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Quesada O, Yildiz M, Henry TD, Bergstedt S, Chambers J, Shah A, Stanberry L, Volpenhein L, Aziz D, Lantz R, Palmer C, Ugwu J, Ahsan MJ, Garberich RF, Rohm HS, Aguirre FV, Garcia S, Sharkey SW. Mortality in ST-Segment Elevation Myocardial Infarction With Nonobstructive Coronary Arteries and Mimickers. JAMA Netw Open 2023; 6:e2343402. [PMID: 37971742 PMCID: PMC10654797 DOI: 10.1001/jamanetworkopen.2023.43402] [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] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/06/2023] [Accepted: 10/02/2023] [Indexed: 11/19/2023] Open
Abstract
Importance The clinical characteristics and prognosis of patients with ST-segment elevation myocardial infarction (STEMI) with nonobstructive coronaries (MINOCA) are largely unknown. Objective To assess differences in 5-year mortality in patients presenting with STEMI due to MINOCA and MINOCA mimickers as compared with obstructive disease. Design, Setting, and Participants A retrospective analysis of a prospective registry-based cohort study of consecutive STEMI activations at 3 regional Midwest STEMI programs. STEMI without a culprit artery and elevated troponin levels were categorized as MINOCA (absence of coronary artery stenosis >50% and confirmed or suspected coronary artery plaque disruption, epicardial coronary spasm, or coronary embolism/thrombosis) or MINOCA mimickers (takotsubo cardiomyopathy, myocarditis, or nonischemic cardiomyopathy). Data were analyzed from March 2003 to December 2020. Main Outcomes and Measures Adjusted Cox regression analysis was used to assess 5-year mortality risk in STEMI presenting with MINOCA and MINOCA mimickers in comparison with obstructive disease. Results Among 8560 consecutive patients with STEMI, mean (SD) age was 62 (14) years, 30% were female (2609 participants), and 94% were non-Hispanic White (4358 participants). The cohort included 8151 patients with STEMI due to obstructive disease (95.2%), 120 patients with MINOCA (1.4%), and 289 patients with MINOCA mimickers (3.8%). Patients were followed up for a median (IQR) of 7.1 (3.6-10.7) years. Patients with MINOCA and MINOCA mimickers were less likely to be discharged with cardiac medications compared with obstructive disease. At 5-year follow-up, mortality in STEMI presenting with obstructive disease (1228 participants [16%]) was similar to MINOCA (20 participants [18%]; χ21 = 1.1; log-rank P = .29) and MINOCA mimickers (52 participants [18%]; χ21 = 2.3; log-rank P = .13). In adjusted Cox regression analysis compared with obstructive disease, the 5-year mortality hazard risk was 1.93 times higher in MINOCA (95% CI, 1.06-3.53) and similar in MINOCA mimickers (HR, 1.08; 95% CI, 0.79-1.49). Conclusions and Relevance In this large multicenter cohort study of consecutive clinical patients with STEMI, presenting with MINOCA was associated with a higher risk of mortality than obstructive disease; the risk of mortality was similar in patients with MINOCA mimickers and obstructive disease. Further investigation is necessary to understand the pathophysiologic mechanisms involved in this high-risk STEMI population.
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Affiliation(s)
- Odayme Quesada
- Women's Heart Center, The Christ Hospital Heart and Vascular Institute, Cincinnati, Ohio
- The Carl and Edyth Lindner Center for Research and Education, The Christ Hospital, Cincinnati, Ohio
| | - Mehmet Yildiz
- The Carl and Edyth Lindner Center for Research and Education, The Christ Hospital, Cincinnati, Ohio
| | - Timothy D Henry
- The Carl and Edyth Lindner Center for Research and Education, The Christ Hospital, Cincinnati, Ohio
| | - Seth Bergstedt
- Minneapolis Heart Institute Foundation at Abbott Northwestern Hospital, Minneapolis, Minnesota
| | - Jenny Chambers
- Prairie Heart Institute at St John's Hospital, Springfield, Illinois
| | - Ananya Shah
- Minneapolis Heart Institute Foundation at Abbott Northwestern Hospital, Minneapolis, Minnesota
| | - Larissa Stanberry
- Minneapolis Heart Institute Foundation at Abbott Northwestern Hospital, Minneapolis, Minnesota
| | - Lucas Volpenhein
- The Carl and Edyth Lindner Center for Research and Education, The Christ Hospital, Cincinnati, Ohio
| | - Dalia Aziz
- The Carl and Edyth Lindner Center for Research and Education, The Christ Hospital, Cincinnati, Ohio
| | - Rebekah Lantz
- The Carl and Edyth Lindner Center for Research and Education, The Christ Hospital, Cincinnati, Ohio
| | - Cassady Palmer
- The Carl and Edyth Lindner Center for Research and Education, The Christ Hospital, Cincinnati, Ohio
| | | | | | - Ross F Garberich
- Minneapolis Heart Institute Foundation at Abbott Northwestern Hospital, Minneapolis, Minnesota
| | - Heather S Rohm
- The Carl and Edyth Lindner Center for Research and Education, The Christ Hospital, Cincinnati, Ohio
| | - Frank V Aguirre
- Prairie Heart Institute at St John's Hospital, Springfield, Illinois
| | - Santiago Garcia
- The Carl and Edyth Lindner Center for Research and Education, The Christ Hospital, Cincinnati, Ohio
| | - Scott W Sharkey
- Minneapolis Heart Institute Foundation at Abbott Northwestern Hospital, Minneapolis, Minnesota
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Quesada O, Yildiz M, Henry TD, Okeson BK, Chambers J, Shah A, Stanberry L, Volpenhein L, Aziz D, Lantz R, Palmer C, Ugwu J, Ahsan MJ, Garberich RF, Rohm HS, Aguirre FV, Garcia S, Sharkey SW. Characteristics and Long-term Mortality in Patients with ST-Segment Elevation Myocardial Infarction with Non-Obstructive Coronary Arteries (STE-MINOCA): A High Risk Cohort. medRxiv 2023:2023.02.05.23285502. [PMID: 36798420 PMCID: PMC9934717 DOI: 10.1101/2023.02.05.23285502] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/10/2023]
Abstract
Background The prognosis of ST-segment elevation myocardial infarction with non-obstructive coronaries (STE-MINOCA) is largely unknown. Methods The objective of this study is to evaluate the prevalence, characteristics, and 5-year mortality of patients with STE-MINOCA compared to STEMI with coronary artery obstruction (STEMI-Obstruction) using a multicenter cohort of consecutive STEMI patients at 3 regional Midwest STEMI programs from 2003 to 2020. STE-MINOCA was defined based on (1) coronary stenosis < 60% by visual estimation, (2) ischemia with elevated troponin, and (3) no alternative diagnosis. STE-MINOCA was further classified based on American Heart Association (AHA) definition as AHA STE-MINOCA and AHA STE-MINOCA Mimicker. Results 8,566 STEMI patients, including 420 (4.9%) STE-MINOCA (26.9% AHA STE-MINOCA and 73.1% AHA STE-MINOCA Mimicker) were followed for a median of 7.1 years. Compared to STEMI-Obstruction, STE-MINOCA were younger, more often female, had fewer cardiovascular risk factors, and were less likely to be discharged on cardiac medications. At five years, mortality was higher in STE-MINOCA compared with STEMI-Obstruction (18% vs. 15%, p=0.033). In propensity score-matched analysis, STE-MINOCA had a 1.4-fold (95% CI: 1.04-1.89, p=0.028) higher risk of 5-year all-cause mortality compared with STEMI-Obstruction. Furthermore, 5-year mortality risk was significantly higher in AHA STE-MINOCA Mimicker (19% vs. 15%, p=0.043) but similar in AHA STE-MINOCA (17% vs. 15%, p=0.42) compared with STEMI-Obstruction. Conclusions In this large multicenter STEMI cohort, nearly 5% of patients presented with STE-MINOCA. At five years, mortality approached 20% among patients with STE-MINOCA. Despite the lower risk profile, STE-MINOCA patients were at 40% higher risk of 5-year all-cause mortality compared with STEMI-Obstruction. Additionally, 5-year all-cause mortality risk was higher in AHA STE-MINOCA Mimicker but similar in AHA STE-MINOCA compared to STEMI-Obstruction.
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Yildiz M, Guddeti RR, Shivapour D, Smith L, Sharkey SW, Schmidt CW, Okeson BK, Dworak M, Garberich RF, Rohm HS, Pacheco-Coronado R, Smith TD, Kereiakes DJ, Garcia S, Henry TD. Frequency, Etiology, and Impact of Unplanned Repeat Coronary Angiography After ST-Elevation Myocardial Infarction. Am J Cardiol 2022; 163:1-7. [PMID: 34809859 DOI: 10.1016/j.amjcard.2021.09.038] [Citation(s) in RCA: 0] [Impact Index Per Article: 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: 08/19/2021] [Revised: 09/20/2021] [Accepted: 09/24/2021] [Indexed: 11/26/2022]
Abstract
Unplanned repeat coronary angiography (CAG) after balloon angioplasty for ST-elevation myocardial infarction (STEMI) was common before the advent of coronary stenting. Limited data are available regarding the role of unplanned repeat CAG in contemporary percutaneous coronary intervention (PCI) for STEMI. Therefore, we analyzed a large, 2-center prospective STEMI registry (January 2011 to June 2020) stratified by the presence or absence of unplanned repeat CAG during index hospitalization. Patients with planned CAG for staged PCI or experimental drug administration were excluded. Among 3,637 patients with STEMI, 130 underwent unplanned repeat CAG (3.6%) during index hospitalization. These patients were more likely to have cardiogenic shock (16% vs 9.8%, p = 0.021), left anterior descending culprit (44% vs 31%, p <0.001), lower left ventricular ejection fraction (45% vs 52%, p <0.001), and higher peak troponin levels (22 vs 8 ng/ml, p <0.001) than those without repeat CAG. At repeat CAG, 80 patients had a patent stent (62%) including 65 requiring no further intervention (50%) and 15 who underwent intervention on a nonculprit lesion (12%). Only 32 patients had stent thrombosis (25%). Repeat CAG was associated with a higher incidence of recurrent MI (19% vs 0%, p <0.001) and major bleeding (12% vs 4.5%, p <0.001), yet similar in-hospital mortality (7% vs 6.4%, p = 0.93) than those without repeat CAG. In conclusion, in the era of contemporary PCI for STEMI, unplanned repeat CAG during index hospitalization was infrequent and more commonly observed in patients with left anterior descending culprit in the presence of significant left ventricular dysfunction or shock and was associated with higher in-hospital recurrent myocardial infarction and major bleeding complications.
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Handran CB, Kunz M, Larson DM, Garberich RF, Baran K, Henry JT, Sharkey SW, Henry TD. The impact of regional STEMI systems on protocol use and quality improvement initiatives in community hospitals without cardiac catheterization laboratories. Am Heart J Plus 2022; 13:100077. [PMID: 38560053 PMCID: PMC10978212 DOI: 10.1016/j.ahjo.2021.100077] [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] [Figures] [Subscribe] [Scholar Register] [Received: 08/03/2021] [Revised: 11/16/2021] [Accepted: 11/19/2021] [Indexed: 04/04/2024]
Abstract
Study objective Since the 1990s, national guidelines have recommended hospitals develop STEMI treatment protocols and monitor quality. A 2003 survey of Minnesota hospitals without cardiac catheterization laboratories (CCL) found <2/3 had STEMI protocols, <50% had a quality assessment (QA) process, and protocols in existence were incomplete. We evaluated temporal changes in STEMI processes in relationship to changes in mortality. Design setting and participants Follow-up surveys were mailed to emergency departments at 108 Minnesota hospitals without CCL. Results Among 87% of responding hospitals, 89% had formal protocols or guidelines for STEMI management compared to 63% in 2003 (p < 0.001). In 2010, 67% of hospitals had triage/transfer criteria and 15% of hospitals used protocols for transfer decisions, compared to only 8% (p < 0.001) and 1% (p = 0.098), respectively, in 2003. The percentage of hospitals transferring patients with STEMI from the emergency department increased from 23% in 2003 to 56% in 2010 (p < 0.001). During this time, age-adjusted acute MI mortality rate in Minnesota decreased 33% and was more pronounced in areas with regional STEMI systems. Conclusions Since 2003, utilization of STEMI guidelines, protocols, and standing orders in Minnesota hospitals without CCL has markedly improved with <10% of hospitals lacking specific STEMI management protocols. The majority of hospitals routinely transfer patients with STEMI for primary PCI and have comprehensive QA processes. This improvement was stimulated by regional STEMI systems, further supporting the current class I recommendation for STEMI systems of care in current guidelines. The decline in Minnesota STEMI mortality paralleled the growth of regional STEMI systems.
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Affiliation(s)
| | - Miranda Kunz
- Minneapolis Heart Institute Foundation at Abbott Northwestern Hospital, Minneapolis, MN, United States of America
| | - David M. Larson
- Ridgeview Medical Center, Waconia, MN, United States of America
| | - Ross F. Garberich
- Minneapolis Heart Institute Foundation at Abbott Northwestern Hospital, Minneapolis, MN, United States of America
| | - Kelsey Baran
- Berkshire Medical Center, Pittsfield, MA, United States of America
| | - Jason T. Henry
- Sarah Cannon Research Institute at HealthONE, Denver, CO, United States of America
| | - Scott W. Sharkey
- Minneapolis Heart Institute Foundation at Abbott Northwestern Hospital, Minneapolis, MN, United States of America
| | - Timothy D. Henry
- The Carl and Edyth Lindner Center for Research and Education, The Christ Hospital, Cincinnati, OH, United States of America
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Behrend K, Lillyblad M, Skelton P, Stanberry L, Garberich RF, Eckman PM, Hryniewicz K. Serotonergic antidepressants and hospitalization for bleeding in patients supported with a continuous flow left ventricular assist device. J Heart Lung Transplant 2021; 40:1599-1604. [PMID: 34419371 DOI: 10.1016/j.healun.2021.06.019] [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: 09/16/2020] [Revised: 05/18/2021] [Accepted: 06/28/2021] [Indexed: 10/20/2022] Open
Abstract
BACKGROUND Continuous flow left ventricular assist devices (CF -LVAD) improve survival in patients with advanced heart failure, but confer risk of bleeding complications. Serotonergic antidepressants (SA) are commonly used in heart failure patients receiving LVADs, but their inhibitory effect on platelet function may contribute to bleeding risk. METHODS We performed a retrospective analysis of LVAD patients at our institution from 2016 -2019 comparing patients treated with SA after LVAD to those without SA. Demographic and clinical variables related to bleeding were collected on discharge from index hospitalization for CF-LVAD implantation and on admission for any bleeding event. The primary endpoint was incidence of bleeding requiring hospitalization after discharge. Secondary endpoints included overall number of admissions for bleeding, time to first hospitalization for a bleeding event, and incidence rate of hospitalizations for bleeding per patient year. RESULTS 100 patients met inclusion criteria for the study. A total of 5 patients without a history of SA use and 31 patients who were prescribed SA after CF -LVAD implant were readmitted for a bleeding event after initial implant hospitalization (15% vs 46%, p = 0.004). Bleeding rate per person year (0.3 vs 0.61, p = 0.01) were significantly less in patients without SA use. Age-adjusted multivariable analysis found SA use to be associated with a hospitalization for bleeding (HR 2.3, 95% CI 0.99 -5.4). The higher incidence of hospitalization for bleeding was driven by non-gastrointestinal anatomical sites (6% vs 28%, p = 0.02) with a HR 7.7 (95% CI 0.96 -62). CONCLUSIONS SA treatment after CF-LVAD implantation was associated with an increased risk for bleeding complications requiring hospitalization, particularly non-gastrointestinal bleeding.
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Affiliation(s)
- Keith Behrend
- Abbott Northwestern Hospital and Minneapolis Heart Institute, Part of Allina Health, Minneapolis, Minnesota.
| | - Matthew Lillyblad
- Abbott Northwestern Hospital and Minneapolis Heart Institute, Part of Allina Health, Minneapolis, Minnesota
| | - Paige Skelton
- Abbott Northwestern Hospital and Minneapolis Heart Institute, Part of Allina Health, Minneapolis, Minnesota
| | - Larissa Stanberry
- Abbott Northwestern Hospital and Minneapolis Heart Institute, Part of Allina Health, Minneapolis, Minnesota
| | - Ross F Garberich
- Abbott Northwestern Hospital and Minneapolis Heart Institute, Part of Allina Health, Minneapolis, Minnesota
| | - Peter M Eckman
- Abbott Northwestern Hospital and Minneapolis Heart Institute, Part of Allina Health, Minneapolis, Minnesota
| | - Katarzyna Hryniewicz
- Abbott Northwestern Hospital and Minneapolis Heart Institute, Part of Allina Health, Minneapolis, Minnesota
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Tyler JM, Brown C, Jentzer JC, Baran DA, van Diepen S, Kapur NK, Garberich RF, Garcia S, Sharkey SW, Henry TD. Variability in reporting of key outcome predictors in acute myocardial infarction cardiogenic shock trials. Catheter Cardiovasc Interv 2021; 99:19-26. [PMID: 33871159 DOI: 10.1002/ccd.29710] [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] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/13/2021] [Revised: 03/23/2021] [Accepted: 04/02/2021] [Indexed: 11/09/2022]
Abstract
BACKGROUND Among acute myocardial infarction patients with cardiogenic shock (AMICS), a number of key variables predict mortality, including cardiac arrest (CA) and shock classification as proposed by Society for Cardiovascular Angiography and Intervention (SCAI). Given this prognostic importance, we examined the frequency of reporting of high risk variables in published randomized controlled trials (RCTs) of AMICS patients. METHODS We identified 15 RCTs enrolling 2,500 AMICS patients and then reviewed rates of CA, baseline neurologic status, right heart catheterization data, lactate levels, inotrope and vasopressor requirement, hypothermia, mechanical ventilation, left ventricular ejection fraction (LVEF), mechanical circulatory support, and specific cause of death based on the primary manuscript and Data in S1. RESULTS A total of 2,500 AMICS patients have been enrolled in 15 clinical trials over 21 years with only four trials enrolling >80 patients. The reporting frequency and range for key prognostic factors was: neurologic status (0% reported), hypothermia (28% reported, prevalence 33-75%), specific cause of death (33% reported), cardiac index and wedge pressure (47% reported, range 1.6-2.3 L min-1 m-2 and 15-24 mmHg), lactate (60% reported, range 4-7.7 mmol/L), LVEF (73% reported, range 25-45%), CA (80% reported, prevalence 0-92%), MCS (80% reported, prevalence 13-100%), and mechanical ventilation (93% reported, prevalence 35-100%). This variability was reflected in the 30-day mortality which ranged from 20-73%. CONCLUSIONS In a comprehensive review of seminal RCTs in AMICS, important predictors of outcome were frequently not reported. Future efforts to standardize CS trial data collection and reporting may allow for better assessment of novel therapies for AMICS.
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Affiliation(s)
- Jeffrey M Tyler
- Interventional Cardiolgy at Scripps Clinic, Cedars Sinai Smidt Heart Institute, Los Angeles, California, USA
| | - Christopher Brown
- Interventional Cardiolgy at Scripps Clinic, Cedars Sinai Smidt Heart Institute, Los Angeles, California, USA
| | - Jacob Colin Jentzer
- Department of Cardiovascular Medicine and Division of Pulmonary and Critical Care Medicine, Mayo Clinic, Rochester, Minnesota, USA
| | - David A Baran
- Advanced Heart Failure Center, Sentara Heart Hospital, Norfolk, Virginia, USA
| | - Sean van Diepen
- Department of Critical Care Medicine and Division of Cardiology, Department of Medicine, University of Alberta, Edmonton, Alberta, Canada
| | - Navin K Kapur
- The CardioVascular Center, Tufts Medical Center, Boston, Massachusetts, USA
| | - Ross F Garberich
- Minneapolis Heart Institute Foundation at Abbott Northwestern Hospital, Minneapolis, Minnesota, USA
| | - Santiago Garcia
- Minneapolis Heart Institute Foundation at Abbott Northwestern Hospital, Minneapolis, Minnesota, USA
| | - Scott W Sharkey
- Minneapolis Heart Institute Foundation at Abbott Northwestern Hospital, Minneapolis, Minnesota, USA
| | - Timothy D Henry
- The Carl and Edyth Lindner Center for Research and Education, The Christ Hospital, Cincinnati, Ohio, USA
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Vemmou E, Khatri J, Doing AH, Dattilo P, Toma C, Sheikh A, Alaswad K, Jefferson BK, Patel TN, Chandwaney RH, Jaffer FA, Jaber W, Samady H, Gkargkoulas F, Moses JW, Lembo NJ, Kirtane AJ, Parikh M, Ali ZA, Megaly M, Omer M, Nikolakopoulos I, Xenogiannis I, Stanberry L, Garberich RF, Rangan BV, Garcia S, Burke MN, Abdullah S, Banerjee S, Brilakis ES, Karmpaliotis D. Impact of Intravascular Ultrasound Utilization for Stent Optimization on 1-Year Outcomes After Chronic Total Occlusion Percutaneous Coronary Intervention. J Invasive Cardiol 2020; 32:392-399. [PMID: 32694224] [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] [Subscribe] [Scholar Register] [Indexed: 06/11/2023]
Abstract
BACKGROUND The impact of intravascular ultrasound (IVUS) utilization for stent optimization on the long-term outcomes in chronic total occlusion (CTO) percutaneous coronary intervention (PCI) has received limited study. METHODS We examined the outcomes of CTO-PCI with and without IVUS use for stent optimization in 922 CTO-PCIs performed between 2012 and 2019 at 12 United States centers. Major adverse cardiac event (MACE) was defined as the composite of cardiac death, acute coronary syndrome, and target-vessel revascularization. RESULTS IVUS was used in 344 procedures (37%) for stent optimization. Mean patient age was 65 ± 10 years and 83% were men. Patients in the IVUS group were less likely to have a prior myocardial infarction (39% vs 50%; P<.01), more likely to undergo right coronary artery CTO-PCI (49% vs 55%; P=.01), and had higher mean J-CTO score (2.6 ± 1.1 vs 2.4 ± 1.2; P=.04). The final crossing strategy in patients in the IVUS group was less likely to be antegrade wire escalation (54% vs 57%) and more likely to be retrograde (29% vs 21%; P<.01). Median follow-up was 141 days (interquartile range, 30-365 days). The incidence of 12-month MACE was similar in the IVUS and no-IVUS groups (20.3% vs 18.3%; log-rank P=.67). CONCLUSION IVUS was used for stent optimization in approximately one-third of CTO-PCIs. Despite higher lesion complexity in the IVUS group, the incidence of MACE was similar during follow-up.
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Affiliation(s)
| | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | - Emmanouil S Brilakis
- Minneapolis Heart Institute, 920 East 28th Street #300, Minneapolis, MN 55407 USA.
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Storey KM, Wang J, Garberich RF, Bennett NM, Traverse JH, Arndt TL, Schmidt CW, Henry TD. Long-Term (3 Years) Outcomes of Ranolazine Therapy for Refractory Angina Pectoris (from the Ranolazine Refractory Registry). Am J Cardiol 2020; 129:1-4. [PMID: 32540170 DOI: 10.1016/j.amjcard.2020.05.020] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/17/2019] [Revised: 05/04/2020] [Accepted: 05/12/2020] [Indexed: 11/19/2022]
Abstract
Ranolazine is approved for patients with chronic stable angina but has not been formally studied in patients with refractory angina pectoris (RAP). Patients with RAP have limited therapeutic options and significant limitations in their quality of life. The Ranolazine Refractory Angina Registry was designed to evaluate the safety, tolerability, and effectiveness of ranolazine in RAP patients in order to expand treatment options for this challenging patient population. Using an extensive prospective database, we enrolled 158 consecutive patients evaluated in a dedicated RAP clinic. Angina class, medications, major adverse cardiac events including death, myocardial infarction, and revascularization were obtained at 12, 24, and 36 months. At 3 years, 95 (60%) patients remained on ranolazine. A ≥2 class improvement in angina was seen in 48% (38 of 80 patients with known Canadian Cardiovascular Society class) of those who remained on ranolazine. Discontinuation due to side effects, ineffectiveness, cost, and progression of disease were the principle reasons for discontinuation, but primarily occurred within the first year. In conclusion, ranolazine is an effective antianginal therapy at 3-year follow-up in patients with RAP and may reduce cardiac readmission.
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Affiliation(s)
| | - Julia Wang
- Minneapolis Heart Institute Foundation, Minneapolis, Minnesota
| | | | - Noel M Bennett
- Minneapolis Heart Institute Foundation, Minneapolis, Minnesota
| | - Jay H Traverse
- Minneapolis Heart Institute Foundation, Minneapolis, Minnesota
| | - Theresa L Arndt
- Minneapolis Heart Institute Foundation, Minneapolis, Minnesota
| | | | - Timothy D Henry
- The Carl and Edyth Lindner Center for Research and Education, The Christ Hospital, Cincinnati, Ohio.
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Johnson GL, Henry TD, Povsic TJ, Losordo DW, Garberich RF, Stanberry LI, Strauss CE, Traverse JH. CD34 + cell therapy significantly reduces adverse cardiac events, health care expenditures, and mortality in patients with refractory angina. Stem Cells Transl Med 2020; 9:1147-1152. [PMID: 32531108 PMCID: PMC7519768 DOI: 10.1002/sctm.20-0046] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2020] [Revised: 05/07/2020] [Accepted: 05/10/2020] [Indexed: 12/20/2022] Open
Abstract
Patients with refractory angina who are suboptimal candidates for further revascularization have improved exercise time, decreased angina frequency, and reduced major adverse cardiac events with intramyocardial delivery of CD34+ cells. However, the effect of CD34+ cell therapy on health care expenditures before and after treatment is unknown. We determined the effect of CD34+ cell therapy on cardiac‐related hospital visits and costs during the 12 months following stem cell injection compared with the 12 months prior to injection. Cardiac‐related hospital admissions and procedures were retrospectively tabulated for patients enrolled at one site in one of three double‐blinded, placebo‐controlled CD34+ trials in the 12 months before and after intramyocardial injections of CD34+ cells vs placebo. Fifty‐six patients were randomized to CD34+ cell therapy (n = 37) vs placebo (n = 19). Patients randomized to cell therapy experienced 1.57 ± 1.39 cardiac‐related hospital visits 12 months before injection, compared with 0.78 ± 1.90 hospital visits 12 months after injection, which was associated with a 62% cost reduction translating to an average savings of $5500 per cell therapy patient. Patients in the placebo group also demonstrated a reduction in cardiac‐related hospital events and costs, although to a lesser degree than the CD34+ group. Through 1 January 2019, 24% of CD34+ subjects died at an average of 6.5 ± 2.4 years after enrollment, whereas 47% of placebo patients died at an average of 3.7 ± 1.9 years after enrollment. In conclusion, CD34+ cell therapy for subjects with refractory angina is associated with improved mortality and a reduction in hospital visits and expenditures for cardiac procedures in the year following treatment.
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Affiliation(s)
- Grace L Johnson
- Minneapolis Heart Institute Foundation, Abbott Northwestern Hospital, Minneapolis, Minnesota, USA
| | - Timothy D Henry
- Minneapolis Heart Institute Foundation, Abbott Northwestern Hospital, Minneapolis, Minnesota, USA.,Cardiovascular Division, The Christ Hospital, Cincinnati, Ohio, USA
| | - Thomas J Povsic
- Division of Cardiology, Duke University School of Medicine, Durham, North Carolina, USA
| | | | - Ross F Garberich
- Minneapolis Heart Institute Foundation, Abbott Northwestern Hospital, Minneapolis, Minnesota, USA
| | - Larissa I Stanberry
- Minneapolis Heart Institute Foundation, Abbott Northwestern Hospital, Minneapolis, Minnesota, USA
| | - Craig E Strauss
- Minneapolis Heart Institute Foundation, Abbott Northwestern Hospital, Minneapolis, Minnesota, USA
| | - Jay H Traverse
- Minneapolis Heart Institute Foundation, Abbott Northwestern Hospital, Minneapolis, Minnesota, USA.,Cardiovascular Division, University of Minnesota School of Medicine, Minneapolis, Minnesota, USA
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Traverse JH, Swingen CM, Henry TD, Fox J, Wang YL, Chavez IJ, Lips DL, Lesser JR, Pedersen WR, Burke NM, Pai A, Lindberg JL, Garberich RF. NHLBI-Sponsored Randomized Trial of Postconditioning During Primary Percutaneous Coronary Intervention for ST-Elevation Myocardial Infarction. Circ Res 2019; 124:769-778. [PMID: 30602360 DOI: 10.1161/circresaha.118.314060] [Citation(s) in RCA: 35] [Impact Index Per Article: 7.0] [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: 01/27/2023]
Abstract
RATIONALE Postconditioning at the time of primary percutaneous coronary intervention (PCI) for ST-segment-elevation myocardial infarction may reduce infarct size and improve myocardial salvage. However, clinical trials have shown inconsistent benefit. OBJECTIVE We performed the first National Heart, Lung, and Blood Institute-sponsored trial of postconditioning in the United States using strict enrollment criteria to optimize the early benefits of postconditioning and assess its long-term effects on left ventricular (LV) function. METHODS AND RESULTS We randomized 122 ST-segment-elevation myocardial infarction patients to postconditioning (4, 30 seconds PTCA [percutaneous transluminal coronary angioplasty] inflations/deflations)+PCI (n=65) versus routine PCI (n=57). All subjects had an occluded major epicardial artery (thrombolysis in myocardial infarction=0) with ischemic times between 1 and 6 hours with no evidence of preinfarction angina or collateral blood flow. Cardiac magnetic resonance imaging measured at 2 days post-PCI showed no difference between the postconditioning group and control in regards to infarct size (22.5±14.5 versus 24.0±18.5 g), myocardial salvage index (30.3±15.6% versus 31.5±23.6%), or mean LV ejection fraction. Magnetic resonance imaging at 12 months showed a significant recovery of LV ejection fraction in both groups (61.0±11.4% and 61.4±9.1%; P<0.01). Subjects randomized to postconditioning experienced more favorable remodeling over 1 year (LV end-diastolic volume =157±34 to 150±38 mL) compared with the control group (157±40 to 165±45 mL; P<0.03) and reduced microvascular obstruction ( P=0.05) on baseline magnetic resonance imaging and significantly less adverse LV remodeling compared with control subjects with microvascular obstruction ( P<0.05). No significant adverse events were associated with the postconditioning protocol and all patients but one (hemorrhagic stroke) survived through 1 year of follow-up. CONCLUSIONS We found no early benefit of postconditioning on infarct size, myocardial salvage index, and LV function compared with routine PCI. However, postconditioning was associated with improved LV remodeling at 1 year of follow-up, especially in subjects with microvascular obstruction. CLINICAL TRIAL REGISTRATION URL: http://www.clinicaltrials.gov . Unique identifier: NCT01324453.
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Affiliation(s)
- Jay H Traverse
- From the Minneapolis Heart Institute Foundation at Abbott Northwestern Hospital, MN (J.H.T., T.D.H., J.F., Y.L.W., I.J.C., D.L.L., J.R.L., W.R.P., N.M.B., A.P., J.L.L., R.F.G.).,Cardiovascular Division, The University of Minnesota School of Medicine, Minneapolis (J.H.T., C.M.S.)
| | - Cory M Swingen
- Cardiovascular Division, The University of Minnesota School of Medicine, Minneapolis (J.H.T., C.M.S.)
| | - Timothy D Henry
- From the Minneapolis Heart Institute Foundation at Abbott Northwestern Hospital, MN (J.H.T., T.D.H., J.F., Y.L.W., I.J.C., D.L.L., J.R.L., W.R.P., N.M.B., A.P., J.L.L., R.F.G.)
| | - Jane Fox
- From the Minneapolis Heart Institute Foundation at Abbott Northwestern Hospital, MN (J.H.T., T.D.H., J.F., Y.L.W., I.J.C., D.L.L., J.R.L., W.R.P., N.M.B., A.P., J.L.L., R.F.G.)
| | - Yale L Wang
- From the Minneapolis Heart Institute Foundation at Abbott Northwestern Hospital, MN (J.H.T., T.D.H., J.F., Y.L.W., I.J.C., D.L.L., J.R.L., W.R.P., N.M.B., A.P., J.L.L., R.F.G.)
| | - Ivan J Chavez
- From the Minneapolis Heart Institute Foundation at Abbott Northwestern Hospital, MN (J.H.T., T.D.H., J.F., Y.L.W., I.J.C., D.L.L., J.R.L., W.R.P., N.M.B., A.P., J.L.L., R.F.G.)
| | - Daniel L Lips
- From the Minneapolis Heart Institute Foundation at Abbott Northwestern Hospital, MN (J.H.T., T.D.H., J.F., Y.L.W., I.J.C., D.L.L., J.R.L., W.R.P., N.M.B., A.P., J.L.L., R.F.G.)
| | - John R Lesser
- From the Minneapolis Heart Institute Foundation at Abbott Northwestern Hospital, MN (J.H.T., T.D.H., J.F., Y.L.W., I.J.C., D.L.L., J.R.L., W.R.P., N.M.B., A.P., J.L.L., R.F.G.)
| | - Wesley R Pedersen
- From the Minneapolis Heart Institute Foundation at Abbott Northwestern Hospital, MN (J.H.T., T.D.H., J.F., Y.L.W., I.J.C., D.L.L., J.R.L., W.R.P., N.M.B., A.P., J.L.L., R.F.G.)
| | - Nicholas M Burke
- From the Minneapolis Heart Institute Foundation at Abbott Northwestern Hospital, MN (J.H.T., T.D.H., J.F., Y.L.W., I.J.C., D.L.L., J.R.L., W.R.P., N.M.B., A.P., J.L.L., R.F.G.)
| | - Akila Pai
- From the Minneapolis Heart Institute Foundation at Abbott Northwestern Hospital, MN (J.H.T., T.D.H., J.F., Y.L.W., I.J.C., D.L.L., J.R.L., W.R.P., N.M.B., A.P., J.L.L., R.F.G.)
| | - Jana L Lindberg
- From the Minneapolis Heart Institute Foundation at Abbott Northwestern Hospital, MN (J.H.T., T.D.H., J.F., Y.L.W., I.J.C., D.L.L., J.R.L., W.R.P., N.M.B., A.P., J.L.L., R.F.G.)
| | - Ross F Garberich
- From the Minneapolis Heart Institute Foundation at Abbott Northwestern Hospital, MN (J.H.T., T.D.H., J.F., Y.L.W., I.J.C., D.L.L., J.R.L., W.R.P., N.M.B., A.P., J.L.L., R.F.G.)
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11
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Sharkey SW, Kalra A, Henry TD, Smith TD, Pink VR, Lesser JR, Garberich RF, Maron MS, Maron BJ. Coexistence of acute takotsubo syndrome and acute coronary syndrome. Catheter Cardiovasc Interv 2019; 96:825-829. [PMID: 31696663 DOI: 10.1002/ccd.28595] [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] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/22/2019] [Revised: 10/13/2019] [Accepted: 10/27/2019] [Indexed: 11/08/2022]
Abstract
BACKGROUND Takotsubo syndrome (TS) is an acute cardiac condition with presentation indistinguishable from acute coronary syndrome (ACS), and mechanism independent of epicardial coronary obstruction. Acute coronary artery plaque rupture/occlusion is not expected in TS. Nonetheless, the physiologic stress of ACS might itself trigger TS, leading to coexistence of both conditions, and diagnostic uncertainty. METHODS From 2011 to 2014, we encountered 137 consecutive patients with typical TS (without acute coronary plaque rupture/occlusion). During this time, among a population of 3,506 consecutive ACS patients, nine (0.3%) presented with features of both ACS and TS, that is, acute onset, troponin elevation, acute plaque rupture/occlusion, and reversible LV ballooning not corresponding to culprit coronary distribution. RESULTS The nine patients (seven female) with TS-ACS coexistence, average age 70 ± 13 years, presented with chest pain (n = 6), nausea/vomiting (n = 2), or cardiac arrest (n = 1), ST-elevation (n = 5), all with troponin elevation (peak 1.3 ± 1.2 ng/ml). Each had single vessel coronary disease; right coronary (n = 3), circumflex (n = 3), mid-LAD (n = 2), ramus intermedius (n = 1), with percutaneous coronary intervention in seven patients (78%). Initial ejection fraction was 26 ± 7%, with apical ballooning in eight patients and mid-LV ballooning in one patient. Each patient had LV ballooning resolution and ejection fraction normalization to 57 ± 3%, hospital survival was 89%. CONCLUSIONS Among patients with ACS, a subset have evidence of coexisting TS, findings which further expand the clinical profile of both conditions, raising the possibility that ACS itself may trigger TS.
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Affiliation(s)
- Scott W Sharkey
- Minneapolis Heart Institute Foundation at Abbott Northwestern Hospital, Minneapolis, Minnesota
| | - Ankur Kalra
- Minneapolis Heart Institute Foundation at Abbott Northwestern Hospital, Minneapolis, Minnesota
| | - Timothy D Henry
- Minneapolis Heart Institute Foundation at Abbott Northwestern Hospital, Minneapolis, Minnesota.,Lindner Center for Research and Education at The Christ Hospital, Cincinnati, Ohio
| | - Timothy D Smith
- Lindner Center for Research and Education at The Christ Hospital, Cincinnati, Ohio
| | - Victoria R Pink
- Minneapolis Heart Institute Foundation at Abbott Northwestern Hospital, Minneapolis, Minnesota
| | - John R Lesser
- Minneapolis Heart Institute Foundation at Abbott Northwestern Hospital, Minneapolis, Minnesota
| | - Ross F Garberich
- Minneapolis Heart Institute Foundation at Abbott Northwestern Hospital, Minneapolis, Minnesota
| | - Martin S Maron
- Hypertrophic Cardiomyopathy Center, Tufts Medical Center, Boston, Massachusetts
| | - Barry J Maron
- Minneapolis Heart Institute Foundation at Abbott Northwestern Hospital, Minneapolis, Minnesota.,Hypertrophic Cardiomyopathy Center, Tufts Medical Center, Boston, Massachusetts
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12
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Levine GN, Dai X, Henry TD, Calfon Press M, Denktas AE, Garberich RF, Jacobs AK, Jaski BE, Kaul P, Kontos MC, Stouffer GA, Smith SC. In-Hospital ST-Segment Elevation Myocardial Infarction: Improving Diagnosis, Triage, and Treatment. JAMA Cardiol 2019; 3:527-531. [PMID: 29466558 DOI: 10.1001/jamacardio.2017.5356] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
Importance In-hospital ST-segment elevation myocardial infarction (STEMI) is a unique clinical entity with epidemiology, incidence, and outcomes distinct from that of out-of-hospital STEMI and has only within the past 10 years begun to receive increased attention and research. Patients with in-hospital STEMI are older, have more comorbidities, and more frequently have coagulopathies and contraindications for anticoagulation and fibrinolytic therapy. A standardized clinical definition of in-hospital STEMI is lacking. The objectives of this special communication are to (1) summarize the knowledge base regarding in-hospital STEMI; (2) review the challenges of diagnosis and treatment of patients with in-hospital STEMI; (3) present a standardized clinical definition for in-hospital STEMI; and (4) provide a quality improvement protocol to improve diagnosis, triage, and treatment of patients with in-hospital STEMI. Observations Patients with in-hospital STEMI less frequently present with typical angina symptoms, and an electrocardiogram is often obtained owing to changes in clinical status, changes on telemetry, or a finding of elevated cardiac biomarker. The frequent nontypical presentations often lead to substantial delays in the diagnosis of STEMI. Only 34% to 71% of patients with in-hospital STEMI undergo diagnostic catheterization, and only 22% to 56% undergo percutaneous coronary intervention. Even in contemporary reports, some studies report in-hospital mortality in the range of 31% to 42%. Three areas of delay in the treatment of patients with in-hospital STEMI that merit particular attention are (1) delays in electrocardiogram acquisition, (2) delays in electrocardiogram interpretation, and (3) delays in activation of existing STEMI systems of care. Conclusions and Relevance Treatment of patients with in-hospital STEMI is more complex and challenging than treatment of patients who develop out-of-hospital STEMI, leading to delays in diagnosis and triage and less frequent use of reperfusion therapy. Quality improvement programs targeted at decreasing delays and streamlining treatment of such patients may improve treatment and outcome.
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Affiliation(s)
| | - Xuming Dai
- Division of Cardiology, McAllister Heart Institute, University of North Carolina at Chapel Hill
| | | | - Marcella Calfon Press
- Cardiology Division, Department of Medicine, Ronald Reagan Medical Center, University of California, Los Angeles in Westwood
| | | | - Ross F Garberich
- Minneapolis Heart Institute Foundation at Abbott Northwestern Hospital, Minneapolis, Minnesota
| | | | - Brian E Jaski
- San Diego Cardiac Center, Sharp Memorial Hospital, San Diego, California
| | | | | | - George A Stouffer
- Division of Cardiology, McAllister Heart Institute, University of North Carolina at Chapel Hill
| | - Sidney C Smith
- Division of Cardiology, McAllister Heart Institute, University of North Carolina at Chapel Hill
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13
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Lobo AS, Cantu SM, Sharkey SW, Grey EZ, Storey K, Witt D, Benson G, Garberich RF, Kubota Y, Bairey Merz CN, Henry TD. Revascularization in Patients With Spontaneous Coronary Artery Dissection and ST-Segment Elevation Myocardial Infarction. J Am Coll Cardiol 2019; 74:1290-1300. [DOI: 10.1016/j.jacc.2019.06.065] [Citation(s) in RCA: 59] [Impact Index Per Article: 11.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/30/2019] [Revised: 06/03/2019] [Accepted: 06/13/2019] [Indexed: 02/07/2023]
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14
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Urbach J, Hou CR, Lesser JR, Stanberry LI, Garberich RF, Caye D, Sorajja P, Gössl M. Computed Tomographic Angiography-Derived Risk Factors for Vascular Complications in Percutaneous Transfemoral Transcatheter Aortic Valve Implantation. Am J Cardiol 2019; 124:98-104. [PMID: 31029410 DOI: 10.1016/j.amjcard.2019.03.043] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/14/2019] [Revised: 03/12/2019] [Accepted: 03/15/2019] [Indexed: 12/20/2022]
Abstract
Transfemoral aortic valve implantation (TAVI) has become a viable alternative to surgical valve implantation, particularly for higher risk patients; however, vascular complications (VCs) remain a concern in transfemoral TAVI. We aimed to determine clinical and computed tomographic angiography-derived risk factors associated with Valve Academic Research Consortium (VARC)-2 criteria VCs in patients who underwent TAVI. From 2011 to 2017, 481 patients underwent percutaneous transfemoral TAVI at the Minneapolis Heart Institute and were screened for procedural and postprocedural access-related VC according to VARC-2 criteria. Clinical and clinical and computed tomographic angiography-derived data were collected to establish risk factors for VC. A total of 99 (21%) patients had VARC-2 VCs. Closure device failure (CDF) occurred in 56 of 99 (57%), minor VCs in 37 of 99 (37%), and major VCs occurred in 6 of 99 (6%). Access site-related VCs were preceded by CDF in 18 of 43 (42%) patients and the risk of major/minor VCs was 14 times greater in patients who experienced closure complications. The incidence of CDF was higher in common femoral artery (CFA) access sites with circumferential vessel wall calcification of more than 90° (p = 0.02) and when skin-surface to CFA access-site distance at an optimal access angle of 45° exceeded 80 mm (p = 0.03). In conclusion, both the degree of circumferential CFA access site calcification and distance to skin surface at an optimal access angle may improve risk stratification of access planning in patients who underwent percutaneous transfemoral TAVI.
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15
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Ahmed A, Sorajja P, Garberich RF, Farivar RS, Harris KM, Gössl M. Association of Guideline Adherence for Serial Evaluations With Survival and Adverse Clinical Events in Patients With Asymptomatic Severe Aortic Stenosis. JAMA Cardiol 2019; 2:1141-1146. [PMID: 28877303 DOI: 10.1001/jamacardio.2017.2952] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
Importance For patients with asymptomatic severe aortic stenosis and normal left ventricular function, current practice guidelines empirically recommend serial evaluations every 6 to 12 months. The benefit of this clinical monitoring is unknown. Objective To determine the association of guideline adherence with clinical outcomes in patients with asymptomatic severe aortic stenosis. Design, Setting, and Participants This retrospective cohort study involved 300 patients with asymptomatic severe aortic stenosis who were seen in the ambulatory Minneapolis Heart Institute at Abbott Northwestern Hospital. Rates of survival and adverse clinical events, including myocardial infarction, stroke, and heart failure hospitalization, were compared between patients who adhered to serial evaluation guidance and those who did not. Medical records were reviewed from July 25, 2007, to December 6, 2012. Data analysis took place from February 4, 2017, to July 10, 2017. Main Outcomes and Measures All-cause mortality, heart failure hospitalization, and major adverse clinical events during follow-up. Results The study population of 300 comprised 143 men (47.7%) and had a mean (SD) age of 78.6 (11.5) years. There were no differences in age, race/ethnicity, sex, comorbidities, insurance status, left ventricular function, and aortic stenosis severity between patients with (n = 202) and patients without (n = 98) guideline adherence. Aortic valve replacement (surgical or catheter based) was performed more frequently (54.0% vs 19.4%; P < .001) and the median (interquartile range) time for this performance was earlier (2.2 [1.2-3.6] years vs 3.5 [2.0-5.8] years; P < .001) in patients with guideline adherence. All-cause mortality was higher for nonadherent patients (hazard ratio [HR], 1.57; 95% CI, 1.07-2.30; P < .001), and these patients also had a higher rate of hospital admission for heart failure decompensation in follow-up (HR, 1.66; 95% CI, 1.27-2.18; P < .001). Four-year survival that is free from death and heart failure hospitalization was higher for adherent patients than for nonadherent patients (38.7% vs 23.3%; P < .001), and this difference remained significant in models adjusted for baseline variables (adjusted HR, 1.54; 95% CI, 1.04-2.29; P = .03). Conclusions and Relevance The findings of this study support the need for close monitoring of patients with asymptomatic severe aortic stenosis and help to validate current guidelines for serial evaluations. These findings also support initiatives to improve guideline adherence in clinical practice.
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Affiliation(s)
- Aisha Ahmed
- Valve Science Center, Minneapolis Heart Institute Foundation, Minneapolis, Minnesota.,Minneapolis Heart Institute at Abbott Northwestern Hospital, Minneapolis, Minnesota
| | - Paul Sorajja
- Valve Science Center, Minneapolis Heart Institute Foundation, Minneapolis, Minnesota.,Minneapolis Heart Institute at Abbott Northwestern Hospital, Minneapolis, Minnesota
| | - Ross F Garberich
- Valve Science Center, Minneapolis Heart Institute Foundation, Minneapolis, Minnesota.,Minneapolis Heart Institute at Abbott Northwestern Hospital, Minneapolis, Minnesota
| | - R Saeid Farivar
- Valve Science Center, Minneapolis Heart Institute Foundation, Minneapolis, Minnesota.,Minneapolis Heart Institute at Abbott Northwestern Hospital, Minneapolis, Minnesota
| | - Kevin M Harris
- Valve Science Center, Minneapolis Heart Institute Foundation, Minneapolis, Minnesota.,Minneapolis Heart Institute at Abbott Northwestern Hospital, Minneapolis, Minnesota
| | - Mario Gössl
- Valve Science Center, Minneapolis Heart Institute Foundation, Minneapolis, Minnesota.,Minneapolis Heart Institute at Abbott Northwestern Hospital, Minneapolis, Minnesota
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16
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Bennett NM, Rutten-Ramos S, Arndt TL, Garberich RF, Traverse JH, Poulose AK, Mitchell P, Storey KM, Henry TD. Health Status and Quality of Life of Patients Enrolled in a Specialized Refractory Angina Clinic. ACTA ACUST UNITED AC 2019. [DOI: 10.21925/mplsheartjournal-d-18-00008] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
As the mortality of coronary artery disease improves and the population ages, an increasing number of patients with refractory angina are not candidates for percutaneous or surgical revascularization. We evaluated the impact of a dedicated refractory angina clinic on quality of life. In 76 patients who completed the Medical Outcomes Study 36-Item Short-Form Health Survey and Seattle Angina Questionnaire at baseline and 1 year, the Medical Outcomes Study results showed the proportion of patients who rated their health as “good” or “excellent” more than doubled from baseline to 1 year (15.8% vs. 42.2%; P < .001). Similarly, the Seattle Angina Questionnaire score was significantly improved at 1 year compared to baseline (P = .025), as were angina stability (P = 0.017) and angina frequency (P = .010). In conclusion, treatment in a dedicated clinic is associated with improved quality of life in patients with refractory angina.
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Affiliation(s)
- Noel M. Bennett
- Minneapolis Heart Institute Foundation, Abbott Northwestern Hospital, Minneapolis, MN; Cedars-Sinai Heart Institute, Los Angeles, CA
| | - Stephanie Rutten-Ramos
- Minneapolis Heart Institute Foundation, Abbott Northwestern Hospital, Minneapolis, MN; Cedars-Sinai Heart Institute, Los Angeles, CA
| | - Theresa L. Arndt
- Minneapolis Heart Institute Foundation, Abbott Northwestern Hospital, Minneapolis, MN; Cedars-Sinai Heart Institute, Los Angeles, CA
| | - Ross F. Garberich
- Minneapolis Heart Institute Foundation, Abbott Northwestern Hospital, Minneapolis, MN; Cedars-Sinai Heart Institute, Los Angeles, CA
| | - Jay H. Traverse
- Minneapolis Heart Institute Foundation, Abbott Northwestern Hospital, Minneapolis, MN; Cedars-Sinai Heart Institute, Los Angeles, CA
| | - Anil K. Poulose
- Minneapolis Heart Institute Foundation, Abbott Northwestern Hospital, Minneapolis, MN; Cedars-Sinai Heart Institute, Los Angeles, CA
| | - Patricia Mitchell
- Minneapolis Heart Institute Foundation, Abbott Northwestern Hospital, Minneapolis, MN; Cedars-Sinai Heart Institute, Los Angeles, CA
| | - Katelyn M. Storey
- Minneapolis Heart Institute Foundation, Abbott Northwestern Hospital, Minneapolis, MN; Cedars-Sinai Heart Institute, Los Angeles, CA
| | - Timothy D. Henry
- Minneapolis Heart Institute Foundation, Abbott Northwestern Hospital, Minneapolis, MN; Cedars-Sinai Heart Institute, Los Angeles, CA
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17
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Traverse JH, Garberich RF. Response by Traverse and Garberich to Letter Regarding Article, "NHLBI-Sponsored Randomized Trial of Postconditioning During Primary Percutaneous Coronary Intervention for ST-Elevation Myocardial Infarction". Circ Res 2019; 124:e57-e58. [PMID: 30973808 DOI: 10.1161/circresaha.119.314860] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Affiliation(s)
- Jay H Traverse
- Minneapolis Heart Institute Foundation, Abbott Northwestern Hospital, Minneapolis, MN
| | - Ross F Garberich
- Minneapolis Heart Institute Foundation, Abbott Northwestern Hospital, Minneapolis, MN
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18
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Huynh N, Thordsen S, Thomas T, Mackey-Bojack SM, Duncanson ER, Nwuado D, Garberich RF, Harris KM. Clinical and pathologic findings of aortic dissection at autopsy: Review of 336 cases over nearly 6 decades. Am Heart J 2019; 209:108-115. [PMID: 30660330 DOI: 10.1016/j.ahj.2018.11.006] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/16/2018] [Accepted: 11/10/2018] [Indexed: 01/16/2023]
Abstract
BACKGROUND We aimed to characterize the clinical and pathologic findings of aortic dissection (AD) over a nearly 60-year period. METHODS The Jesse E. Edwards Registry of Cardiovascular Disease database was queried for cardiac specimens from autopsies with AD as a diagnosis and compared 2 cohorts: early (1956-1992) and current (1993-2015). RESULTS From 1956 to 2015, 338 cases (166 early, 170 current) with AD were included (mean age: 60; 62% male). The AD was 86% type A and 14% type B. Sixty-two percent of cases were under medical care at time of death (61% early, 62% current, P = not significant). Of those under medical care, 63% were not diagnosed prior to death (64% early, 62% current, P = not significant). Risks for dissection did not differ between time intervals and include left ventricular hypertrophy, suggestive of hypertension (84%), prior cardiovascular surgery (38%), bicuspid valve (14%), and connective tissue disease (9%). An intimal tear was identified in the ascending aorta in the majority (68%), followed by descending (14%), root (9.5%), and arch (7%). Aortic rupture occurred in 58%, most frequently in the ascending aorta (41%). CONCLUSIONS In a large cardiovascular registry, >60% of cases of AD were not detected clinically and first identified at autopsy. Although diagnostic techniques have significantly improved over the time interval, the percentage of AD discovered at autopsy did not differ from the early to the current era. The most prevalent risk factors for dissection including hypertension and prior cardiovascular surgery remain similar in both time periods. AD death is related to rupture of the aorta in the majority of cases.
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19
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Knickelbine T, Jia L, White SK, Garberich RF, Oberembt SJ, Wills S, Miedema MD, Brilakis ES. A systematic approach for successful PCSK9 inhibitor prescribing in clinical practice. J Clin Lipidol 2019; 13:265-271. [DOI: 10.1016/j.jacl.2019.01.005] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2018] [Revised: 01/07/2019] [Accepted: 01/10/2019] [Indexed: 11/24/2022]
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20
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Burns MR, Schneider LM, Sorajja P, Garberich RF, Rush PS, Foag K, Strauss CE, Perry T, Sweeney Claussen A, Farivar RS, Gössl M. Clinical and Economic Outcomes of the Minimalist Approach for Transcatheter Aortic Valve Replacement. Structural Heart 2019. [DOI: 10.1080/24748706.2018.1560520] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
Affiliation(s)
- Marcus R. Burns
- Valve Science Center, Minneapolis Heart Institute Foundation, Minneapolis Heart Institute at Abbott Northwestern Hospital, Minneapolis, Minnesota, USA
| | - Lynelle M. Schneider
- Valve Science Center, Minneapolis Heart Institute Foundation, Minneapolis Heart Institute at Abbott Northwestern Hospital, Minneapolis, Minnesota, USA
| | - Paul Sorajja
- Valve Science Center, Minneapolis Heart Institute Foundation, Minneapolis Heart Institute at Abbott Northwestern Hospital, Minneapolis, Minnesota, USA
| | - Ross F. Garberich
- Valve Science Center, Minneapolis Heart Institute Foundation, Minneapolis Heart Institute at Abbott Northwestern Hospital, Minneapolis, Minnesota, USA
| | - Pamela S. Rush
- Valve Science Center, Minneapolis Heart Institute Foundation, Minneapolis Heart Institute at Abbott Northwestern Hospital, Minneapolis, Minnesota, USA
| | - Katie Foag
- Valve Science Center, Minneapolis Heart Institute Foundation, Minneapolis Heart Institute at Abbott Northwestern Hospital, Minneapolis, Minnesota, USA
| | - Craig E. Strauss
- Valve Science Center, Minneapolis Heart Institute Foundation, Minneapolis Heart Institute at Abbott Northwestern Hospital, Minneapolis, Minnesota, USA
| | - Tjorvi Perry
- Valve Science Center, Minneapolis Heart Institute Foundation, Minneapolis Heart Institute at Abbott Northwestern Hospital, Minneapolis, Minnesota, USA
| | - Andrea Sweeney Claussen
- Valve Science Center, Minneapolis Heart Institute Foundation, Minneapolis Heart Institute at Abbott Northwestern Hospital, Minneapolis, Minnesota, USA
| | - R. Said Farivar
- Valve Science Center, Minneapolis Heart Institute Foundation, Minneapolis Heart Institute at Abbott Northwestern Hospital, Minneapolis, Minnesota, USA
| | - Mario Gössl
- Valve Science Center, Minneapolis Heart Institute Foundation, Minneapolis Heart Institute at Abbott Northwestern Hospital, Minneapolis, Minnesota, USA
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21
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Sharma R, Tradewell M, Kohl LP, Garberich RF, Traverse JH, Poulose A, Brilakis ES, Arndt T, Henry TD. Revascularization in "no option" patients with refractory angina: Frequency, etiology and outcomes. Catheter Cardiovasc Interv 2018; 92:1215-1219. [PMID: 30079551 DOI: 10.1002/ccd.27707] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/09/2018] [Revised: 04/16/2018] [Accepted: 05/30/2018] [Indexed: 11/09/2022]
Abstract
BACKGROUND A significant proportion of patients with complex, advanced coronary artery disease have refractory angina (RA) despite maximal pharmacological therapy and are deemed suboptimal candidates for revascularization. These patients are frequently termed "no-option" patients. However, despite this designation, many subsequently undergo coronary revascularization. We sought to determine the incidence, etiology and outcome of revascularization in "no-option" patients. METHODS AND RESULTS We examined a comprehensive, prospective RA database to identify 342 of 1363 (25.1%) patients who subsequently underwent revascularization after a median interval of 2.2 years from the "no-option" diagnosis. Coronary revascularization was achieved by percutaneous coronary intervention (PCI) (n = 274, 20.1%), coronary bypass graft surgery (n = 44, 3.2%) or both (n = 24, 1.8%). During a median follow-up of 5.1 years, patients who underwent revascularization had lower annual mortality (2% vs. 4.4%, P < .001). Detailed paired angiographic records were available for 181 PCI patients with a combined 302 lesions. Of these interventions, 48% were for a new lesion, 31% for an existing lesion and 21% for restenosis. The location was a native vessel in 77% and a bypass graft in 23%. CONCLUSIONS The "no-option" or non-revascularizable designation is frequently based on angiography at a single time-point. However, coronary artery disease is a progressive and dynamic process and new lesions often develop in such patients. Given the association between revascularization and better survival, careful consideration should be given to repeat revascularization in patients with refractory angina previously classified as "no-option".
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Affiliation(s)
- Rahul Sharma
- Cedars-Sinai Heart Institute, Los Angeles, California
| | - Michael Tradewell
- Minneapolis Heart Institute Foundation at Abbott Northwestern Hospital, Minneapolis, Minnesota
| | - Louis P Kohl
- Minneapolis Heart Institute Foundation at Abbott Northwestern Hospital, Minneapolis, Minnesota.,Hennepin County Medical Center, Minneapolis, Minnesota
| | - Ross F Garberich
- Minneapolis Heart Institute Foundation at Abbott Northwestern Hospital, Minneapolis, Minnesota
| | - Jay H Traverse
- Minneapolis Heart Institute Foundation at Abbott Northwestern Hospital, Minneapolis, Minnesota
| | - Anil Poulose
- Minneapolis Heart Institute Foundation at Abbott Northwestern Hospital, Minneapolis, Minnesota
| | - Emmanouil S Brilakis
- Minneapolis Heart Institute Foundation at Abbott Northwestern Hospital, Minneapolis, Minnesota
| | - Theresa Arndt
- Minneapolis Heart Institute Foundation at Abbott Northwestern Hospital, Minneapolis, Minnesota
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22
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Campbell AR, Rodriguez AJ, Larson DM, Strauss CE, Garberich RF, Partridge MF, Henry TD, Sharkey SW. Resource utilization and outcome among patients with selective versus nonselective troponin testing. Am Heart J 2018; 199:68-74. [PMID: 29754668 DOI: 10.1016/j.ahj.2018.01.010] [Citation(s) in RCA: 6] [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: 01/25/2018] [Accepted: 01/25/2018] [Indexed: 10/18/2022]
Abstract
OBJECTIVE In patients with suspected acute coronary syndrome (ACS), troponin testing is effective for diagnosis and prognosis. Troponin testing has now expanded to include patients without suspected ACS. This nonselective troponin testing has unknown consequences for resource utilization and outcome. Therefore, we examined selective versus nonselective troponin testing with respect to patient characteristics, resource utilization, and outcome. METHODS This retrospective 1-year study included all patients with troponin testing at a U.S. emergency department. Testing was classified as selective (ACS) or nonselective (non-ACS) based on admission ICD-9 codes. Troponin upper reference limit (URL) was ≥99th percentile. RESULTS Among 47,053 patients, troponin was measured in 9109 (19%) of whom 5764 were hospitalized. Admission diagnosis was non-ACS in 4427 (77%) and ACS in 1337 (23%). Non-ACS patients were older, 71±17 versus 65±16 years, with longer hospital stay, 77 versus 32 h, and greater 1-year mortality 22% versus 6.7%; P<.001. In patients with troponin ≥URL, revascularization was performed in 64 (4.7%) of non-ACS versus 213 (48%) of ACS; P<.001. In patients with troponin <URL, 1-year mortality was 16% in non-ACS versus 3.5% in ACS; P<.001. In those with troponin ≥URL, 1-year mortality was 35% in non-ACS versus 13% in ACS; P<.001. Death was non-cardiac in >80% of the non-ACS population CONCLUSIONS: Contemporary troponin testing is frequently nonselective. The non-ACS and ACS populations differ significantly regarding clinical characteristics, revascularization rates, and outcomes. Troponin elevation is a powerful predictor of 1-year mortality in non-ACS, this association reveals an opportunity for risk stratification and targeted therapy. KEY QUESTIONS In patients with suspected acute coronary syndrome (ACS), troponin testing is effective for diagnosis and prognosis. However, troponin testing has now expanded to include patients without suspected ACS. This nonselective troponin testing has unknown consequences for hospital resource utilization and patient outcome. Our findings demonstrate contemporary troponin testing is largely nonselective (77% of testing was performed in patients without acute coronary syndrome). In comparison to patients with acute coronary syndrome, those with non-acute coronary syndrome are older, with longer hospital stay, lower revascularization rates, and greater 1-year mortality. Troponin elevation identifies a high-risk population in both acute coronary syndrome and non-acute coronary syndrome populations, yet effective treatment for the latter is lacking.
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23
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Roberts WO, Schwartz RS, Kraus SM, Schwartz JG, Peichel G, Garberich RF, Lesser JR, Oesterle SN, Wickstrom KK, Knickelbine T, Harris KM. Long-Term Marathon Running Is Associated with Low Coronary Plaque Formation in Women. Med Sci Sports Exerc 2017; 49:641-645. [PMID: 27824692 DOI: 10.1249/mss.0000000000001154] [Citation(s) in RCA: 29] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
Abstract
INTRODUCTION Marathon running is presumed to improve cardiovascular risk, but health benefits of high volume running are unknown. High-resolution coronary computed tomography angiography and cardiac risk factor assessment were completed in women with long-term marathon running histories to compare to sedentary women with similar risk factors. METHODS Women who had run at least one marathon per year for 10-25 yr underwent coronary computed tomography angiography, 12-lead ECG, blood pressure and heart rate measurement, lipid panel, and a demographic/health risk factor survey. Sedentary matched controls were derived from a contemporaneous clinical study database. CT scans were analyzed for calcified and noncalcified plaque prevalence, volume, stenosis severity, and calcium score. RESULTS Women marathon runners (n = 26), age 42-82 yr, with combined 1217 marathons (average 47) exhibited significantly lower coronary plaque prevalence and less calcific plaque volume. The marathon runners also had less risk factors (smoking, hypertension, and hyperlipidemia); significantly lower resting heart rate, body weight, body mass index, and triglyceride levels; and higher high-density lipoprotein cholesterol levels compared with controls (n = 28). The five women runners with coronary plaque had run marathons for more years and were on average 12 yr older (65 vs 53) than the runners without plaque. CONCLUSION Women marathon runners had minimal coronary artery calcium counts, lower coronary artery plaque prevalence, and less calcified plaque volume compared with sedentary women. Developing coronary artery plaque in long-term women marathon runners appears related to older age and more cardiac risk factors, although the runners with coronary artery plaque had accumulated significantly more years running marathons.
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Affiliation(s)
- William O Roberts
- 1Department of Family Medicine and Community Health, University of Minnesota, Minneapolis, MN; 2Minneapolis Heart Institute and Foundation at Abbott Northwestern Hospital, Minneapolis, MN; 3The Integra Group, Brooklyn Park, MN; 4Stanford University School of Medicine, Stanford, CA; 5Division of Cardiology, Department of Medicine, University of Minnesota, Minneapolis, MN; 6Retired Medtronic Inc., Minneapolis, MN; and 7Department of Internal Medicine, University of Arizona, Tucson, AZ
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24
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Harris KM, Creswell LL, Haas TS, Thomas T, Tung M, Isaacson E, Garberich RF, Maron BJ. Death and Cardiac Arrest in U.S. Triathlon Participants, 1985 to 2016: A Case Series. Ann Intern Med 2017; 167:529-535. [PMID: 28975231 DOI: 10.7326/m17-0847] [Citation(s) in RCA: 44] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
BACKGROUND Reports of race-related triathlon fatalities have raised questions regarding athlete safety. OBJECTIVE To describe death and cardiac arrest among triathlon participants. DESIGN Case series. SETTING United States. PARTICIPANTS Participants in U.S. triathlon races from 1985 to 2016. MEASUREMENTS Data on deaths and cardiac arrests were assembled from such sources as the U.S. National Registry of Sudden Death in Athletes (which uses news media, Internet searches, LexisNexis archival databases, and news clipping services) and USA Triathlon (USAT) records. Incidence of death or cardiac arrest in USAT-sanctioned races from 2006 to 2016 was calculated. RESULTS A total of 135 sudden deaths, resuscitated cardiac arrests, and trauma-related deaths were compiled; mean (±SE) age of victims was 46.7 ± 12.4 years, and 85% were male. Most sudden deaths and cardiac arrests occurred in the swim segment (n = 90); the others occurred during bicycling (n = 7), running (n = 15), and postrace recovery (n = 8). Fifteen trauma-related deaths occurred during the bike segment. Incidence of death or cardiac arrest among USAT participants (n = 4 776 443) was 1.74 per 100 000 (2.40 in men and 0.74 in women per 100 000; P < 0.001). In men, risk increased substantially with age and was much greater for those aged 60 years and older (18.6 per 100 000 participants). Death or cardiac arrest risk was similar for short, intermediate, and long races (1.61 vs. 1.41 vs. 1.92 per 100 000 participants). At autopsy, 27 of 61 decedents (44%) had clinically relevant cardiovascular abnormalities, most frequently atherosclerotic coronary disease or cardiomyopathy. LIMITATIONS Case identification may be incomplete and may underestimate events, particularly in the early study period. In addition, prerace medical history is unknown in most cases. CONCLUSION Deaths and cardiac arrests during the triathlon are not rare; most have occurred in middle-aged and older men. Most sudden deaths in triathletes happened during the swim segment, and clinically silent cardiovascular disease was present in an unexpected proportion of decedents. PRIMARY FUNDING SOURCE Minneapolis Heart Institute Foundation.
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Affiliation(s)
- Kevin M Harris
- From Minneapolis Heart Institute Foundation at Abbott Northwestern Hospital, Minneapolis, Minnesota; University of Mississippi Medical Center, Jackson, Mississippi; and Tufts Medical Center, Boston, Massachusetts
| | - Lawrence L Creswell
- From Minneapolis Heart Institute Foundation at Abbott Northwestern Hospital, Minneapolis, Minnesota; University of Mississippi Medical Center, Jackson, Mississippi; and Tufts Medical Center, Boston, Massachusetts
| | - Tammy S Haas
- From Minneapolis Heart Institute Foundation at Abbott Northwestern Hospital, Minneapolis, Minnesota; University of Mississippi Medical Center, Jackson, Mississippi; and Tufts Medical Center, Boston, Massachusetts
| | - Taylor Thomas
- From Minneapolis Heart Institute Foundation at Abbott Northwestern Hospital, Minneapolis, Minnesota; University of Mississippi Medical Center, Jackson, Mississippi; and Tufts Medical Center, Boston, Massachusetts
| | - Monica Tung
- From Minneapolis Heart Institute Foundation at Abbott Northwestern Hospital, Minneapolis, Minnesota; University of Mississippi Medical Center, Jackson, Mississippi; and Tufts Medical Center, Boston, Massachusetts
| | - Erin Isaacson
- From Minneapolis Heart Institute Foundation at Abbott Northwestern Hospital, Minneapolis, Minnesota; University of Mississippi Medical Center, Jackson, Mississippi; and Tufts Medical Center, Boston, Massachusetts
| | - Ross F Garberich
- From Minneapolis Heart Institute Foundation at Abbott Northwestern Hospital, Minneapolis, Minnesota; University of Mississippi Medical Center, Jackson, Mississippi; and Tufts Medical Center, Boston, Massachusetts
| | - Barry J Maron
- From Minneapolis Heart Institute Foundation at Abbott Northwestern Hospital, Minneapolis, Minnesota; University of Mississippi Medical Center, Jackson, Mississippi; and Tufts Medical Center, Boston, Massachusetts
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25
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Wei J, Mehta PK, Grey E, Garberich RF, Hauser R, Bairey Merz CN, Henry TD. Sex-based differences in quality of care and outcomes in a health system using a standardized STEMI protocol. Am Heart J 2017; 191:30-36. [PMID: 28888267 DOI: 10.1016/j.ahj.2017.06.005] [Citation(s) in RCA: 50] [Impact Index Per Article: 7.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/14/2017] [Accepted: 06/14/2017] [Indexed: 01/22/2023]
Abstract
BACKGROUND Recent data from the National Cardiovascular Data Registry indicate that women with ST-segment-elevation myocardial infarction (STEMI) continue to have higher mortality and reported delays in treatment compared with men. We aimed to determine whether the sex difference in mortality exists when treatment disparities are reduced. METHODS Using a prospective regional percutaneous coronary intervention (PCI)-based STEMI system database with a standardized STEMI protocol, we evaluated baseline characteristics, treatment, and clinical outcomes of STEMI patients stratified by sex. RESULTS From March 2003 to January 2016, 4,918 consecutive STEMI patients presented to the Minneapolis Heart Institute at Abbott Northwestern Hospital regional STEMI system including 1,416 (28.8%) women. Compared with men, women were older (68.4 vs 60.9 years) with higher rates of hypertension (66.7% vs 55.7%), diabetes (21.7% vs 17.4%), and cardiogenic shock (11.5% vs 8.0%) (all P < .001). Pre-revascularization medications and PCI were performed with same frequencies, but women were less likely to receive statin or antiplatelet therapy at discharge. After age adjustment, women had similar in-hospital mortality to men (5.1% vs 4.8%, P = .60) despite slightly longer door-to-balloon time (95 vs 92 minutes, P = .004). Five-year follow-up confirmed absence of a sex disparity in age-adjusted survival post-STEMI. CONCLUSIONS Previously reported treatment disparities between men and women are diminished in a regional PCI-based STEMI system using a standardized STEMI protocol. No sex differences in short-term or long-term age-adjusted mortality are present in this registry despite some treatment disparities. These results suggest that STEMI health care disparities and mortality in women can be improved using STEMI protocols and systems.
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Affiliation(s)
- Janet Wei
- Cedars-Sinai Heart Institute, Cedars-Sinai Medical Center, Los Angeles, CA.
| | - Puja K Mehta
- Cedars-Sinai Heart Institute, Cedars-Sinai Medical Center, Los Angeles, CA; Emory Clinical Cardiovascular Research Institute, Emory University, Atlanta, GA
| | - Elizabeth Grey
- Minneapolis Heart Institute Foundation, Abbott Northwestern Hospital, Minneapolis, MN
| | - Ross F Garberich
- Minneapolis Heart Institute Foundation, Abbott Northwestern Hospital, Minneapolis, MN
| | - Robert Hauser
- Minneapolis Heart Institute Foundation, Abbott Northwestern Hospital, Minneapolis, MN
| | - C Noel Bairey Merz
- Cedars-Sinai Heart Institute, Cedars-Sinai Medical Center, Los Angeles, CA
| | - Timothy D Henry
- Cedars-Sinai Heart Institute, Cedars-Sinai Medical Center, Los Angeles, CA
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26
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Skeik N, Ostertag-Hill CA, Garberich RF, Alden PB, Alexander JQ, Cragg AH, Manunga JM, Stephenson EJ, Titus JM, Sullivan TM. Diagnosis, Management, and Outcome of Aortitis at a Single Center. Vasc Endovascular Surg 2017; 51:470-479. [PMID: 28859604 DOI: 10.1177/1538574417704296] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
BACKGROUND Aortitis is a rare condition with inflammatory or infectious etiology that can be difficult to diagnose due to the highly variable clinical presentation and nonspecific symptoms. However, current literature on the diagnosis, management, and prognosis of aortitis is extremely scarce. METHODS We retrospectively reviewed all patients' charts who were diagnosed with giant cell arteritis, Takayasu arteritis, or noninfectious aortitis presenting at a single center between January 1, 2009, and April 17, 2015. Data collected included demographics, medical history, comorbidities, laboratory and imaging data, management, and outcome. RESULTS Among the included 15 patients presenting with aortitis at our center, 53% were diagnosed with Takayasu arteritis, 33% with idiopathic inflammatory aortitis, and 13% with giant cell arteritis. All patients received steroid treatment, 67% received adjunctive immunosuppressants or immunomodulators, and 33% underwent interventional procedures. Based on clinical presentation and laboratory and imaging findings at the last follow-up visit for each patient, 67% showed improvement, 27% had no change in disease activity, and 7% had a progression of the disease. CONCLUSIONS Takayasu arteritis was found to be more common than idiopathic inflammatory aortitis and giant cell arteritis among our 15 cases diagnosed with aortitis. All patients received medical therapy and 33% received interventional procedures, leading to 67% improvement of disease activity or related complications. This article also offers a comprehensive review of the diagnosis, management, and outcome of aortitis, supplementing the very limited literature on this disease.
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Affiliation(s)
- Nedaa Skeik
- 1 Vascular Medicine, Minneapolis Heart Institute, Minneapolis, MN, USA
| | | | - Ross F Garberich
- 2 Minneapolis Heart Institute Research Foundation, Minneapolis, MN, USA
| | - Peter B Alden
- 3 Vascular Surgery, Minneapolis Heart Institute, Minneapolis, MN, USA
| | - Jason Q Alexander
- 3 Vascular Surgery, Minneapolis Heart Institute, Minneapolis, MN, USA
| | - Andrew H Cragg
- 3 Vascular Surgery, Minneapolis Heart Institute, Minneapolis, MN, USA
| | - Jesse M Manunga
- 3 Vascular Surgery, Minneapolis Heart Institute, Minneapolis, MN, USA
| | | | - Jessica M Titus
- 3 Vascular Surgery, Minneapolis Heart Institute, Minneapolis, MN, USA
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27
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Rowin EJ, Maron BJ, Haas TS, Garberich RF, Wang W, Link MS, Maron MS. Hypertrophic Cardiomyopathy With Left Ventricular Apical Aneurysm: Implications for Risk Stratification and Management. J Am Coll Cardiol 2017; 69:761-773. [PMID: 28209216 DOI: 10.1016/j.jacc.2016.11.063] [Citation(s) in RCA: 226] [Impact Index Per Article: 32.3] [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: 10/06/2016] [Revised: 11/17/2016] [Accepted: 11/18/2016] [Indexed: 12/12/2022]
Abstract
BACKGROUND A previously under-recognized subset of hypertrophic cardiomyopathy (HCM) patients with left ventricular (LV) apical aneurysms is being identified with increasing frequency. However, risks associated with this subgroup are unknown. OBJECTIVES The authors aimed to clarify clinical course and prognosis of a large cohort of HCM patients with LV apical aneurysms over long-term follow-up. METHODS The authors retrospectively analyzed 1,940 consecutive HCM patients at 2 centers, 93 of which (4.8%) were identified with LV apical aneurysms; mean age was 56 ± 13 years, and 69% were male. RESULTS Over 4.4 ± 3.2 years, 3 of the 93 patients with LV apical aneurysms (3%) died suddenly or of heart failure, but 22 (24%) survived with contemporary treatment interventions: 18 experienced appropriate implantable cardioverter-defibrillator discharges, 2 underwent heart transplants, and 2 were resuscitated after cardiac arrest. The sudden death (SD) event rate was 4.7%/year, which includes sudden death, successful resuscitation from cardiac arrest or appropriate ICD interventions triggered by VF or rapid VT. Notably, recurrent monomorphic ventricular tachycardia requiring ≥2 implantable cardioverter-defibrillator shocks occurred in 13 patients, including 6 who underwent successful radiofrequency ablation of the arrhythmic focus without ventricular tachycardia recurrence. Five non-anticoagulated patients experienced nonfatal thromboembolic events (1.1%/year), whereas 13 with apical clots and anticoagulation did not incur embolic events. There was no consistent relationship between aneurysm size and adverse HCM-related events. Rate of HCM-related deaths combined with life-saving aborted disease-related events was 6.4%/year, 3-fold greater than the 2.0%/year event rate in 1,847 HCM patients without aneurysms (p < 0.001). CONCLUSIONS HCM patients with LV apical aneurysms are at high risk for arrhythmic sudden death and thromboembolic events. Identification of this phenotype expands risk stratification and can lead to effective treatment interventions for potentially life-threatening complications.
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Affiliation(s)
- Ethan J Rowin
- Hypertrophic Cardiomyopathy Institute, Division of Cardiology, Tufts Medical Center, Boston, Massachusetts
| | - Barry J Maron
- Hypertrophic Cardiomyopathy Institute, Division of Cardiology, Tufts Medical Center, Boston, Massachusetts
| | - Tammy S Haas
- Hypertrophic Cardiomyopathy Center, Minneapolis Heart Institute Foundation, Minneapolis, Minnesota
| | - Ross F Garberich
- Hypertrophic Cardiomyopathy Center, Minneapolis Heart Institute Foundation, Minneapolis, Minnesota
| | - Weijia Wang
- Hypertrophic Cardiomyopathy Institute, Division of Cardiology, Tufts Medical Center, Boston, Massachusetts
| | - Mark S Link
- Hypertrophic Cardiomyopathy Institute, Division of Cardiology, Tufts Medical Center, Boston, Massachusetts
| | - Martin S Maron
- Hypertrophic Cardiomyopathy Institute, Division of Cardiology, Tufts Medical Center, Boston, Massachusetts.
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28
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Dai X, Garberich RF, Jaski BE, Smith SC, Henry TD. In-Hospital ST Elevation Myocardial Infarction: Clinical Characteristics, Management Challenges, and Outcome. Interv Cardiol Clin 2017; 5:471-480. [PMID: 28581996 DOI: 10.1016/j.iccl.2016.06.005] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
Timely reperfusion therapy reduces complications and improves survival in ST elevation myocardial infarction (STEMI). An effective chain of survival has been established for STEMIs occur in the community (outpatient STEMI). Recent studies have identified a subgroup of patients who develop STEMI while hospitalized for primary conditions, often not directly related to coronary artery disease (in-hospital STEMI or inpatient STEMI). This article summarizes current understanding of patient demographics, clinical characteristics, care delivery system and outcomes of in-hospital STEMI, comparing with outpatient STEMI. We also identified opportunities for quality improvement and proposed strategies and future directions to improve care for these patients.
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Affiliation(s)
- Xuming Dai
- Division of Cardiology, University of North Carolina at Chapel Hill, 160 Dental Circle, Chapel Hill, NC 27599, USA.
| | - Ross F Garberich
- Minneapolis Heart Institute Foundation, Abbott Northwestern Hospital, 920 East 28th Street, Suite 100, Minneapolis, MN 55407, USA
| | - Brian E Jaski
- San Diego Cardiac Center, Sharp Healthcare, 3131 Berger Avenue, San Diego, CA 92123, USA
| | - Sidney C Smith
- Division of Cardiology, University of North Carolina at Chapel Hill, 160 Dental Circle, Chapel Hill, NC 27599, USA
| | - Timothy D Henry
- Cedars-Sinai Heart Institute, 127 South San Vicente Boulevard, Suite A3100, Los Angeles, CA 90048, USA
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29
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Miedema MD, Garberich RF, Schnaidt LJ, Peterson E, Strauss C, Sharkey S, Knickelbine T, Newell MC, Henry TD. Statin Eligibility and Outpatient Care Prior to ST-Segment Elevation Myocardial Infarction. J Am Heart Assoc 2017; 6:JAHA.116.005333. [PMID: 28404560 PMCID: PMC5533022 DOI: 10.1161/jaha.116.005333] [Citation(s) in RCA: 9] [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] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/03/2022]
Abstract
Background The impact of the 2013 American College of Cardiology/American Heart Association cholesterol guidelines on statin eligibility in individuals otherwise destined to experience cardiovascular disease (CVD) events is unclear. Methods and Results We analyzed a prospective cohort of consecutive ST‐segment elevation myocardial infarction (STEMI) patients from a regional STEMI system with data on patient demographics, low‐density lipoprotein cholesterol levels, CVD risk factors, medication use, and outpatient visits over the 2 years prior to STEMI. We determined pre‐STEMI eligibility according to American College of Cardiology/American Heart Association guidelines and the prior Third Report of the Adult Treatment Panel guidelines. Our sample included 1062 patients with a mean age of 63.7 (13.0) years (72.5% male), and 761 (71.7%) did not have known CVD prior to STEMI. Only 62.5% and 19.3% of individuals with and without prior CVD were taking a statin before STEMI, respectively. In individuals not taking a statin, median (interquartile range) low‐density lipoprotein cholesterol levels in those with and without known CVD were low (108 [83, 138] mg/dL and 110 [87, 133] mg/dL). For individuals not taking a statin, only 38.7% were statin eligible by ATP III guidelines. Conversely, 79.0% would have been statin eligible according to American College of Cardiology/American Heart Association guidelines. Less than half of individuals with (49.2%) and without (41.1%) prior CVD had seen a primary care provider during the 2 years prior to STEMI. Conclusions In a large cohort of STEMI patients, application of American College of Cardiology/American Heart Association guidelines more than doubled pre‐STEMI statin eligibility compared with Third Report of the Adult Treatment Panel guidelines. However, access to and utilization of health care, a necessity for guideline implementation, was suboptimal prior to STEMI.
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Affiliation(s)
- Michael D Miedema
- Minneapolis Heart Institute Foundation, Minneapolis, MN .,Minneapolis Heart Institute, Minneapolis, MN
| | | | | | - Erin Peterson
- Minneapolis Heart Institute Foundation, Minneapolis, MN
| | - Craig Strauss
- Minneapolis Heart Institute Foundation, Minneapolis, MN.,Minneapolis Heart Institute, Minneapolis, MN
| | - Scott Sharkey
- Minneapolis Heart Institute Foundation, Minneapolis, MN.,Minneapolis Heart Institute, Minneapolis, MN
| | - Thomas Knickelbine
- Minneapolis Heart Institute Foundation, Minneapolis, MN.,Minneapolis Heart Institute, Minneapolis, MN
| | - Marc C Newell
- Minneapolis Heart Institute Foundation, Minneapolis, MN.,Minneapolis Heart Institute, Minneapolis, MN
| | - Timothy D Henry
- Minneapolis Heart Institute Foundation, Minneapolis, MN.,Minneapolis Heart Institute, Minneapolis, MN.,Department of Cardiology, Cedars-Sinai Heart Institute, Los Angeles, CA
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30
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Pera VK, Larson DM, Sharkey SW, Garberich RF, Solie CJ, Wang YL, Traverse JH, Poulose AK, Henry TD. New or presumed new left bundle branch block in patients with suspected ST-elevation myocardial infarction. Eur Heart J Acute Cardiovasc Care 2017; 7:208-217. [PMID: 29064258 DOI: 10.1177/2048872617691508] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
Abstract
AIMS Using a comprehensive large prospective regional ST-elevation myocardial infarction (STEMI) system database, we evaluated the prevalence, clinical and angiographic characteristics, and outcomes in patients with ischemic symptoms and new or presumed new left bundle branch block (LBBB). We then tested a new hierarchical diagnosis and triage algorithm to identify more accurately new LBBB patients with an acute culprit lesion. METHODS AND RESULTS From March 2003 to June 2013, 3903 consecutive STEMI patients were treated using the Minneapolis Heart Institute regional STEMI protocol including 131 patients (3.3%) with new LBBB. These patients had fewer culprit arteries (54.2% vs. 86.4%; P<0.001), were older, more commonly women, with a lower ejection fraction, and more frequently presented with cardiac arrest or heart failure than those without new LBBB. At 1 year follow-up, all-cause mortality accounting for baseline differences was higher in patients with new LBBB (hazard ratio 1.73, 95% confidence interval 1.17-2.58; P=0.007). The new algorithm yielded high sensitivity (97%) and negative predictive value (94%) for identification of a culprit lesion. Using the definition of new LBBB with either hemodynamically unstable features or Sgarbossa concordance criteria on electrocardiogram (ECG), 45% of new LBBB patients would have been treated as 'STEMI equivalent'. CONCLUSION Patients with acute ischemic symptoms and new LBBB represent a high-risk population with unique clinical challenges. If validated in an independent dataset, the new algorithm may improve the diagnostic accuracy regarding reperfusion therapy for new LBBB patients.
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Affiliation(s)
- Vijaya K Pera
- 1 Division of Cardiology, Minneapolis Heart Institute Foundation at Abbott Northwestern Hospital, USA
| | - David M Larson
- 1 Division of Cardiology, Minneapolis Heart Institute Foundation at Abbott Northwestern Hospital, USA
| | - Scott W Sharkey
- 1 Division of Cardiology, Minneapolis Heart Institute Foundation at Abbott Northwestern Hospital, USA
| | - Ross F Garberich
- 1 Division of Cardiology, Minneapolis Heart Institute Foundation at Abbott Northwestern Hospital, USA
| | - Christopher J Solie
- 1 Division of Cardiology, Minneapolis Heart Institute Foundation at Abbott Northwestern Hospital, USA
| | - Yale L Wang
- 1 Division of Cardiology, Minneapolis Heart Institute Foundation at Abbott Northwestern Hospital, USA
| | - Jay H Traverse
- 1 Division of Cardiology, Minneapolis Heart Institute Foundation at Abbott Northwestern Hospital, USA
| | - Anil K Poulose
- 1 Division of Cardiology, Minneapolis Heart Institute Foundation at Abbott Northwestern Hospital, USA
| | - Timothy D Henry
- 1 Division of Cardiology, Minneapolis Heart Institute Foundation at Abbott Northwestern Hospital, USA.,2 Division of Cardiology, Cedars-Sinai Heart Institute, USA
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31
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Halder LC, Richardson LB, Garberich RF, Zimbwa P, Bennett MK. Time in Therapeutic Range for Left Ventricular Assist Device Patients Anticoagulated With Warfarin: A Correlation to Clinical Outcomes. ASAIO J 2017; 63:37-40. [DOI: 10.1097/mat.0000000000000449] [Citation(s) in RCA: 30] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
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Strauss CE, Kebede TD, Porten BR, Garberich RF, Calcaterra D, Manunga JM, Harris KM. Why the Delay? Identification of Factors Which Delay Diagnosis of Acute Aortic Dissection. ACTA ACUST UNITED AC 2017. [DOI: 10.21925/mplsheartjournal-d-16-00008] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
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Maron BJ, Haas TS, Ahluwalia A, Murphy CJ, Garberich RF. Demographics and Epidemiology of Sudden Deaths in Young Competitive Athletes: From the United States National Registry. Am J Med 2016; 129:1170-1177. [PMID: 27039955 DOI: 10.1016/j.amjmed.2016.02.031] [Citation(s) in RCA: 171] [Impact Index Per Article: 21.4] [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: 02/02/2016] [Revised: 02/08/2016] [Accepted: 02/08/2016] [Indexed: 10/22/2022]
Abstract
BACKGROUND Sudden deaths in young competitive athletes are tragic events, with high public visibility. The importance of race and gender with respect to sport and the diagnosis and causes of sudden death in athletes has generated substantial interest. METHODS The US National Registry of Sudden Death in Athletes, 1980-2011, was accessed to define the epidemiology and causes of sudden deaths in competitive athletes. A total of 2406 deaths were identified in young athletes aged 19 ± 6 years engaged in 29 diverse sports. RESULTS Among the 842 athletes with autopsy-confirmed cardiovascular diagnoses, the incidence in males exceeded that in females by 6.5-fold (1:121; 691 vs 1:787,392 athlete-years; P ≤.001). Hypertrophic cardiomyopathy was the single most common cause of sudden death, occurring in 302 of 842 athletes (36%) and accounting for 39% of male sudden deaths, almost 4-fold more common than among females (11%; P ≤.001). More frequent among females were congenital coronary artery anomalies (33% vs 17% of males; P ≤.001), arrhythmogenic right ventricular cardiomyopathy (13% vs 4%; P = .002), and clinically diagnosed long QT syndrome (7% vs 1.5%; P ≤.002). The cardiovascular death rate among African Americans/other minorities exceeded whites by almost 5-fold (1:12,778 vs 1:60; 746 athlete-years; P <.001), and hypertrophic cardiomyopathy was more common among African Americans/other minorities (42%) than in whites (31%; P ≤.001). Male and female basketball players were 3-fold more likely to be African American/other minorities than white. CONCLUSIONS Within this large forensic registry of competitive athletes, cardiovascular sudden deaths due to genetic and/or congenital heart diseases were uncommon in females and more common in African Americans/other minorities than in whites. Hypertrophic cardiomyopathy is an under-appreciated cause of sudden death in male minority athletes.
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Affiliation(s)
- Barry J Maron
- Hypertrophic Cardiomyopathy Center, Minneapolis Heart Institute Foundation, Minn.
| | - Tammy S Haas
- Hypertrophic Cardiomyopathy Center, Minneapolis Heart Institute Foundation, Minn
| | - Aneesha Ahluwalia
- Hypertrophic Cardiomyopathy Center, Minneapolis Heart Institute Foundation, Minn
| | - Caleb J Murphy
- Hypertrophic Cardiomyopathy Center, Minneapolis Heart Institute Foundation, Minn
| | - Ross F Garberich
- Hypertrophic Cardiomyopathy Center, Minneapolis Heart Institute Foundation, Minn
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Maron MS, Rowin EJ, Olivotto I, Casey SA, Arretini A, Tomberli B, Garberich RF, Link MS, Chan RHM, Lesser JR, Maron BJ. Contemporary Natural History and Management of Nonobstructive Hypertrophic Cardiomyopathy. J Am Coll Cardiol 2016; 67:1399-1409. [PMID: 27012399 DOI: 10.1016/j.jacc.2016.01.023] [Citation(s) in RCA: 117] [Impact Index Per Article: 14.6] [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: 12/08/2015] [Revised: 01/11/2016] [Accepted: 01/13/2016] [Indexed: 11/25/2022]
Abstract
BACKGROUND Left ventricular outflow tract gradients are absent in an important proportion of patients with hypertrophic cardiomyopathy (HCM). However, the natural course of this important patient subgroup remains largely unresolved. OBJECTIVES The authors systematically employed exercise (stress) echocardiography to define those patients without obstruction to left ventricular outflow at rest and/or under physiological exercise and to examine their natural history and clinical course to create a more robust understanding of this complex disease. METHODS We prospectively studied 573 consecutive HCM patients in 3 centers (44 ± 17 years; 66% male) with New York Heart Association functional class I/II symptoms at study entry, including 249 in whom left ventricular outflow tract obstruction was absent both at rest and following physiological exercise (<30 mm Hg; nonobstructive HCM) and retrospectively assembled clinical follow-up data. RESULTS Over a median follow-up of 6.5 years, 225 of 249 nonobstructive patients (90%) remained in classes I/II, whereas 24 (10%) developed progressive heart failure to New York Heart Association functional classes III/IV. Nonobstructive HCM patients were less likely to experience advanced limiting class III/IV symptoms than the 324 patients with outflow obstruction (1.6%/year vs. 7.4%/year rest obstruction vs. 3.2%/year provocable obstruction; p < 0.001). However, 7 nonobstructive patients (2.8%) did require heart transplantation for progression to end stage versus none of the obstructive patients. HCM-related mortality among nonobstructive patients was low (n = 8; 0.5%/year), with 5- and 10-year survival rates of 99% and 97%, respectively, which is not different from expected all-cause mortality in an age- and sex-matched U.S. population (p = 0.15). CONCLUSIONS HCM patients with nonobstructive disease appear to experience a relatively benign clinical course, associated with a low risk for advanced heart failure symptoms, other disease complications, and HCM-related mortality, and largely without the requirement for major treatment interventions. A small minority of nonobstructive HCM patients progress to heart transplant.
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Affiliation(s)
- Martin S Maron
- Hypertrophic Cardiomyopathy Center, Division of Cardiology, Tufts Medical Center, Boston, Massachusetts.
| | - Ethan J Rowin
- Hypertrophic Cardiomyopathy Center, Division of Cardiology, Tufts Medical Center, Boston, Massachusetts
| | - Iacopo Olivotto
- Regional Referral Center for Myocardial Disease, Azienda Ospedaliera Careggi, Florence, Italy
| | - Susan A Casey
- The Hypertrophic Cardiomyopathy Center, Minneapolis Heart Institute Foundation, Minneapolis, Minnesota
| | - Anna Arretini
- Regional Referral Center for Myocardial Disease, Azienda Ospedaliera Careggi, Florence, Italy
| | - Benedetta Tomberli
- Regional Referral Center for Myocardial Disease, Azienda Ospedaliera Careggi, Florence, Italy
| | - Ross F Garberich
- The Hypertrophic Cardiomyopathy Center, Minneapolis Heart Institute Foundation, Minneapolis, Minnesota
| | - Mark S Link
- Hypertrophic Cardiomyopathy Center, Division of Cardiology, Tufts Medical Center, Boston, Massachusetts
| | - Raymond H M Chan
- Department of Medicine (Cardiovascular Division) and Radiology, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts
| | - John R Lesser
- The Hypertrophic Cardiomyopathy Center, Minneapolis Heart Institute Foundation, Minneapolis, Minnesota
| | - Barry J Maron
- The Hypertrophic Cardiomyopathy Center, Minneapolis Heart Institute Foundation, Minneapolis, Minnesota
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Ebinger JE, Porten BR, Strauss CE, Garberich RF, Han C, Wahl SK, Sun BC, Abdelhadi RH, Henry TD. Design, Challenges, and Implications of Quality Improvement Projects Using the Electronic Medical Record: Case Study: A Protocol to Reduce the Burden of Postoperative Atrial Fibrillation. Circ Cardiovasc Qual Outcomes 2016; 9:593-9. [PMID: 27553597 DOI: 10.1161/circoutcomes.116.003122] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/18/2016] [Accepted: 07/20/2016] [Indexed: 11/16/2022]
Abstract
Postoperative atrial fibrillation (POAF) is a frequent complication of cardiac surgery, which results in increased morbidity, mortality, length of stay, and hospital costs. We developed and followed a process map to implement a protocol to decrease POAF: (1) identify stakeholders and form a working committee, (2) formal literature and guideline review, (3) retrospective analysis of current institutional data, (4) data modeling to determine expected effects of change, (4) protocol development and implementation into the electronic medical record, and (5) ongoing review of data and protocol adjustment. Retrospective analysis demonstrated that POAF occurred in 29.8% of all cardiovascular surgery cases. Median length of stay was 2 days longer (P<0.001), and median total variable costs $2495 higher (P<0.001) in POAF patients. Modeling predicted that up to 60 cases of POAF and >$200 000 annually could be saved. A clinically based electronic medical record tool was implemented into the electronic medical record to aid preoperative clinic providers in identifying patients eligible for prophylactic amiodarone. Initial results during the 9-month period after implementation demonstrated a reduction in POAF in patients using the protocol, compared with those who qualified but did not receive amiodarone and those not evaluated (11.1% versus 38.7% and 38.8%; P=0.022); however, only 17.3% of patients used the protocol. A standardized methodological approach to quality improvement and electronic medical record integration has potential to significantly decrease the incidence of POAF, length of stay, and total variable cost in patients undergoing elective coronary artery bypass graft and valve surgeries. This framework for quality improvement interventions may be adapted to similar clinical problems beyond POAF.
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Affiliation(s)
- Joseph E Ebinger
- From the Cedars-Sinai Heart Institute, Los Angeles, CA (J.E.E., T.D.H.); and Minneapolis Heart Institute Foundation, Abbott Northwestern Hospital, MN (B.R.P., C.E.S., R.F.G., C.H., S.K.W., B.C.S., R.H.A.)
| | - Brandon R Porten
- From the Cedars-Sinai Heart Institute, Los Angeles, CA (J.E.E., T.D.H.); and Minneapolis Heart Institute Foundation, Abbott Northwestern Hospital, MN (B.R.P., C.E.S., R.F.G., C.H., S.K.W., B.C.S., R.H.A.)
| | - Craig E Strauss
- From the Cedars-Sinai Heart Institute, Los Angeles, CA (J.E.E., T.D.H.); and Minneapolis Heart Institute Foundation, Abbott Northwestern Hospital, MN (B.R.P., C.E.S., R.F.G., C.H., S.K.W., B.C.S., R.H.A.)
| | - Ross F Garberich
- From the Cedars-Sinai Heart Institute, Los Angeles, CA (J.E.E., T.D.H.); and Minneapolis Heart Institute Foundation, Abbott Northwestern Hospital, MN (B.R.P., C.E.S., R.F.G., C.H., S.K.W., B.C.S., R.H.A.)
| | - Christopher Han
- From the Cedars-Sinai Heart Institute, Los Angeles, CA (J.E.E., T.D.H.); and Minneapolis Heart Institute Foundation, Abbott Northwestern Hospital, MN (B.R.P., C.E.S., R.F.G., C.H., S.K.W., B.C.S., R.H.A.)
| | - Sharon K Wahl
- From the Cedars-Sinai Heart Institute, Los Angeles, CA (J.E.E., T.D.H.); and Minneapolis Heart Institute Foundation, Abbott Northwestern Hospital, MN (B.R.P., C.E.S., R.F.G., C.H., S.K.W., B.C.S., R.H.A.)
| | - Benjamin C Sun
- From the Cedars-Sinai Heart Institute, Los Angeles, CA (J.E.E., T.D.H.); and Minneapolis Heart Institute Foundation, Abbott Northwestern Hospital, MN (B.R.P., C.E.S., R.F.G., C.H., S.K.W., B.C.S., R.H.A.)
| | - Raed H Abdelhadi
- From the Cedars-Sinai Heart Institute, Los Angeles, CA (J.E.E., T.D.H.); and Minneapolis Heart Institute Foundation, Abbott Northwestern Hospital, MN (B.R.P., C.E.S., R.F.G., C.H., S.K.W., B.C.S., R.H.A.)
| | - Timothy D Henry
- From the Cedars-Sinai Heart Institute, Los Angeles, CA (J.E.E., T.D.H.); and Minneapolis Heart Institute Foundation, Abbott Northwestern Hospital, MN (B.R.P., C.E.S., R.F.G., C.H., S.K.W., B.C.S., R.H.A.).
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VonAchen P, Hamann J, Houghland T, Lesser JR, Wang Y, Caye D, Rosenthal K, Garberich RF, Daniels M, Schwartz RS. Accessory renal arteries: Prevalence in resistant hypertension and an important role in nonresponse to radiofrequency renal denervation. Cardiovasc Revasc Med 2016; 17:470-473. [PMID: 27493150 DOI: 10.1016/j.carrev.2016.07.009] [Citation(s) in RCA: 8] [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] [Received: 06/05/2016] [Accepted: 07/18/2016] [Indexed: 10/21/2022]
Abstract
OBJECTIVE The aim of this study was to understand the role of accessory renal arteries in resistant hypertension, and to establish their role in nonresponse to radiofrequency renal denervation (RDN) procedures. BACKGROUND Prior studies suggest a role for accessory renal arteries in hypertensive syndromes, and recent clinical trials of renal denervation report that these anomalies are highly prevalent in resistant hypertension. This study evaluated the relationships among resistant hypertension, accessory renal arteries, and the response to radiofrequency (RF) renal denervation. METHODS Computed Tomography Angiography (CTA) and magnetic resonance imaging (MRI) scans from 58 patients with resistant hypertension undergoing RF renal denervation (RDN) were evaluated. Results were compared with CT scans in 57 healthy, normotensive subjects undergoing screening as possible renal transplant donors. All scans were carefully studied for accessory renal arteries, and were correlated with long term blood pressure reduction. RESULTS Accessory renal arteries were markedly more prevalent in the hypertensive patients than normotensive renal donors (59% vs 32% respectively, p=0.004). RDN had an overall nonresponse rate of 29% (response rate 71%). Patients without accessory vessels had a borderline higher response rate to RDN than those with at least one accessory vessel (83% vs 62% respectively, p=0.076) and a higher RDN response than patients with untreated accessory arteries (83% vs 55%; p=0.040). For accessory renal arteries and nonresponse, the sensitivity was 76%, specificity 49%, with positive and negative predictive values 38% and 83% respectively. CONCLUSIONS Accessory renal arteries were markedly over-represented in resistant hypertensives compared with healthy controls. While not all patients with accessory arteries were nonresponders, nonresponse was related to both the presence and non-treatment of accessory arteries. Addressing accessory renal arteries in future clinical trials may improve RDN therapeutic efficacy.
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Affiliation(s)
- Paige VonAchen
- Minneapolis Heart Institute and Foundation at Abbott Northwestern Hospital, Minneapolis, MN
| | | | - Thomas Houghland
- Minneapolis Heart Institute and Foundation at Abbott Northwestern Hospital, Minneapolis, MN
| | - John R Lesser
- Minneapolis Heart Institute and Foundation at Abbott Northwestern Hospital, Minneapolis, MN
| | - Yale Wang
- Minneapolis Heart Institute and Foundation at Abbott Northwestern Hospital, Minneapolis, MN
| | - David Caye
- Minneapolis Heart Institute and Foundation at Abbott Northwestern Hospital, Minneapolis, MN
| | - Kristi Rosenthal
- Minneapolis Heart Institute and Foundation at Abbott Northwestern Hospital, Minneapolis, MN
| | - Ross F Garberich
- Minneapolis Heart Institute and Foundation at Abbott Northwestern Hospital, Minneapolis, MN
| | | | - Robert S Schwartz
- Minneapolis Heart Institute and Foundation at Abbott Northwestern Hospital, Minneapolis, MN.
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Kalra A, Harris KM, Maron BA, Maron MS, Garberich RF, Haas TS, Lesser JR, Maron BJ. Relation of Doppler Tissue Imaging Parameters With Heart Failure Progression in Hypertrophic Cardiomyopathy. Am J Cardiol 2016; 117:1808-14. [PMID: 27089980 DOI: 10.1016/j.amjcard.2016.03.018] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/20/2016] [Revised: 03/11/2016] [Accepted: 03/11/2016] [Indexed: 11/27/2022]
Abstract
Refractory progressive heart failure (HF) is becoming the predominant cause of mortality in nonobstructive hypertrophic cardiomyopathy (HC). To anticipate development of this important and often unpredictable clinical course, we investigated whether left ventricular diastolic dysfunction, assessed by echocardiographic Doppler parameters, could identify a subset of patients with HC without obstruction at rest who would experience progression of HF. Diastolic function parameters, assessed by Doppler tissue imaging (DTI), mitral inflow, and pulmonary venous flow were measured in 274 consecutive adult patients with HC evaluated from 2003 to 2007. DTI and other diastolic and clinical/demographic parameters were measured against the composite end point of HF/death, heart transplantation, or progression to advanced New York Heart Association functional class III/IV symptoms and sudden death (SD)/implantable defibrillator (ICD) interventions. HF end points were reached in 19 of 274 patients (7%) over a follow-up period of 4.0 ± 2.3 years. Variables significantly associated with HF outcome by univariate analysis included male gender, initial New York Heart Association class II, lower ejection fraction, and reduced septal and lateral e' mitral annular tissue velocities. Multivariable analysis showed only a reduced lateral e' mitral annular tissue velocity to be independently associated with the composite HF end points (HR 0.77; 95% CI 0.65 to 0.91; p = 0.003). In addition, estimated pulmonary arterial systolic pressure and extensive late gadolinium enhancement by magnetic resonance were also associated with HF outcome (p = 0.04 and p <0.001, respectively). No Doppler (or clinical) variable was associated with SD/appropriate ICD interventions. In conclusion, in HC without outflow obstruction at rest, diastolic dysfunction, evidenced by DTI-reduced lateral e' mitral annular tissue velocity, was associated with adverse long-term HF outcome but was unrelated to SD. This echocardiographic marker provides a potential noninvasive strategy for anticipating progressive HF in this HC patient group.
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Maron BJ, Haas TS, Duncanson ER, Garberich RF, Baker AM, Mackey-Bojack S. Comparison of the Frequency of Sudden Cardiovascular Deaths in Young Competitive Athletes Versus Nonathletes: Should We Really Screen Only Athletes? Am J Cardiol 2016; 117:1339-41. [PMID: 26949036 DOI: 10.1016/j.amjcard.2016.01.026] [Citation(s) in RCA: 43] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/20/2015] [Revised: 01/18/2016] [Accepted: 01/18/2016] [Indexed: 11/25/2022]
Abstract
The issue of sudden death in young athletes and consideration for the most practical and optimal strategy to identify those genetic and/or congenital heart diseases responsible for these tragic events continues to be debated. However, proponents of broad-based and mandatory national preparticipation screening, including with 12-lead electrocardiograms have confined the focus to a relatively small segment of the youthful population who choose to engage in competitive athletic programs at the high school, college, and elite-professional level. Therefore, lost in this discussion of preparticipation screening of athletes is that the larger population of young people not involved in competitive sports (and, therefore, a priori are excluded from systematic screening) who nevertheless may die suddenly of the same cardiovascular diseases as athletes. To substantiate this hypothesis, we accessed the forensic Hennepin County, Minnesota registry in which cardiovascular sudden deaths were 8-fold more common in nonathletes (n = 24) than athletes (n = 3) and threefold more frequent in terms of incidence. The most common diseases responsible for sudden death were hypertrophic cardiomyopathy (n = 6) and arrhythmogenic right ventricular cardiomyopathy (n = 4). These data raise ethical considerations inherent in limiting systematic screening for unsuspected genetic and/or congenital heart disease to competitive athletes.
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Han CR, Strauss CE, Garberich RF, Chavez IJ, Henry TD, Poulose AK. Abstract 13: Real-time Decision Support and Physician Feedback Optimizes Use of Vascular Closure Devices in High Bleed Risk Patients Undergoing Percutaneous Coronary Intervention. Circ Cardiovasc Qual Outcomes 2016. [DOI: 10.1161/circoutcomes.9.suppl_2.13] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background:
Bleeding complications following Percutaneous Coronary Interventions (PCI) occur in 2-6% of cases. Designed to provide rapid hemostasis, vascular closure devices (VCDs) have been found to have the largest benefit in high bleed risk cases but are utilized less often in these patients. Decision support tools and real-time feedback may impact physician practice patterns and increase utilization of VCDs in cases with high bleed risk.
Methods:
In May 2012, a real-time decision support tool was introduced to prospectively evaluate PCI bleed risk and stratify patients into high, intermediate, and low bleeding risk based on a validated model using data from the National Cardiovascular Data Registry. In January 2014, a group goal of 50% utilization of VCDs in high-bleed risk patients was set and weekly reports to individual interventional cardiologists performing PCI were provided. Group and individual physician practice patterns before and after the goal and real-time feedback were assessed.
Results:
From May 2012 to August 2015, 5,285 patients received PCI, including 1,399 (26.5%) who were classified as high bleed risk. Prior to the group utilization goal and real-time feedback being implemented, VCD use in high bleed risk patients was 40.3% (292 of 725) and utilization by individual provider ranged from 7.4% (5 of 68) to 83.1% (103 of 124) of cases. After implementation of the group utilization goal and real-time feedback, 74.2% (500 of 674) high bleed risk received VCDs and utilization by individual provider ranged from 61.4% (43 of 70) to 87.9% (87 of 99) of cases. Therefore, the physician group saw a relative increase of 84.1% in VCD utilization (40.3% vs. 74.2%; p<0.001). Additionally, among individual providers, VCD use significantly increased for 7 of 8 physicians (see figure) and the group practice variation in use of VCDs decreased (standard deviation of VCD utilization across physicians decreased from 22.9% to 8.7%, p=0.021).
Conclusions:
Implementation of real-time feedback and clearly defined group goals for the use of VCDs in high bleed risk cases significantly increased VCD use in patients known to have the greatest benefit. These interventions also reduced the variation in care for high bleed risk patients.
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Affiliation(s)
| | | | | | - Ivan J Chavez
- Minneapolis Heart Institute Foundation, Minneapolis, MN
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Maron BJ, Rowin EJ, Casey SA, Lesser JR, Garberich RF, McGriff DM, Maron MS. Hypertrophic Cardiomyopathy in Children, Adolescents, and Young Adults Associated With Low Cardiovascular Mortality With Contemporary Management Strategies. Circulation 2016; 133:62-73. [DOI: 10.1161/circulationaha.115.017633] [Citation(s) in RCA: 109] [Impact Index Per Article: 13.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/21/2015] [Accepted: 10/16/2015] [Indexed: 01/08/2023]
Abstract
Background—
Youthful age has been considered the time of greatest risk for patients with hypertrophic cardiomyopathy (HCM), largely because of the possibility of sudden death. The last 2 decades have witnessed more reliable identification of at-risk patients and utilization of implantable cardioverter-defibrillators for prevention of sudden death, and other contemporary treatment options. Whether such management advances have significantly altered the considerable mortality rate for young HCM patients remains unresolved.
Methods and Results—
We studied long-term outcome in 474 consecutive HCM patients between 7 and 29 years of age presenting at 2 referral institutions. Over 7.1±5.1 years of follow-up (6.0 [3.0, 10.0]), 452 patients (95%) survived, with 95% experiencing no or mild symptoms. HCM-related death occurred in 18 patients (3%; 0.54%/y): arrhythmic sudden death (n=12), progressive heart failure and heart transplant complications (n=5), or postoperatively (n=1). In contrast, aborted life-threatening events occurred in 63 other high-risk patients (13%) with implantable cardioverter-defibrillator interventions for ventricular tachyarrhythmias (n=31), resuscitated out-of-hospital cardiac arrest (n=20), or heart transplant for advanced heart failure (n=12), 1.8%/y, 3-fold higher than HCM mortality. Five- and 10-year survival (considering only HCM deaths) was high (97% and 94%, respectively), virtually identical to that reported in middle-aged adult HCM patients (98% and 94%,
P
=0.23).
Conclusions—
In a large hospital-based cohort of young HCM patients, representing an age group considered at greatest risk, low mortality rates can be achieved with the application of contemporary cardiovascular treatment strategies, largely because of reliable identification of high-risk patients who benefited from implantable cardioverter-defibrillators for sudden death prevention, thereby creating the opportunity for extended longevity and good quality of life.
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Affiliation(s)
- Barry J. Maron
- From Hypertrophic Cardiomyopathy Center, Minneapolis Heart Institute Foundation, MN (B.J.M., S.A.C., J.R.L., R.F.G., D.M.M.); and Hypertrophic Cardiomyopathy Center, Tufts Medical Center, Boston MA (E.J.R., M.S.M.)
| | - Ethan J. Rowin
- From Hypertrophic Cardiomyopathy Center, Minneapolis Heart Institute Foundation, MN (B.J.M., S.A.C., J.R.L., R.F.G., D.M.M.); and Hypertrophic Cardiomyopathy Center, Tufts Medical Center, Boston MA (E.J.R., M.S.M.)
| | - Susan A. Casey
- From Hypertrophic Cardiomyopathy Center, Minneapolis Heart Institute Foundation, MN (B.J.M., S.A.C., J.R.L., R.F.G., D.M.M.); and Hypertrophic Cardiomyopathy Center, Tufts Medical Center, Boston MA (E.J.R., M.S.M.)
| | - John R. Lesser
- From Hypertrophic Cardiomyopathy Center, Minneapolis Heart Institute Foundation, MN (B.J.M., S.A.C., J.R.L., R.F.G., D.M.M.); and Hypertrophic Cardiomyopathy Center, Tufts Medical Center, Boston MA (E.J.R., M.S.M.)
| | - Ross F. Garberich
- From Hypertrophic Cardiomyopathy Center, Minneapolis Heart Institute Foundation, MN (B.J.M., S.A.C., J.R.L., R.F.G., D.M.M.); and Hypertrophic Cardiomyopathy Center, Tufts Medical Center, Boston MA (E.J.R., M.S.M.)
| | - Deepa M. McGriff
- From Hypertrophic Cardiomyopathy Center, Minneapolis Heart Institute Foundation, MN (B.J.M., S.A.C., J.R.L., R.F.G., D.M.M.); and Hypertrophic Cardiomyopathy Center, Tufts Medical Center, Boston MA (E.J.R., M.S.M.)
| | - Martin S. Maron
- From Hypertrophic Cardiomyopathy Center, Minneapolis Heart Institute Foundation, MN (B.J.M., S.A.C., J.R.L., R.F.G., D.M.M.); and Hypertrophic Cardiomyopathy Center, Tufts Medical Center, Boston MA (E.J.R., M.S.M.)
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Johnson BK, Garberich RF, Henry TD, Katsiyiannis WT, Sengupta J, Kalra A, Hauser RG, Lardy ME, Newell MC. Eligibility and utilization of implantable cardioverter-defibrillators in a regional STEMI system. Heart Rhythm 2015; 13:538-46. [PMID: 26576706 DOI: 10.1016/j.hrthm.2015.10.019] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/06/2015] [Indexed: 10/22/2022]
Abstract
BACKGROUND Studies have shown mortality benefit for implantable cardioverter-defibrillators (ICDs) in ST-elevation myocardial infarction (STEMI) patients with reduced left ventricular ejection fraction (LVEF), but contemporary eligibility and appropriate utilization of ICDs is unknown. OBJECTIVE The purpose of this study was to determine the contemporary eligibility and appropriate utilization of ICDs post-STEMI. METHODS Using the prospective Minneapolis Heart Institute regional STEMI registry, LVEF before discharge and at follow-up were stratified into 3 groups: normal (LVEF ≥50%), mildly reduced (LVEF 35%-49%), and severely reduced (LVEF <35%). RESULTS From March 2003 to June 2012, 3626 patients were treated. Patients with in-hospital death (n = 187), ICD in place (n = 21), negative cardiac biomarkers (n = 337), and undocumented in-hospital LVEF (n = 9) were excluded, leaving 3072 patients in the final analysis, including 1833 (59.7%) with LVEF ≥50%, 875 (28.5%) with LVEF between 35% and 49%, and 364 (11.8%) with LVEF <35% before hospital discharge. Overall, 1029 patients (33.5%) underwent follow-up echocardiography ≥40 days post-STEMI, including 140 of the 364 patients (38.5%) discharged with LVEF <35%. In total, 73 patients (7.1%) with follow-up echocardiography ≥40 days post-STEMI met criteria for an ICD (68 LVEF ≤30%, 5 LVEF 30%-35%, and New York Heart Association class II or greater). Only 26 of these patients (35.6%) underwent ICD placement within 1 year post-STEMI. Overall, only 10% to 15% of potentially eligible patients had an ICD implemented. CONCLUSION Rates of ICD implantation in appropriate STEMI patients after 40 days are low. Strategies are needed to identify and expand access to these high-risk patients.
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Affiliation(s)
- Benjamin K Johnson
- Minneapolis Heart Institute Foundation at Abbott Northwestern Hospital, Minneapolis, Minnesota; Hennepin County Medical Center, Minneapolis, Minnesota
| | - Ross F Garberich
- Minneapolis Heart Institute Foundation at Abbott Northwestern Hospital, Minneapolis, Minnesota
| | - Timothy D Henry
- Minneapolis Heart Institute Foundation at Abbott Northwestern Hospital, Minneapolis, Minnesota; Cedars-Sinai Heart Institute, Los Angeles, California
| | - William T Katsiyiannis
- Minneapolis Heart Institute Foundation at Abbott Northwestern Hospital, Minneapolis, Minnesota
| | - Jay Sengupta
- Minneapolis Heart Institute Foundation at Abbott Northwestern Hospital, Minneapolis, Minnesota
| | - Ankur Kalra
- Minneapolis Heart Institute Foundation at Abbott Northwestern Hospital, Minneapolis, Minnesota
| | - Robert G Hauser
- Minneapolis Heart Institute Foundation at Abbott Northwestern Hospital, Minneapolis, Minnesota
| | - Meghan E Lardy
- Minneapolis Heart Institute Foundation at Abbott Northwestern Hospital, Minneapolis, Minnesota
| | - Marc C Newell
- Minneapolis Heart Institute Foundation at Abbott Northwestern Hospital, Minneapolis, Minnesota.
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42
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Skeik N, Soo-Hoo SS, Porten BR, Graber J, Alden P, Cragg A, Alexander JQ, Rizvi A, Manunga JM, Garberich RF, Sullivan T. Arterial Embolisms and Thrombosis in Upper Extremity Ischemia. Vasc Endovascular Surg 2015; 49:100-9. [DOI: 10.1177/1538574415596740] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/28/2023]
Abstract
Objective: Upper extremity ischemia (UEI) is an uncommon condition that can lead to permanent disability. There is a limited understanding of the etiology, management, and outcomes of the disease. Methods: We retrospectively reviewed the charts of all patients who were diagnosed with “embolism and/or thrombosis of arteries of upper extremity” at our institution from January 2005 to December 2013. Results: Patients diagnosed with embolisms were older ( P < .001), more likely to undergo thromboembolectomy ( P < .001), had higher rates of hypertension ( P = .001), and had longer lengths of hospital stay ( P = .002). There were no significant differences in complications or mortality at 30 days and up to 1 year. Conclusion: At our center, embolism was found to be the most common etiology for UEI followed by thrombosis and stenosis. Patients presented with embolism were older, were more likely to undergo thromboembolectomy, and had higher rates of hypertension and longer hospital stays.
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Affiliation(s)
- Nedaa Skeik
- Vascular Medicine, Minneapolis Heart Institute, Minneapolis, MN, USA
| | | | | | - John Graber
- Vascular Surgery Department, Abbott Northwestern Hospital, Minneapolis, MN, USA
| | - Peter Alden
- Vascular Surgery Department, Abbott Northwestern Hospital, Minneapolis, MN, USA
| | - Andrew Cragg
- Vascular Surgery Department, Abbott Northwestern Hospital, Minneapolis, MN, USA
- Interventional Radiology, Minneapolis Heart Institute
| | - Jason Q. Alexander
- Vascular Surgery Department, Abbott Northwestern Hospital, Minneapolis, MN, USA
| | - Adnan Rizvi
- Vascular Surgery Department, Abbott Northwestern Hospital, Minneapolis, MN, USA
| | - Jesse M. Manunga
- Vascular Surgery Department, Abbott Northwestern Hospital, Minneapolis, MN, USA
| | | | - Timothy Sullivan
- Vascular Surgery Department, Abbott Northwestern Hospital, Minneapolis, MN, USA
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43
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Sharkey SW, Pink VR, Lesser JR, Garberich RF, Maron MS, Maron BJ. Clinical Profile of Patients With High-Risk Tako-Tsubo Cardiomyopathy. Am J Cardiol 2015; 116:765-72. [PMID: 26144453 DOI: 10.1016/j.amjcard.2015.05.054] [Citation(s) in RCA: 42] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/28/2015] [Revised: 05/20/2015] [Accepted: 05/20/2015] [Indexed: 01/27/2023]
Abstract
Although tako-tsubo cardiomyopathy (TTC) is regarded as a reversible condition with favorable outcome, a malignant clinical course evolves in some subjects. In this single-institution experience, we describe the clinical profile of patients with adverse TTC outcome. A cohort of 249 consecutive patients with TTC was interrogated for those with acute unstable presentation during the first 24 hours. Forty-seven patients (19%) experienced early complicated clinical course with cardiac arrest in 9 (ventricular fibrillation, n = 4, pulseless electrical activity, n = 3, and asystole, n = 2) or marked hypotension in 38 (systolic blood pressure ≤90 mm Hg requiring vasopressors and/or balloon pump). Of the 47 patients, Killip class III to IV heart failure was present in 30 (64%). Despite treatment, 8 patients (3%; all women) died inhospital due to respiratory failure, cardiogenic shock, or anoxic brain injury. All 8 inhospital deaths occurred among the 47 patients with unstable presentation, including 2 after cardiac arrest and 6 with marked hypotension. Post-TTC event mortality for a period of 4.7 ± 3.4 years significantly exceeded that in a matched general US population (standardized mortality ratio 1.4; 95% confidence interval 1.1 to 1.9; p = 0.005) largely due to noncardiac co-morbidities. In conclusion, contrary to widespread perception, TTC is not an entirely benign and reversible condition. Among this large cohort, a high-risk subgroup was identified with cardiac arrest or hemodynamic instability, accounting for all hospital deaths. Hospital nonsurvivors had a variety of irreversible co-morbid conditions with the potential to compromise clinical status and adversely affect short-term survival. Long-term survival after hospital discharge was also reduced compared with the general population because of noncardiac co-morbidities.
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44
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Handran CB, Garberich RF, Lesser JR, Henry TD, Gilmore M, Schwartz RB. The Left Main Bifurcation Angle and Changes Throughout the Cardiac Cycle: Quantitative Implications for Left Main Bifurcation Stenting and Stents. J Invasive Cardiol 2015; 27:401-404. [PMID: 25999137] [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: 06/04/2023]
Abstract
OBJECTIVE The objective of this study was to quantify the left main (LM) bifurcation angles and their changes throughout the cardiac cycle. BACKGROUND LM stenting is an accepted alternative to coronary artery bypass grafting. However, the LM bifurcation has great anatomic variability. Three-dimensional angles and their cyclic changes are important for coronary stenting. METHODS Patients undergoing coronary computed tomography angiography (CCTA) for chest pain were scanned and analyzed in three-dimensional views for left main-left anterior descending (LM-LAD), left main-left circumflex (LM-LCX), and left anterior descending-left circumflex (LAD-LCX) angles and their cyclic changes. Calculations and assessment of angles, angular variability, and how these angles change throughout the cardiac cycle were analyzed. RESULTS Forty-four patient scans were analyzed. The median end-diastolic LM-LCX angle was 130° and the LAD-LCX was 74°. Median end-systolic angle for the LM-LCX was 133°, and LAD-LCX was 69°. Large differences were found across all three absolute angles (LM-LCX, LAD-LCX, LM-LAD). Marked variability also occurred in how these angles changed throughout the cardiac cycle. CONCLUSIONS LM bifurcation geometry in patients shows marked absolute angle variability, as does diastolic-systolic angle movement. LM bifurcation stents should accommodate wide interpatient bifurcation angles at rest for both the LM-LAD and LM-LCX angles.
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Affiliation(s)
| | | | | | | | | | - Robert B Schwartz
- Minneapolis Heart Institute Foundation at Abbott Northwestern Hospital, 920 East 28th Street, Suite 620, Minneapolis, MN 55407 USA.
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45
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Maron BJ, Casey SA, Chan RH, Garberich RF, Rowin EJ, Maron MS. Independent Assessment of the European Society of Cardiology Sudden Death Risk Model for Hypertrophic Cardiomyopathy. Am J Cardiol 2015; 116:757-64. [PMID: 26183790 DOI: 10.1016/j.amjcard.2015.05.047] [Citation(s) in RCA: 129] [Impact Index Per Article: 14.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/11/2015] [Revised: 05/20/2015] [Accepted: 05/20/2015] [Indexed: 10/23/2022]
Abstract
Risk stratification for sudden death (SD) is an essential component of hypertrophic cardiomyopathy (HC) management, given the proven effectiveness of implantable cardioverter-defibrillators (ICD) for preventing SD. Although highly effective in identifying high-risk patients, current stratification algorithms remain incomplete and novel strategies are encouraged. In this regard, reliability of the statistical model to predict SD risk in HC, as recommended by the recent European Society of Cardiology (ESC) guidelines, was retrospectively tested in an independent cohort of 1,629 consecutive patients with HC aged ≥16 years. Of the 1,629 patients, 35 incurred SD events, but only 4 of these (11%) had high predictive risk scores >6%/5 years consistent with an ICD recommendation, and most (60%; n = 21) had scores <4%/5 years that would not justify ICDs. Of 46 high-risk patients with appropriate ICD interventions for ventricular fibrillation/tachycardia, 27 (59%) had low SD risk scores of <4%/5 years, regarded by ESC as insufficient to recommend ICDs, and only 12 (26%) had scores >6%/5 years, considered an ICD indication; 11 of these 12 had already met conventional criteria warranting implantation with 2 to 3 risk markers. Of 414 patients with ICDs but without appropriate interventions, 258 (62%) had low risk scores (<4%/5 years) that would argue against implant. In conclusion, primary risk stratification using the ESC prognostic score applied retrospectively to a large independent HC cohort proved unreliable for prediction of future SD events. Most patients with HC with SD or appropriate ICD interventions were misclassified with low risk scores and therefore would have remained unprotected from arrhythmic SD without ICDs.
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Maron BJ, Rowin EJ, Casey SA, Link MS, Lesser JR, Chan RHM, Garberich RF, Udelson JE, Maron MS. Hypertrophic Cardiomyopathy in Adulthood Associated With Low Cardiovascular Mortality With Contemporary Management Strategies. J Am Coll Cardiol 2015; 65:1915-28. [PMID: 25953744 DOI: 10.1016/j.jacc.2015.02.061] [Citation(s) in RCA: 219] [Impact Index Per Article: 24.3] [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: 01/14/2015] [Revised: 02/20/2015] [Accepted: 02/23/2015] [Indexed: 01/12/2023]
Abstract
BACKGROUND Hypertrophic cardiomyopathy (HCM) has been prominently associated with adverse disease complications, including sudden death or heart failure death and a generally adverse prognosis, with annual mortality rates of up to 6%. OBJECTIVES This study determined whether recent advances in management strategy, including implantable cardioverter-defibrillators (ICDs), heart transplantation, or other therapeutic measures have significantly improved survival and the clinical course of adult HCM patients. METHODS We addressed long-term outcomes in 1,000 consecutive adult HCM patients presenting at 30 to 59 years of age (mean 45±8 years) over 7.2±5.2 years of follow-up. RESULTS Of 1,000 patients, 918 (92%) survived to 53±9.2 years of age (range 32 to 80 years) with 91% experiencing no or only mild symptoms at last evaluation. HCM-related death occurred in 40 patients (4% [0.53%/year]) at 50±10 years from the following events: progressive heart failure (n=17); arrhythmic sudden death (SD) (n=17); and embolic stroke (n=2). In contrast, 56 other high-risk patients (5.6%) survived life-threatening events, most commonly with ICD interventions for ventricular tachyarrhythmias (n=33) or heart transplantation for advanced heart failure (n=18 [0.79%/year]). SD occurred in patients who declined ICD recommendations, had evaluations before application of prophylactic ICDs to HCM, or were without conventional risk factors. The 5- and 10-year survival rates (confined to HCM deaths) were 98% and 94%, respectively, not different from the expected all-cause mortality in the general U.S. population (p=0.25). Multivariate independent predictors of adverse outcome were younger age at diagnosis, female sex, and increased left atrial dimension. CONCLUSIONS In a large longitudinally assessed adult HCM cohort, we have demonstrated that contemporary management strategies and treatment interventions, including ICDs for SD prevention, have significantly altered the clinical course, now resulting in a low disease-related mortality rate of 0.5%/year and an opportunity for extended longevity.
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Affiliation(s)
- Barry J Maron
- Hypertrophic Cardiomyopathy Center, Minneapolis Heart Institute Foundation, Minneapolis, Minnesota.
| | - Ethan J Rowin
- Hypertrophic Cardiomyopathy Center, Tufts Medical Center, Boston, Massachusetts
| | - Susan A Casey
- Hypertrophic Cardiomyopathy Center, Minneapolis Heart Institute Foundation, Minneapolis, Minnesota
| | - Mark S Link
- Hypertrophic Cardiomyopathy Center, Tufts Medical Center, Boston, Massachusetts
| | - John R Lesser
- Hypertrophic Cardiomyopathy Center, Minneapolis Heart Institute Foundation, Minneapolis, Minnesota
| | - Raymond H M Chan
- Hypertrophic Cardiomyopathy Center, Tufts Medical Center, Boston, Massachusetts
| | - Ross F Garberich
- Hypertrophic Cardiomyopathy Center, Minneapolis Heart Institute Foundation, Minneapolis, Minnesota
| | - James E Udelson
- Hypertrophic Cardiomyopathy Center, Tufts Medical Center, Boston, Massachusetts
| | - Martin S Maron
- Hypertrophic Cardiomyopathy Center, Tufts Medical Center, Boston, Massachusetts
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Garberich RF, Traverse JH, Claussen MT, Rodriguez G, Poulose AK, Chavez IJ, Rutten-Ramos S, Hildebrandt DA, Henry TD. Response to letter regarding article, "ST-elevation myocardial infarction diagnosed after hospital admission". Circulation 2015; 131:e7. [PMID: 25561481 DOI: 10.1161/circulationaha.114.012786] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Affiliation(s)
| | | | | | | | | | - Ivan J Chavez
- Minneapolis Heart Institute Foundation, Minneapolis, MN
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48
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Shah RU, Henry TD, Rutten-Ramos S, Garberich RF, Tighiouart M, Bairey Merz CN. Increasing Percutaneous Coronary Interventions for ST-Segment Elevation Myocardial Infarction in the United States. JACC Cardiovasc Interv 2015; 8:139-146. [DOI: 10.1016/j.jcin.2014.07.017] [Citation(s) in RCA: 41] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/09/2014] [Accepted: 07/02/2014] [Indexed: 01/18/2023]
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49
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Stark MM, Schwartz RS, Satran D, Lesser JR, Sharkey SW, Garberich RF, Solie CJ, Longe TF, Flygenring BP, Lin D, Larson DM, Henry TD. "No culprit" ST-elevation myocardial infarction: role of cardiac magnetic resonance imaging. Crit Pathw Cardiol 2014; 13:135-140. [PMID: 25396289 DOI: 10.1097/hpc.0000000000000023] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/04/2023]
Abstract
Patients with presumed ST-elevation myocardial infarction (STEMI) have no clear culprit artery in approximately 10-15% of cases. We examined the value of cardiac magnetic resonance (CMR) for diagnosis in patients with "no culprit" STEMI. Data from a comprehensive prospective registry of STEMI patients were reviewed from March 2003 to December 2009. "No culprit" patients were followed for diagnosis and clinical outcome. CMR was performed at the discretion of the attending cardiologist. Of 2728 consecutive presumed STEMI patients, 412 (15%) had no clear culprit artery. Of these, 202 (49%) had abnormal cardiac biomarkers with a definitive diagnosis in 157 (78%). Diagnoses in this group included myocardial infarction without a culprit lesion (24%), myopericarditis (22%), and stress cardiomyopathy (21%). In 210 (51%) patients with normal biomarkers, only 84 (40%) received a definitive diagnosis. Diagnoses in this group included myopericarditis (27%), noncardiac causes (21%), and cardiomyopathy (14%). CMR was performed in 123 (30%) "no culprit" patients. Patients who had CMR were more likely to have a definitive diagnosis than those who did not (95/123 [77%] vs. 144/289 [50%]; P=0.01). In particular, "no culprit" patients with abnormal biomarkers were more likely to have a definitive diagnosis with CMR. CMR led to a diagnosis different from the presumptive clinical diagnosis in 53% of all cases. CMR is a valuable diagnostic tool to improve diagnostic accuracy in patients with "no culprit" STEMI.
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Affiliation(s)
- Madeline M Stark
- From the *Minneapolis Heart Institute Foundation, Abbott Northwestern Hospital, Minneapolis, MN; †Park Nicollet Heart and Vascular Center, St. Louis Park, MN; and ‡Cedars-Sinai Heart Institute, Los Angeles, CA
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50
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Thorsgard ME, Morrissette GJ, Sun B, Eales F, Kshettry V, Flavin T, Tyberg R, Garberich RF, Harris KM. Impact of Intraoperative Transesophageal Echocardiography on Acute Type-A Aortic Dissection. J Cardiothorac Vasc Anesth 2014; 28:1203-7. [DOI: 10.1053/j.jvca.2014.05.012] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/20/2014] [Indexed: 11/11/2022]
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