputations and all-cause mortality were greater in the CKD/ESRD group, irrespective of the indication. Evidence-based strategies to manage this at-risk population who require PAD interventions are essential.
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Affiliation(s)
| | - Azfar Bilal Sheikh
- Section of Cardiovascular Medicine, Yale New Haven Hospital, New Haven, Conn
| | - Sameer Nagpal
- Section of Cardiovascular Medicine, Yale New Haven Hospital, New Haven, Conn
| | - Qurat-Ul-Ain Jelani
- Section of Cardiovascular Medicine, Yale New Haven Hospital, New Haven, Conn
| | - Kim G Smolderen
- Section of Cardiovascular Medicine, Yale New Haven Hospital, New Haven, Conn
| | - Christopher Regan
- Section of Cardiovascular Medicine, Yale New Haven Hospital, New Haven, Conn
| | - Costin Ionescu
- Section of Cardiovascular Medicine, Yale New Haven Hospital, New Haven, Conn
| | | | - Marabel Schneider
- Section of Cardiovascular Medicine, Yale New Haven Hospital, New Haven, Conn
| | | | - Carlos Mena-Hurtado
- Section of Cardiovascular Medicine, Yale New Haven Hospital, New Haven, Conn
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11
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Jelani QUA, Mena-Hurtado C, Burg M, Soufer R, Gosch K, Jones PG, Spertus JA, Safdar B, Smolderen KG. Relationship Between Depressive Symptoms and Health Status in Peripheral Artery Disease: Role of Sex Differences. J Am Heart Assoc 2020; 9:e014583. [PMID: 32781883 PMCID: PMC7660812 DOI: 10.1161/jaha.119.014583] [Citation(s) in RCA: 12] [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] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/02/2022]
Abstract
Background The association of depressive symptoms with health status in peripheral artery disease (PAD) is understudied. No reports of differential impact on women have been described. Methods and Results The PORTRAIT (Patient‐Centered Outcomes Related to Treatment Practices in Peripheral Artery Disease Investigating Trajectories) registry enrolled 1243 patients from vascular specialty clinics with new or worsening PAD symptoms. Depressive symptoms were assessed at baseline and 3 months using the 8‐Item Patient Health Questionnaire (score ≥10 indicating clinically relevant depressive symptoms). Disease‐specific and generic health status were measured by Peripheral Artery Questionnaire and EQ‐5D Visual Analogue Scale at baseline and 3, 6, and 12 months. An adjusted general linear model for repeated measures was constructed for baseline and 3‐, 6‐, and 12‐month health status outcomes by depressive symptoms at baseline. Differences by sex were tested with interaction effects. The mean age was 67.6±9.4 years with 38% (n=470) women. More women than men (21.1% versus 12.9%; P<0.001) presented with severe depressive symptoms. In the adjusted model, patients with depressive symptoms had worse health status at each time point (all P<0.0001). Results were similar for EQ‐5D Visual Analogue Scale scores. The magnitude in 1‐year change in health status scores did not differ by sex. Depressive symptoms explained 19% of the association between sex differences in 1‐year Peripheral Artery Questionnaire summary scores. Conclusions Women with PAD have a high burden of depressive symptoms. Depressive symptoms were associated with a strikingly worse disease‐specific health status recovery path over the year following PAD diagnosis in men and women. Developing and testing interventions to address depressive symptoms in PAD are urgently needed. Registration URL: https://www.clinicaltrials.gov; Unique identifier: NCT01419080.
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Affiliation(s)
- Qurat-Ul-Ain Jelani
- Vascular Medicine Outcomes Program Section of Cardiovascular Medicine Department of Internal Medicine Yale University School of Medicine New Haven CT
| | - Carlos Mena-Hurtado
- Vascular Medicine Outcomes Program Section of Cardiovascular Medicine Department of Internal Medicine Yale University School of Medicine New Haven CT
| | - Matthew Burg
- Department of Internal Medicine Yale University School of Medicine New Haven CT
| | - Robert Soufer
- Cardiovascular Medicine VA Connecticut Healthcare System West Haven CT
| | - Kensey Gosch
- Saint Luke's Mid America Heart Institute Kansas City MO
| | - Philip G Jones
- Saint Luke's Mid America Heart Institute Kansas City MO.,University of Missouri-Kansas City MO
| | - John A Spertus
- Saint Luke's Mid America Heart Institute Kansas City MO.,University of Missouri-Kansas City MO
| | - Basmah Safdar
- Department of Emergency Medicine Yale School of Medicine New Haven CT
| | - Kim G Smolderen
- Vascular Medicine Outcomes Program Section of Cardiovascular Medicine Department of Internal Medicine Yale University School of Medicine New Haven CT
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12
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Sheikh AB, Anantha-Narayanan M, Smolderen KG, Jelani QUA, Nagpal S, Schneider M, Llanos F, Ionescu C, Regan C, Attaran R, Altin SE, Mena-Hurtado C. Utility of Intravascular Ultrasound in Peripheral Vascular Interventions: Systematic Review and Meta-Analysis. Vasc Endovascular Surg 2020; 54:413-422. [DOI: 10.1177/1538574420920998] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Objectives: We sought to compare outcomes between intravascular ultrasound– (IVUS) versus angiography (AO)-guided peripheral vascular interventions (PVIs). Introduction: Intravascular ultrasound facilitates plaque visualization and angioplasty during PVIs for peripheral arterial disease. It is unclear whether IVUS may improve the durability of PVIs and lead to improved clinical outcomes. Methods: This is a study-level meta-analysis of observational studies. The primary end points of this study were rates of primary patency and reintervention. Secondary end points included rates of vascular complications, periprocedural adverse events, amputations, technical success, all-cause mortality, and myocardial infarction. Results: Eight observational studies were included in this analysis with 93 551 patients. Mean follow-up was 24.2 ± 15 months. Intravascular ultrasound–guided PVIs had similar patency rates when compared with AO-guided PVIs (relative risk [RR]: 1.30, 95% confidence interval [CI]: 0.99-1.71, P = .062). There was no difference in rates of reintervention in IVUS-guided PVIs when compared to non-IVUS-guided PVIs (RR: 0.41, 95% CI: 0.15-1.13, P = .085). There is a lower risk of periprocedural adverse events (RR: 0.81, 95% CI: 0.70-0.94, P = .006) and vascular complications (RR: 0.81, 95% CI: 0.68-0.96, P = .013) in the IVUS group. All-cause mortality (RR: 0.76, 95% CI: 0.56-1.04, P = .084), amputation rates (RR 0.83, 95% CI: 0.32-2.15, P = .705), myocardial infarctions (RR: 1.19, 95% CI: 0.58-2.41, P = .637), and technical success (RR: 1.01, 95% CI: 0.86-1.19, P = .886) were similar between the groups. Conclusions: Intravascular ultrasound–guided PVIs had similar primary patency and reintervention when compared with AO-guided PVIs with significantly lower rates of periprocedural adverse events and vascular complications in the IVUS-guided group.
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Affiliation(s)
- Azfar Bilal Sheikh
- Vascular Medicine Outcomes Program (VAMOS), Yale School of Medicine, Yale New Haven Hospital, New Haven, CT, USA
| | - Mahesh Anantha-Narayanan
- Vascular Medicine Outcomes Program (VAMOS), Yale School of Medicine, Yale New Haven Hospital, New Haven, CT, USA
| | - Kim G. Smolderen
- Vascular Medicine Outcomes Program (VAMOS), Yale School of Medicine, Yale New Haven Hospital, New Haven, CT, USA
| | - Qurat-Ul-Ain Jelani
- Vascular Medicine Outcomes Program (VAMOS), Yale School of Medicine, Yale New Haven Hospital, New Haven, CT, USA
| | - Sameer Nagpal
- Vascular Medicine Outcomes Program (VAMOS), Yale School of Medicine, Yale New Haven Hospital, New Haven, CT, USA
| | - Marabel Schneider
- Vascular Medicine Outcomes Program (VAMOS), Yale School of Medicine, Yale New Haven Hospital, New Haven, CT, USA
| | - Fiorella Llanos
- Vascular Medicine Outcomes Program (VAMOS), Yale School of Medicine, Yale New Haven Hospital, New Haven, CT, USA
| | - Costin Ionescu
- Vascular Medicine Outcomes Program (VAMOS), Yale School of Medicine, Yale New Haven Hospital, New Haven, CT, USA
| | - Christopher Regan
- Vascular Medicine Outcomes Program (VAMOS), Yale School of Medicine, Yale New Haven Hospital, New Haven, CT, USA
| | - Robert Attaran
- Vascular Medicine Outcomes Program (VAMOS), Yale School of Medicine, Yale New Haven Hospital, New Haven, CT, USA
| | - S. Elissa Altin
- Vascular Medicine Outcomes Program (VAMOS), Yale School of Medicine, Yale New Haven Hospital, New Haven, CT, USA
| | - Carlos Mena-Hurtado
- Vascular Medicine Outcomes Program (VAMOS), Yale School of Medicine, Yale New Haven Hospital, New Haven, CT, USA
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13
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Jelani QUA, Jhamnani S, Spatz ES, Spertus J, Smolderen KG, Wang J, Desai NR, Jones P, Gosch K, Shah S, Attaran R, Mena-Hurtado C. Financial barriers in accessing medical care for peripheral artery disease are associated with delay of presentation and adverse health status outcomes in the United States. Vasc Med 2019; 25:13-24. [PMID: 31603393 DOI: 10.1177/1358863x19872542] [Citation(s) in RCA: 5] [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] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Patient-reported difficulties in affording health care and their association with health status outcomes in peripheral artery disease (PAD) have never been studied. We sought to determine whether financial barriers affected PAD symptoms at presentation, treatment patterns, and patient-reported health status in the year following presentation. A total of 797 United States (US) patients with PAD were identified from the Patient-centered Outcomes Related to TReatment Practices in Peripheral Arterial Disease: Investigating Trajectories (PORTRAIT) study, a prospective, multicenter registry of patients presenting to vascular specialty clinics with PAD. Financial barriers were defined as a composite of no insurance and underinsurance. Disease-specific health status was measured by Peripheral Artery Questionnaire (PAQ) and general health-related quality of life was measured by EuroQol 5 (EQ5D) dimensions at presentation and at 3, 6, and 12 months of follow-up. Among 797 US patients, 21% (n = 165) of patients reported financial barriers. Patients with financial barriers presented at an earlier age (64 ± 9.5 vs 70 ± 9.4 years), with longer duration of symptoms (59% vs 49%) (all p ⩽ 0.05), were more depressed and had higher levels of perceived stress and anxiety. After multivariable adjustment, health status was worse at presentation in patients with financial barriers (PAQ: -7.0 [-10.7, -3.4]; p < 0.001 and EQ5D: -9.2 [-12.74, -5.8]; p < 0.001) as well as through 12 months of follow-up (PAQ: -8.4 [-13.0, -3.8]; p < 0.001 and EQ5D: -9.7 [-13.2, -6.2]; p < 0.001). In conclusion, financial barriers are associated with later presentation as well as poorer health status at presentation and at 12 months. ClinicalTrials.gov Identifier: NCT01419080.
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Affiliation(s)
- Qurat-Ul-Ain Jelani
- Department of Medicine, Division of Cardiology, Yale University School of Medicine, New Haven, CT, USA
| | - Sunny Jhamnani
- Department of Medicine, Division of Cardiology, Yale University School of Medicine, New Haven, CT, USA
| | - Erica S Spatz
- Department of Medicine, Division of Cardiology, Yale University School of Medicine, New Haven, CT, USA
| | - John Spertus
- Department of Statistics, Saint Luke's Mid America Heart Institute, Kansas City, MO, USA.,Biomedical & Health Informatics, University of Missouri-Kansas City School of Medicine, Kansas City, MO, USA
| | - Kim G Smolderen
- Department of Statistics, Saint Luke's Mid America Heart Institute, Kansas City, MO, USA.,Biomedical & Health Informatics, University of Missouri-Kansas City School of Medicine, Kansas City, MO, USA
| | - Jingyan Wang
- Department of Statistics, Saint Luke's Mid America Heart Institute, Kansas City, MO, USA
| | - Nihar R Desai
- Department of Medicine, Division of Cardiology, Yale University School of Medicine, New Haven, CT, USA
| | - Philip Jones
- Department of Statistics, Saint Luke's Mid America Heart Institute, Kansas City, MO, USA
| | - Kensey Gosch
- Department of Statistics, Saint Luke's Mid America Heart Institute, Kansas City, MO, USA
| | - Samit Shah
- Department of Medicine, Division of Cardiology, Yale University School of Medicine, New Haven, CT, USA
| | - Robert Attaran
- Department of Medicine, Division of Cardiology, Yale University School of Medicine, New Haven, CT, USA
| | - Carlos Mena-Hurtado
- Department of Medicine, Division of Cardiology, Yale University School of Medicine, New Haven, CT, USA
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Shapero KS, Jelani QUA, Mena C. Endovascular Treatment of Inferior Vena Cava Thrombosis in Metastatic Malignancy: A Case Report and Review of Literature. Vasc Endovascular Surg 2019; 53:507-511. [DOI: 10.1177/1538574419857992] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
Inferior vena cava (IVC) thrombosis is a specific form of thromboembolism that occurs at a rate of 1.5% in all patients hospitalized with a deep vein thrombosis. Malignant IVC thrombosis may occur due to compression from a tumor mass or metastasis or may also occur through tumor invasion of the venous vasculature. Obstruction of the IVC can lead to IVC syndrome, marked by ascites, lower extremity edema, and even congestive hepatic failure. We present a case of extensive IVC thrombosis in a 69-year-old female with metastatic adrenal cell carcinoma, presenting with severe bilateral lower extremity edema and ascites. Computed tomography showed IVC compression by the caudate lobe due to a metastatic liver mass and extensive clot burden of the IVC extending from the renal veins to the right atrium (RA). She underwent percutaneous IVC stenting with 4 stents placed in tandem from the IVC to the RA. Her hospital course was complicated by gastrointestinal bleed requiring clipping, acute liver failure, and hypophysitis due to trial therapy. Although her IVC symptoms were partially relieved with percutaneous intervention, her acute liver failure worsened and she was ultimately transitioned to hospice care.
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Affiliation(s)
- Kayle S. Shapero
- Department of Medicine, Yale University School of Medicine, New Haven, CT, USA
| | - Qurat-Ul-Ain Jelani
- Section of Cardiovascular Medicine, Department of Medicine, Yale University School of Medicine, New Haven, CT, USA
| | - Carlos Mena
- Section of Cardiovascular Medicine, Department of Medicine, Yale University School of Medicine, New Haven, CT, USA
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15
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Anantha-Narayanan M, Shah SM, Jelani QUA, Garcia S, Ionescu C, Regan C, Mena-Hurtado C. Drug-coated balloon versus plain old balloon angioplasty in femoropopliteal disease: An updated meta-analysis of randomized controlled trials. Catheter Cardiovasc Interv 2019; 94:139-148. [PMID: 30838719 DOI: 10.1002/ccd.28176] [Citation(s) in RCA: 15] [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: 12/31/2018] [Revised: 01/29/2019] [Accepted: 02/18/2019] [Indexed: 11/05/2022]
Abstract
BACKGROUND Drug-coated balloon (DCB) angioplasty has emerged as a mainstay of therapy for the treatment of peripheral arterial disease (PAD) involving the superficial femoral and popliteal arteries. We performed a meta-analysis including all available randomized controlled trials (RCTs) to date which compare DCB to plain balloon angioplasty (POBA) in femoropopliteal disease (FPD). METHODS Five databases were analyzed including EMBASE, PubMed, Cochrane, Scopus, and Web-of-Science from January 2000 to September 2018 for RCTs comparing DCB to POBA in patients with FPD. Heterogeneity was determined using Cochrane's Q-statistics. Random effects model was used. RESULTS Twenty-two RCTs, including five trials of in-stent restenosis (ISR) intervention, with 3,217 patients were included in the analysis. Mean follow-up was approximately 21.6 ± 14.4 months. Overall, DCB use was associated with a 51% reduction in target vessel revascularization (TLR) when compared to POBA at follow-up (relative risk [RR]: 0.49, 95% confidence interval [CI]: 0.40-0.61, P < 0.0001). Rates of TLR were 45% lower in the DCB group when compared to POBA in patients with ISR (RR: 0.55, 95% CI: 0.37-0.81, P = 0.002). DCB was associated with lower rates of binary stenosis, late lumen loss and higher primary safety endpoints. Major amputation and mortality were not different between DCB and POBA. CONCLUSIONS Use of DCBs is associated with improved vessel patency and a lower risk of TLR when compared to POBA in patients with FPD, especially in the setting of ISR. There was no difference in mortality between DCB and POBA in our meta-analysis. Extended follow-up of the available RCT data will be essential to analyze long-term device-related mortality.
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Affiliation(s)
- Mahesh Anantha-Narayanan
- Division of Cardiovascular Diseases, University of Minnesota Medical Center, Minneapolis, Minnesota
| | - Samit M Shah
- Section of Cardiovascular Diseases, Yale-New Haven Hospital, New Haven, Connecticut
| | - Qurat-Ul-Ain Jelani
- Section of Cardiovascular Diseases, Yale-New Haven Hospital, New Haven, Connecticut
| | - Santiago Garcia
- Cardiovascular Division, Minneapolis Heart Institute, Minneapolis, Minnesota
| | - Costin Ionescu
- Section of Cardiovascular Diseases, Yale-New Haven Hospital, New Haven, Connecticut
| | - Christopher Regan
- Section of Cardiovascular Diseases, Yale-New Haven Hospital, New Haven, Connecticut
| | - Carlos Mena-Hurtado
- Section of Cardiovascular Diseases, Yale-New Haven Hospital, New Haven, Connecticut
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16
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Jelani QUA, Harchandani B, Cable RG, Guo Y, Zhong H, Hilbert T, Newman JD, Katz SD. Effects of serial phlebotomy on vascular endothelial function: Results of a prospective double-blind randomized study. Cardiovasc Ther 2018; 36:e12470. [PMID: 30341986 DOI: 10.1111/1755-5922.12470] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/31/2018] [Revised: 10/11/2018] [Accepted: 10/13/2018] [Indexed: 02/07/2023] Open
Abstract
INTRODUCTION Blood donation has been proposed as a potential therapy to reduce risk of cardiovascular disease, but the effects of phlebotomy on vascular function in human subjects have not been well characterized. AIMS We conducted a prospective randomized double-blind study to determine the effects of serial phlebotomy on vascular endothelial function in the brachial artery. Eighty-four iron-replete, non-anemic subjects were randomly assigned to one of three study treatment groups: (a) four serial phlebotomy procedures each followed by intravenous infusion of placebo normal saline; (b) four serial phlebotomy procedures each followed by intravenous infusion to replete lost iron; and (c) four serial sham phlebotomy procedures each followed by intravenous infusion of placebo normal saline. Assigned phlebotomy procedures were conducted at 56-day intervals. We measured brachial artery reactivity (BAR, %) in response to transient oxidative stress induced by oral methionine with high-resolution duplex ultrasound imaging before and one week after the fourth study phlebotomy. RESULTS Before phlebotomy, oral methionine decreased BAR by -2.04% (95% CI -2.58%, -1.50%), P < 0.001) with no significant difference between groups (P = 0.42). After phlebotomy, the BAR response to oral methionine did not significantly change between groups (P = 0.53). Brachial artery nitroglycerin-mediated dilation did not change in response to phlebotomy. CONCLUSIONS Four serial phlebotomy procedures over six months with or without intravenous iron supplementation did not alter vascular endothelial function in the brachial artery when compared with sham phlebotomy.
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Affiliation(s)
- Qurat-Ul-Ain Jelani
- Department of Medicine, New York University School of Medicine, New York University Langone Medical Center, New York City, New York
| | - Bhisham Harchandani
- Department of Medicine, New York University School of Medicine, New York University Langone Medical Center, New York City, New York
| | | | - Yu Guo
- Department of Population Health, New York University Langone Medical Center, New York City, New York
| | - Hua Zhong
- Department of Population Health, New York University Langone Medical Center, New York City, New York
| | - Timothy Hilbert
- Department of Medicine, New York University School of Medicine, New York University Langone Medical Center, New York City, New York
| | - Jonathan D Newman
- Department of Medicine, New York University School of Medicine, New York University Langone Medical Center, New York City, New York
| | - Stuart D Katz
- Department of Medicine, New York University School of Medicine, New York University Langone Medical Center, New York City, New York
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Abstract
Four novel oral anticoagulant agents are currently available for the prevention and treatment of thromboembolic events in patients with nonvalvular atrial fibrillation. We present an unusual case of spontaneous hemopericardium and tamponade in an 87-year-old man with atrial fibrillation who was taking one such agent, dabigatran, as thromboprophylaxis. Our case highlights both a rare bleeding complication of dabigatran use and the effectiveness of idarucizumab, its newly approved reversal agent. Especially in elderly patients, we recommend that clinicians evaluate risk factors, closely monitor patient status, and consider alternatives to the newer anticoagulants when the risk of bleeding is high.
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Kim Y, Soffler M, Paradise S, Naftilan M, Jelani QUA, Dziura J, Sinha R, Safdar B. DEPRESSION AND ANXIETY ARE ASSOCIATED WITH HIGH RATES OF RECURRENT CHEST PAIN. J Am Coll Cardiol 2016. [DOI: 10.1016/s0735-1097(16)30582-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
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Jelani QUA, Norcliffe-Kaufmann L, Kaufmann H, Katz SD. Vascular endothelial function and blood pressure regulation in afferent autonomic failure. Am J Hypertens 2015; 28:166-72. [PMID: 25128693 DOI: 10.1093/ajh/hpu144] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.0] [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] [Indexed: 01/08/2023] Open
Abstract
BACKGROUND Familial dysautonomia (FD) is a rare hereditary disease characterized by loss of afferent autonomic neural fiber signaling and consequent profound impairment of arterial baroreflex function and blood pressure regulation. Whether vascular endothelial dysfunction contributes to defective vasomotor control in this form of afferent autonomic failure is not known. METHODS We assessed blood pressure response to orthostatic stress and vascular endothelial function with brachial artery reactivity testing in 34 FD subjects with afferent autonomic failure and 34 healthy control subjects. RESULTS Forty-four percent of the afferent autonomic failure subjects had uncontrolled hypertension at supine rest (median systolic blood pressure = 148mm Hg, interquartile range (IQR) = 144-155mm Hg; median diastolic blood pressure = 83mm Hg, IQR = 78-105mm Hg), and 88% had abnormal response to orthostatic stress (median decrease in systolic blood pressure after upright tilt = 48mm Hg, IQR = 29-61mm Hg). Flow-mediated brachial artery reactivity did not differ in subjects with afferent autonomic failure vs. healthy control subjects (median = 6.00%, IQR = 1.86-11.77%; vs. median = 6.27%, IQR = 4.65-9.34%; P = 0.75). In afferent autonomic failure subjects, brachial artery reactivity was not associated with resting blood pressure or the magnitude of orthostatic hypotension but was decreased in association with reduced glomerular filtration rate (r = 0.62; P < 0.001). CONCLUSIONS Brachial artery reactivity was preserved in subjects with afferent autonomic failure despite the presence of marked blood pressure dysregulation. Comorbid renal dysfunction was associated with reduced brachial artery reactivity.
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Affiliation(s)
- Qurat-Ul-Ain Jelani
- Leon H. Charney Division of Cardiology, New York University School of Medicine, New York University Langone Medical Center, New York, New York
| | - Lucy Norcliffe-Kaufmann
- Dysautonomia Center, New York University School of Medicine, New York University Langone Medical Center, New York, New York
| | - Horacio Kaufmann
- Dysautonomia Center, New York University School of Medicine, New York University Langone Medical Center, New York, New York
| | - Stuart D Katz
- Leon H. Charney Division of Cardiology, New York University School of Medicine, New York University Langone Medical Center, New York, New York;
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