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Shiyovich A, Berman AN, Besser SA, Biery DW, Kaur G, Divakaran S, Singh A, Huck DM, Weber B, Plutzky J, Di Carli MF, Nasir K, Cannon C, Januzzi JL, Bhatt DL, Blankstein R. Association of Lipoprotein (a) and Standard Modifiable Cardiovascular Risk Factors With Incident Myocardial Infarction: The Mass General Brigham Lp(a) Registry. J Am Heart Assoc 2024; 13:e034493. [PMID: 38761082 DOI: 10.1161/jaha.123.034493] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/23/2024] [Accepted: 03/29/2024] [Indexed: 05/20/2024]
Abstract
BACKGROUND Lipoprotein (a) [Lp(a)] is a robust predictor of coronary heart disease outcomes, with targeted therapies currently under investigation. We aimed to evaluate the association of high Lp(a) with standard modifiable risk factors (SMuRFs) for incident first acute myocardial infarction (AMI). METHODS AND RESULTS This retrospective study used the Mass General Brigham Lp(a) Registry, which included patients aged ≥18 years with an Lp(a) measurement between 2000 and 2019. Exclusion criteria were severe kidney dysfunction, malignant neoplasm, and prior known atherosclerotic cardiovascular disease. Diabetes, dyslipidemia, hypertension, and smoking were considered SMuRFs. High Lp(a) was defined as >90th percentile, and low Lp(a) was defined as <50th percentile. The primary outcome was fatal or nonfatal AMI. A combination of natural language processing algorithms, International Classification of Diseases (ICD) codes, and laboratory data was used to identify the outcome and covariates. A total of 6238 patients met the eligibility criteria. The median age was 54 (interquartile range, 43-65) years, and 45% were women. Overall, 23.7% had no SMuRFs, and 17.8% had ≥3 SMuRFs. Over a median follow-up of 8.8 (interquartile range, 4.2-12.8) years, the incidence of AMI increased gradually, with higher number of SMuRFs among patients with high (log-rank P=0.031) and low Lp(a) (log-rank P<0.001). Across all SMuRF subgroups, the incidence of AMI was significantly higher for patients with high Lp(a) versus low Lp(a). The risk of high Lp(a) was similar to having 2 SMuRFs. Following adjustment for confounders and number of SMuRFs, high Lp(a) remained significantly associated with the primary outcome (hazard ratio, 2.9 [95% CI, 2.0-4.3]; P<0.001). CONCLUSIONS Among patients with no prior atherosclerotic cardiovascular disease, high Lp(a) is associated with significantly higher risk for first AMI regardless of the number of SMuRFs.
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Affiliation(s)
- Arthur Shiyovich
- Division of Cardiovascular Medicine, Department of Medicine Brigham and Women's Hospital, Harvard Medical School Boston MA
- Department of Radiology Brigham and Women's Hospital, Harvard Medical School Boston MA
| | - Adam N Berman
- Division of Cardiovascular Medicine, Department of Medicine Brigham and Women's Hospital, Harvard Medical School Boston MA
| | - Stephanie A Besser
- Division of Cardiovascular Medicine, Department of Medicine Brigham and Women's Hospital, Harvard Medical School Boston MA
| | - David W Biery
- Division of Cardiovascular Medicine, Department of Medicine Brigham and Women's Hospital, Harvard Medical School Boston MA
| | - Gurleen Kaur
- Department of Medicine Brigham and Women's Hospital, Harvard Medical School Boston MA
| | - Sanjay Divakaran
- Division of Cardiovascular Medicine, Department of Medicine Brigham and Women's Hospital, Harvard Medical School Boston MA
- Department of Radiology Brigham and Women's Hospital, Harvard Medical School Boston MA
| | - Avinainder Singh
- Division of Cardiovascular Medicine, Department of Medicine Brigham and Women's Hospital, Harvard Medical School Boston MA
| | - Daniel M Huck
- Division of Cardiovascular Medicine, Department of Medicine Brigham and Women's Hospital, Harvard Medical School Boston MA
- Department of Radiology Brigham and Women's Hospital, Harvard Medical School Boston MA
| | - Brittany Weber
- Division of Cardiovascular Medicine, Department of Medicine Brigham and Women's Hospital, Harvard Medical School Boston MA
| | - Jorge Plutzky
- Division of Cardiovascular Medicine, Department of Medicine Brigham and Women's Hospital, Harvard Medical School Boston MA
| | - Marcelo F Di Carli
- Division of Cardiovascular Medicine, Department of Medicine Brigham and Women's Hospital, Harvard Medical School Boston MA
- Department of Radiology Brigham and Women's Hospital, Harvard Medical School Boston MA
| | - Khurram Nasir
- Division of Cardiovascular Prevention and Wellness, Department of Cardiovascular Medicine Houston Methodist DeBakey Heart and Vascular Center Houston TX
| | - Christopher Cannon
- Division of Cardiovascular Medicine, Department of Medicine Brigham and Women's Hospital, Harvard Medical School Boston MA
| | - James L Januzzi
- Cardiology Division Massachusetts General Hospital, Harvard Medical School, Baim Institute for Clinical Research Boston MA
| | - Deepak L Bhatt
- Division of Cardiovascular Medicine, Department of Medicine Brigham and Women's Hospital, Harvard Medical School Boston MA
- Mount Sinai Heart Icahn School of Medicine at Mount Sinai Health System New York NY
| | - Ron Blankstein
- Division of Cardiovascular Medicine, Department of Medicine Brigham and Women's Hospital, Harvard Medical School Boston MA
- Department of Radiology Brigham and Women's Hospital, Harvard Medical School Boston MA
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Berman AN, Shiyovich A, Biery DW, Cardoso RN, Weber BN, Petranovic M, Besser SA, Hainer J, Wasfy JH, Turchin A, Di Carli MF, Blankstein R, Huck DM. Natural language processing to phenotype coronary computed tomography angiography: Development, validation, and initial results of a large multi-institution cohort. J Cardiovasc Comput Tomogr 2024:S1934-5925(24)00062-5. [PMID: 38458851 DOI: 10.1016/j.jcct.2024.03.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/20/2024] [Revised: 02/27/2024] [Accepted: 03/01/2024] [Indexed: 03/10/2024]
Affiliation(s)
- Adam N Berman
- Division of Cardiovascular Medicine, Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Arthur Shiyovich
- Division of Cardiovascular Medicine, Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - David W Biery
- Division of Cardiovascular Medicine, Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Rhanderson N Cardoso
- Division of Cardiovascular Medicine, Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Brittany N Weber
- Division of Cardiovascular Medicine, Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Milena Petranovic
- Department of Radiology, Division of Thoracic Imaging and Intervention, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Stephanie A Besser
- Division of Cardiovascular Medicine, Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Jon Hainer
- Department of Radiology, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Jason H Wasfy
- Cardiology Division, Department of Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Alexander Turchin
- Division of Endocrinology, Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Marcelo F Di Carli
- Division of Cardiovascular Medicine, Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA; Department of Radiology, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Ron Blankstein
- Division of Cardiovascular Medicine, Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA; Department of Radiology, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Daniel M Huck
- Division of Cardiovascular Medicine, Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA; Department of Radiology, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA.
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3
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Berman AN, Biery DW, Besser SA, Singh A, Shiyovich A, Weber BN, Huck DM, Divakaran S, Hainer J, Kaur G, Blaha MJ, Cannon CP, Plutzky J, Januzzi JL, Booth JN, López JAG, Kent ST, Nasir K, Di Carli MF, Bhatt DL, Blankstein R. Lipoprotein(a) and Major Adverse Cardiovascular Events in Patients With or Without Baseline Atherosclerotic Cardiovascular Disease. J Am Coll Cardiol 2024; 83:873-886. [PMID: 38418000 DOI: 10.1016/j.jacc.2023.12.031] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/19/2023] [Revised: 12/14/2023] [Accepted: 12/22/2023] [Indexed: 03/01/2024]
Abstract
BACKGROUND Lipoprotein(a) [Lp(a)] is associated with an increased risk of atherosclerotic cardiovascular disease (ASCVD). However, whether the optimal Lp(a) threshold for risk assessment should differ based on baseline ASCVD status is unknown. OBJECTIVES The purpose of this study was to assess the association between Lp(a) and major adverse cardiovascular events (MACE) among patients with and without baseline ASCVD. METHODS We studied a retrospective cohort of patients with Lp(a) measured at 2 medical centers in Boston, Massachusetts, from 2000 to 2019. To assess the association of Lp(a) with incident MACE (nonfatal myocardial infarction [MI], nonfatal stroke, coronary revascularization, or cardiovascular mortality), Lp(a) percentile groups were generated with the reference group set at the first to 50th Lp(a) percentiles. Cox proportional hazards modeling was used to assess the association of Lp(a) percentile group with MACE. RESULTS Overall, 16,419 individuals were analyzed with a median follow-up of 11.9 years. Among the 10,181 (62%) patients with baseline ASCVD, individuals in the 71st to 90th percentile group had a 21% increased hazard of MACE (adjusted HR: 1.21; P < 0.001), which was similar to that of individuals in the 91st to 100th group (adjusted HR: 1.26; P < 0.001). Among the 6,238 individuals without established ASCVD, there was a continuously higher hazard of MACE with increasing Lp(a), and individuals in the 91st to 100th Lp(a) percentile group had the highest relative risk with an adjusted HR of 1.93 (P < 0.001). CONCLUSIONS In a large, contemporary U.S. cohort, elevated Lp(a) is independently associated with long-term MACE among individuals with and without baseline ASCVD. Our results suggest that the threshold for risk assessment may be different in primary vs secondary prevention cohorts.
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Affiliation(s)
- Adam N Berman
- Division of Cardiovascular Medicine, Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA. https://twitter.com/adambermanMD
| | - David W Biery
- Division of Cardiovascular Medicine, Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Stephanie A Besser
- Division of Cardiovascular Medicine, Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Avinainder Singh
- Division of Cardiovascular Medicine, Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Arthur Shiyovich
- Division of Cardiovascular Medicine, Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Brittany N Weber
- Division of Cardiovascular Medicine, Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Daniel M Huck
- Division of Cardiovascular Medicine, Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Sanjay Divakaran
- Division of Cardiovascular Medicine, Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Jon Hainer
- Department of Radiology, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Gurleen Kaur
- Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Michael J Blaha
- Johns Hopkins Ciccarone Center for the Prevention of Heart Disease, Baltimore, Maryland, USA
| | - Christopher P Cannon
- Division of Cardiovascular Medicine, Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Jorge Plutzky
- Division of Cardiovascular Medicine, Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - James L Januzzi
- Cardiology Division, Massachusetts General Hospital, Harvard Medical School, Baim Institute for Clinical Research, Boston, Massachusetts, USA
| | - John N Booth
- Center for Observational Research, Amgen Inc, Thousand Oaks, California, USA
| | | | - Shia T Kent
- Center for Observational Research, Amgen Inc, Thousand Oaks, California, USA
| | - Khurram Nasir
- Department of Cardiovascular Medicine, Division of Cardiovascular Prevention and Wellness, Houston Methodist DeBakey Heart and Vascular Center, Houston, Texas, USA
| | - Marcelo F Di Carli
- Division of Cardiovascular Medicine, Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA; Department of Radiology, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Deepak L Bhatt
- Mount Sinai Fuster Heart Hospital, Icahn School of Medicine at Mount Sinai Health System, New York, New York, USA. https://twitter.com/DLBHATTMD
| | - Ron Blankstein
- Division of Cardiovascular Medicine, Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA; Department of Radiology, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA.
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Cardoso R, Choi AD, Shiyovich A, Besser SA, Min JK, Earls J, Andreini D, Al-Mallah MH, Budoff MJ, Cademartiri F, Chinnaiyan K, Choi JH, Chun EJ, Conte E, Gottlieb I, Hadamitzky M, Kim YJ, Lee BK, Leipsic JA, Maffei E, Marques H, de Araújo Gonçalves P, Pontone G, Lee SE, Sung JM, Virmani R, Samady H, Lin FY, Stone PH, Berman DS, Narula J, Shaw LJ, Bax JJ, Chang HJ, Blankstein R. How early can atherosclerosis be detected by coronary CT angiography? Insights from quantitative CT analysis of serial scans in the PARADIGM trial. J Cardiovasc Comput Tomogr 2023; 17:407-412. [PMID: 37798157 DOI: 10.1016/j.jcct.2023.08.012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/22/2023] [Revised: 07/20/2023] [Accepted: 08/21/2023] [Indexed: 10/07/2023]
Abstract
BACKGROUND Non-obstructing small coronary plaques may not be well recognized by expert readers during coronary computed tomography angiography (CCTA) evaluation. Recent developments in atherosclerosis imaging quantitative computed tomography (AI-QCT) enabled by machine learning allow for whole-heart coronary phenotyping of atherosclerosis, but its diagnostic role for detection of small plaques on CCTA is unknown. METHODS We performed AI-QCT in patients who underwent serial CCTA in the multinational PARADIGM study. AI-QCT results were verified by a level III experienced reader, who was blinded to baseline and follow-up status of CCTA. This retrospective analysis aimed to characterize small plaques on baseline CCTA and evaluate their serial changes on follow-up imaging. Small plaques were defined as a total plaque volume <50 mm3. RESULTS A total of 99 patients with 502 small plaques were included. The median total plaque volume was 6.8 mm3 (IQR 3.5-13.9 mm3), most of which was non-calcified (median 6.2 mm3; 2.9-12.3 mm3). The median age at the time of baseline CCTA was 61 years old and 63% were male. The mean interscan period was 3.8 ± 1.6 years. On follow-up CCTA, 437 (87%) plaques were present at the same location as small plaques on baseline CCTA; 72% were larger and 15% decreased in volume. The median total plaque volume and non-calcified plaque volume increased to 18.9 mm3 (IQR 8.3-45.2 mm3) and 13.8 mm3 (IQR 5.7-33.4 mm3), respectively, among plaques that persisted on follow-up CCTA. Small plaques no longer visualized on follow-up CCTA were significantly more likely to be of lower volume, shorter in length, non-calcified, and more distal in the coronary artery, as compared with plaques that persisted at follow-up. CONCLUSION In this retrospective analysis from the PARADIGM study, small plaques (<50 mm3) identified by AI-QCT persisted at the same location and were often larger on follow-up CCTA.
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Affiliation(s)
- Rhanderson Cardoso
- Division of Cardiovascular Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA.
| | - Andrew D Choi
- Department of Cardiology, The George Washington University School of Medicine, Washington, DC, USA
| | - Arthur Shiyovich
- Division of Cardiovascular Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Stephanie A Besser
- Division of Cardiovascular Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | | | | | - Daniele Andreini
- Division of Cardiology and Cardiac Imaging, IRCCS Ospedale Galeazzi Sant'Ambrogio, Milan, Italy; Department of Biomedical and Clinical Sciences, University of Milan, Milan, Italy
| | - Mouaz H Al-Mallah
- Houston Methodist DeBakey Heart & Vascular Center, Houston Methodist Hospital, Houston, TX, USA
| | - Matthew J Budoff
- Department of Medicine, Lundquist Institute at Harbor-UCLA, Torrance, CA, USA
| | | | | | | | - Eun Ju Chun
- Seoul National University Bundang Hospital, Sungnam, South Korea
| | | | - Ilan Gottlieb
- Department of Radiology, Casa de Saude Sao Jose, Rio de Janeiro, Brazil
| | - Martin Hadamitzky
- Department of Radiology and Nuclear Medicine, German Heart Center Munich, Munich, Germany
| | - Yong-Jin Kim
- Seoul National University College of Medicine, Seoul National University Hospital, Seoul, South Korea
| | - Byoung Kwon Lee
- Gangnam Severance Hospital, Younsei University College of Medicine, Seoul, South Korea
| | - Jonathon A Leipsic
- Department of Radiology, St. Paul's Hospital, University of British Columbia, Vancouver, Canada
| | | | | | | | - Gianluca Pontone
- Department of Perioperative Cardiology and Cardiovascular Imaging, Centro Cardiologico Monzino IRCCS, Milan, Italy; Department of Biomedical, Surgical and Dental Sciences, University of Milan, Milan, Italy
| | - Sang-Eun Lee
- Division of Cardiology, Department of Internal Medicine, Ewha Womans University, Seoul, South Korea
| | - Ji Min Sung
- CONNECT-AI Research Center, Yonsei University College of Medicine, Seoul, South Korea
| | - Renu Virmani
- Department of Pathology, CVPath Institute, Gaithersburg, MD, USA
| | - Habib Samady
- Georgia Heart Institute, Northeast Georgia Health System, Gainesville, GA, USA
| | - Fay Y Lin
- Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Peter H Stone
- Division of Cardiovascular Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Daniel S Berman
- Department of Imaging, Cedars-Sinai Medical Center, Cedars-Sinai Heart Institute, Los Angeles, CA, USA
| | - Jagat Narula
- University of Texas Health Houston, Houston, TX, USA
| | - Leslee J Shaw
- Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Jeroen J Bax
- Department of Cardiology, Heart Lung Center, Leiden University Medical Center, Leiden, the Netherlands
| | - Hyuk-Jae Chang
- CONNECT-AI Research Center, Yonsei University College of Medicine, Seoul, South Korea; Division of Cardiology, Severance Cardiovascular Hospital, Yonsei University College of Medicine, Seoul, South Korea
| | - Ron Blankstein
- Division of Cardiovascular Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
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Shiyovich A, Berman AN, Besser SA, Biery DW, Huck DM, Weber B, Cannon C, Januzzi JL, Booth JN, Nasir K, Di Carli MF, López JAG, Kent ST, Bhatt DL, Blankstein R. Cardiovascular outcomes in patients with coronary artery disease and elevated lipoprotein(a): implications for the OCEAN(a)-outcomes trial population. Eur Heart J Open 2023; 3:oead077. [PMID: 37641636 PMCID: PMC10460541 DOI: 10.1093/ehjopen/oead077] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 07/10/2023] [Revised: 07/19/2023] [Accepted: 08/09/2023] [Indexed: 08/31/2023]
Abstract
Aims The ongoing Olpasiran Trials of Cardiovascular Events and Lipoprotein(a) Reduction [OCEAN(a)]-Outcomes trial is evaluating whether Lp(a) lowering can reduce the incidence of cardiovascular events among patients with prior myocardial infarction (MI) or percutaneous coronary intervention (PCI) and elevated Lp(a) (≥200 nmol/L). The purpose of this study is to evaluate the association of elevated Lp(a) with cardiovascular outcomes in an observational cohort resembling the OCEAN(a)-Outcomes trial main enrolment criteria. Methods and results This study included patients aged 18-85 years with Lp(a) measured as part of their clinical care between 2000 and 2019. While patients were required to have a history of MI, or PCI, those with severe kidney dysfunction or a malignant neoplasm were excluded. Elevated Lp(a) was defined as ≥200 nmol/L consistent with the OCEAN(a)-Outcomes trial. The primary outcome was a composite of coronary heart disease death, MI, or coronary revascularization. Natural language processing algorithms, billing and ICD codes, and laboratory data were employed to identify outcomes and covariates. A total of 3142 patients met the eligibility criteria, the median age was 61 (IQR: 52-73) years, 28.6% were women, and 12.3% had elevated Lp(a). Over a median follow-up of 12.2 years (IQR: 6.2-14.3), the primary composite outcome occurred more frequently in patients with versus without elevated Lp(a) [46.0 vs. 38.0%, unadjHR = 1.30 (95% CI: 1.09-1.53), P = 0.003]. Following adjustment for measured confounders, elevated Lp(a) remained independently associated with the primary outcome [adjHR = 1.33 (95% CI: 1.12-1.58), P = 0.001]. Conclusion In an observational cohort resembling the main OCEAN(a)-Outcomes Trial enrolment criteria, patients with an Lp(a) ≥200 nmol/L had a higher risk of cardiovascular outcomes.
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Affiliation(s)
- Arthur Shiyovich
- Division of Cardiovascular Medicine, Department of Medicine, Brigham and Women’s Hospital, Harvard Medical School, Boston, MA 02115, USA
| | - Adam N Berman
- Division of Cardiovascular Medicine, Department of Medicine, Brigham and Women’s Hospital, Harvard Medical School, Boston, MA 02115, USA
| | - Stephanie A Besser
- Division of Cardiovascular Medicine, Department of Medicine, Brigham and Women’s Hospital, Harvard Medical School, Boston, MA 02115, USA
| | - David W Biery
- Division of Cardiovascular Medicine, Department of Medicine, Brigham and Women’s Hospital, Harvard Medical School, Boston, MA 02115, USA
| | - Daniel M Huck
- Division of Cardiovascular Medicine, Department of Medicine, Brigham and Women’s Hospital, Harvard Medical School, Boston, MA 02115, USA
- Department of Radiology, Brigham and Women’s Hospital, Harvard Medical School, Boston, MA 02115, USA
| | - Brittany Weber
- Division of Cardiovascular Medicine, Department of Medicine, Brigham and Women’s Hospital, Harvard Medical School, Boston, MA 02115, USA
| | - Christopher Cannon
- Division of Cardiovascular Medicine, Department of Medicine, Brigham and Women’s Hospital, Harvard Medical School, Boston, MA 02115, USA
| | - James L Januzzi
- Cardiology Division, Massachusetts General Hospital, Harvard Medical School, and Baim Institute for Clinical Research, Boston, MA 02115, USA
| | - John N Booth
- Center for Observational Research, Amgen Inc., Thousand Oaks, CA 91320, USA
| | - Khurram Nasir
- Department of Cardiovascular Medicine, Division of Cardiovascular Prevention and Wellness, Houston Methodist DeBakey Heart and Vascular Center, Houston, TX 77030, USA
| | - Marcelo F Di Carli
- Division of Cardiovascular Medicine, Department of Medicine, Brigham and Women’s Hospital, Harvard Medical School, Boston, MA 02115, USA
- Department of Radiology, Brigham and Women’s Hospital, Harvard Medical School, Boston, MA 02115, USA
| | | | - Shia T Kent
- Center for Observational Research, Amgen Inc., Thousand Oaks, CA 91320, USA
| | - Deepak L Bhatt
- Division of Cardiovascular Medicine, Department of Medicine, Brigham and Women’s Hospital, Harvard Medical School, Boston, MA 02115, USA
- Mount Sinai Heart, Icahn School of Medicine at Mount Sinai Health System, New York, NY 10029, USA
| | - Ron Blankstein
- Division of Cardiovascular Medicine, Department of Medicine, Brigham and Women’s Hospital, Harvard Medical School, Boston, MA 02115, USA
- Department of Radiology, Brigham and Women’s Hospital, Harvard Medical School, Boston, MA 02115, USA
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6
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Kaur G, Berman AN, Biery D, Wu W, Besser SA, Weber B, Carli MFD, Bhatt DL, Blankstein R. SEX DIFFERENCES IN THE ASSOCIATION BETWEEN LIPOPROTEIN(A) AND CARDIOVASCULAR OUTCOMES: THE MASS GENERAL BRIGHAM LP(A) REGISTRY. J Am Coll Cardiol 2023. [DOI: 10.1016/s0735-1097(23)02079-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 03/06/2023]
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7
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Patel HN, Wang S, Rao S, Singh A, Landeras L, Besser SA, Carter S, Mishra S, Nishimura T, Shatz DY, Tung R, Nayak H, Kawaji K, Mor-Avi V, Patel AR. Impact of wideband cardiac magnetic resonance on diagnosis, decision-making and outcomes in patients with implantable cardioverter defibrillators. Eur Heart J Cardiovasc Imaging 2023; 24:181-189. [PMID: 36458878 PMCID: PMC10226743 DOI: 10.1093/ehjci/jeac227] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/26/2022] [Revised: 09/01/2022] [Accepted: 10/21/2022] [Indexed: 12/04/2022] Open
Abstract
AIMS Although myocardial scar assessment using late gadolinium enhancement (LGE) cardiac magnetic resonance (CMR) imaging is frequently indicated for patients with implantable cardioverter defibrillators (ICDs), metal artefact can degrade image quality. With the new wideband technique designed to mitigate device related artefact, CMR is increasingly used in this population. However, the common clinical indications for CMR referral and impact on clinical decision-making and prognosis are not well defined. Our study was designed to address these knowledge gaps. METHODS AND RESULTS One hundred seventy-nine consecutive patients with an ICD (age 59 ± 13 years, 75% male) underwent CMR using cine and wideband pulse sequences for LGE imaging. Electronic medical records were reviewed to determine the reason for CMR referral, whether there was a change in clinical decision-making, and occurrence of major adverse cardiac events (MACEs). Referral indication was the most common evaluation of ventricular tachycardia (VT) substrate (n = 114, 64%), followed by cardiomyopathy (n = 53, 30%). Overall, CMR resulted in a new or changed diagnosis in 64 (36%) patients and impacted clinical management in 51 (28%). The effect on management change was highest in patients presenting with VT. A total of 77 patients (43%) experienced MACE during the follow-up period (median 1.7 years), including 65 in patients with evidence of LGE. Kaplan-Meier analysis showed that ICD patients with LGE had worse outcomes than those without LGE (P = 0.006). CONCLUSION The clinical yield from LGE CMR is high and provides management changing and meaningful prognostic information in a significant proportion of patients with ICDs.
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Affiliation(s)
- Hena N Patel
- Department of Medicine, University of Chicago Medical Center, Chicago, IL 60637, USA
| | - Shuo Wang
- Department of Medicine, University of Chicago Medical Center, Chicago, IL 60637, USA
| | - Swati Rao
- Department of Medicine, University of Chicago Medical Center, Chicago, IL 60637, USA
| | - Amita Singh
- Department of Medicine, University of Chicago Medical Center, Chicago, IL 60637, USA
| | - Luis Landeras
- Department of Radiology, University of Chicago Medical Center, Chicago, IL 60637, USA
| | - Stephanie A Besser
- Department of Medicine, University of Chicago Medical Center, Chicago, IL 60637, USA
| | - Spencer Carter
- Department of Medicine, University of Chicago Medical Center, Chicago, IL 60637, USA
| | - Satish Mishra
- Department of Medicine, University of Chicago Medical Center, Chicago, IL 60637, USA
| | - Takuro Nishimura
- Department of Medicine, University of Chicago Medical Center, Chicago, IL 60637, USA
| | - Dalise Y Shatz
- Department of Medicine, University of Chicago Medical Center, Chicago, IL 60637, USA
| | - Roderick Tung
- Department of Medicine, University of Chicago Medical Center, Chicago, IL 60637, USA
| | - Hemal Nayak
- Department of Medicine, University of Chicago Medical Center, Chicago, IL 60637, USA
| | - Keigo Kawaji
- Illinois Institute of Technology, Department of Biomedical Engineering, Chicago, IL 60616, USA
| | - Victor Mor-Avi
- Department of Medicine, University of Chicago Medical Center, Chicago, IL 60637, USA
| | - Amit R Patel
- Department of Medicine, University of Chicago Medical Center, Chicago, IL 60637, USA
- Department of Radiology, University of Chicago Medical Center, Chicago, IL 60637, USA
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8
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Kong NW, Shatz DY, Besser SA, Upadhyay GA, Tung R. Impact of Race on Outcomes from Catheter Ablation of Ventricular Tachycardia in Structural Heart Disease: A Prospective Registry from South Metropolitan Chicago. Heart Rhythm O2 2023; 4:215-222. [PMID: 36993915 PMCID: PMC10041081 DOI: 10.1016/j.hroo.2023.01.007] [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] [Subscribe] [Scholar Register] [Indexed: 02/01/2023] Open
Abstract
Background Whether racial disparities in outcomes are present after catheter ablation for scar-related ventricular tachycardia (VT) is not known. Objective The purpose of this study was to examine whether racial differences exist in outcomes for patients undergoing VT ablation. Methods From March 2016 through April 2021, consecutive patients undergoing catheter ablation for scar-related VT at the University of Chicago were prospectively enrolled. The primary outcome was VT recurrence, with secondary outcome of mortality alone and composite endpoint of left ventricular assist device placement, heart transplant, or mortality. Results A total of 258 patients were analyzed: 58 (22%) self-identified as Black, and 113 (44%) had ischemic cardiomyopathy. Black patients had significantly higher rates of hypertension (HTN), chronic kidney disease (CKD), and VT storm at presentation. At 7 months, Black patients experienced higher rates of VT recurrence (P = .009). However, after multivariable adjustment, there were no observed differences in VT recurrence (adjusted hazard ratio [aHR] 1.65; 95% confidence interval [CI] 0.91-2.97; P = .10), all-cause mortality (aHR 0.49; 95% CI 0.21-1.17; P = .11), or composite events (aHR 0.76; 95% CI 0.37-1.54; P = .44) between Black and non-Black patients. Conclusion In this diverse prospective registry of patients undergoing catheter ablation for scar-related VT, Black patients experienced higher rates of VT recurrence compared to non-Black patients. When adjusted for highly prevalent HTN, CKD, and VT storm, Black patients had comparable outcomes as non-Black patients.
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Affiliation(s)
- Nathan W. Kong
- Department of Internal Medicine, University of Chicago, Chicago, Illinois
| | - Dalise Y. Shatz
- Center for Arrhythmia Care, Pritzker School of Medicine, University of Chicago, Chicago, Illinois
| | - Stephanie A. Besser
- Center for Arrhythmia Care, Pritzker School of Medicine, University of Chicago, Chicago, Illinois
| | - Gaurav A. Upadhyay
- Center for Arrhythmia Care, Pritzker School of Medicine, University of Chicago, Chicago, Illinois
| | - Roderick Tung
- Center for Arrhythmia Care, Pritzker School of Medicine, University of Chicago, Chicago, Illinois
- Address reprint requests and correspondence: Dr Roderick Tung, The University of Arizona College of Medicine–Phoenix, Banner University Medical Center–Phoenix, 755 E McDowell Rd, Phoenix, AZ 85006.
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Tung R, Xue Y, Chen M, Jiang C, Shatz DY, Besser SA, Hu H, Chung FP, Nakahara S, Kim YH, Satomi K, Shen L, Liang E, Liao H, Gu K, Jiang R, Jiang J, Hori Y, Choi JI, Ueda A, Komatsu Y, Kazawa S, Soejima K, Chen SA, Nogami A, Yao Y. First-Line Catheter Ablation of Monomorphic Ventricular Tachycardia in Cardiomyopathy Concurrent With Defibrillator Implantation: The PAUSE-SCD Randomized Trial. Circulation 2022; 145:1839-1849. [PMID: 35507499 DOI: 10.1161/circulation.122.060039] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 05/25/2023]
Abstract
BACKGROUND Catheter ablation as first-line therapy for ventricular tachycardia (VT) at the time of implantable cardioverter defibrillator (ICD) implantation has not been adopted into clinical guidelines. Also, there is an unmet clinical need to prospectively examine the role of VT ablation in patients with nonischemic cardiomyopathy, an increasingly prevalent population that is referred for advanced therapies globally. METHODS We conducted an international, multicenter, randomized controlled trial enrolling 180 patients with cardiomyopathy and monomorphic VT with an indication for ICD implantation to assess the role of early, first-line ablation therapy. A total of 121 patients were randomly assigned (1:1) to ablation plus an ICD versus conventional medical therapy plus an ICD. Patients who refused ICD (n=47) were followed in a prospective registry after stand-alone ablation treatment. The primary outcome was a composite end point of VT recurrence, cardiovascular hospitalization, or death. RESULTS Randomly assigned patients had a mean age of 55 years (interquartile range, 46-64) and left ventricular ejection fraction of 40% (interquartile range, 30%-49%); 81% were male. The underlying heart disease was ischemic cardiomyopathy in 35%, nonischemic cardiomyopathy in 30%, and arrhythmogenic cardiomyopathy in 35%. Ablation was performed a median of 2 days before ICD implantation (interquartile range, 5 days before to 14 days after). At 31 months, the primary outcome occurred in 49.3% of the ablation group and 65.5% in the control group (hazard ratio, 0.58 [95% CI, 0.35-0.96]; P=0.04). The observed difference was driven by a reduction in VT recurrence in the ablation arm (hazard ratio, 0.51 [95%CI, 0.29-0.90]; P=0.02). A statistically significant reduction in both ICD shocks (10.0% versus 24.6%; P=0.03) and antitachycardia pacing (16.2% versus 32.8%; P=0.04) was observed in patients who underwent ablation compared with control. No differences in cardiovascular hospitalization (32.0% versus. 33.7%; hazard ratio, 0.82 [95% CI, 0.43-1.56]; P=0.55) or mortality (8.9% versus 8.8%; hazard ratio, 1.40 [95% CI, 0.38-5.22]; P=0.62]) were observed. Ablation-related complications occurred in 8.3% of patients. CONCLUSIONS Among patients with cardiomyopathy of varied causes, early catheter ablation performed at the time of ICD implantation significantly reduced the composite primary outcome of VT recurrence, cardiovascular hospitalization, or death. These findings were driven by a reduction in ICD therapies. REGISTRATION URL: https://www. CLINICALTRIALS gov; Unique identifier: NCT02848781.
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Affiliation(s)
- Roderick Tung
- The University of Chicago, Center for Arrhythmia Care, Pritzker School of Medicine, IL (R.T., D.Y.S., S.A.B.)
- Guangdong Provincial People's Hospital, China (R.T., Y.X., H.L.)
- Department of Cardiology, Sir Run Shaw Hospital, School of Medicine, Zhejiang University, Hangzhou, China (R.T.)
| | - Yumei Xue
- Guangdong Provincial People's Hospital, China (R.T., Y.X., H.L.)
| | - Minglong Chen
- The First Affiliated Hospital of Nanjing Medical University, China (M.C., K.G.)
| | - Chenyang Jiang
- Sir Run Run Shaw Hospital, School of Medicine, Zhejiang University, Hangzhou, China (C.J., R.J.)
| | - Dalise Y Shatz
- The University of Chicago, Center for Arrhythmia Care, Pritzker School of Medicine, IL (R.T., D.Y.S., S.A.B.)
| | - Stephanie A Besser
- The University of Chicago, Center for Arrhythmia Care, Pritzker School of Medicine, IL (R.T., D.Y.S., S.A.B.)
| | - Hongde Hu
- Department of Cardiology, West China Hospital, Sichuan University, Chengdu (H.H., J.J.)
| | - Fa-Po Chung
- Taipei Veterans General Hospital, National Yang Ming Chiao Tung University, Taiwan (F.-P.C.)
| | - Shiro Nakahara
- Dokkyo Medical University Saitama Medical Center, Japan (S.N., Y.H.)
| | - Young-Hoon Kim
- Division of Cardiology, Department of Internal Medicine, Korea University Medical Center, Seoul, Korea (Y.-H.K., J.-I.C.)
| | | | - Lishui Shen
- Fuwai Hospital, Arrhythmia Center, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences, Peking Union Medical College, Beijing (L.S., E.L., Y.Y.)
| | - Er'peng Liang
- Fuwai Hospital, Arrhythmia Center, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences, Peking Union Medical College, Beijing (L.S., E.L., Y.Y.)
| | - Hongtao Liao
- Guangdong Provincial People's Hospital, China (R.T., Y.X., H.L.)
| | - Kai Gu
- The First Affiliated Hospital of Nanjing Medical University, China (M.C., K.G.)
| | - Ruhong Jiang
- Sir Run Run Shaw Hospital, School of Medicine, Zhejiang University, Hangzhou, China (C.J., R.J.)
| | - Jian Jiang
- Department of Cardiology, West China Hospital, Sichuan University, Chengdu (H.H., J.J.)
| | - Yuichi Hori
- Dokkyo Medical University Saitama Medical Center, Japan (S.N., Y.H.)
| | - Jong-Il Choi
- Division of Cardiology, Department of Internal Medicine, Korea University Medical Center, Seoul, Korea (Y.-H.K., J.-I.C.)
| | - Akiko Ueda
- Division of Advanced Arrhythmia Management, Kyorin University Hospital, Japan (A.U.)
| | - Yuki Komatsu
- Department of Cardiology, Faculty of Medicine, University of Tsukuba, Japan (Y.K., A.N.)
| | | | - Kyoko Soejima
- Department of Cardiovascular Medicine, Kyorin University Hospital, Japan (K.S.)
| | - Shih-Ann Chen
- Cardiovascular Center, Taichung Veterans General Hospital, Taichung, Taiwan (S.-A.C.)
| | - Akihiko Nogami
- Department of Cardiology, Faculty of Medicine, University of Tsukuba, Japan (Y.K., A.N.)
| | - Yan Yao
- Fuwai Hospital, Arrhythmia Center, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences, Peking Union Medical College, Beijing (L.S., E.L., Y.Y.)
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10
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Allaw AB, Mittal S, Merchant FM, Besser SA, Beaser AD, Aziz Z, Ozcan C, Nayak HM, Tung R, Upadhyay GA. Population-Level Impact of the Guidelines Update on Patient Selection and Outcomes After Cardiac Resynchronization Therapy. JACC Clin Electrophysiol 2022; 8:651-661. [PMID: 35589178 DOI: 10.1016/j.jacep.2022.01.026] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2021] [Revised: 01/21/2022] [Accepted: 01/23/2022] [Indexed: 12/20/2022]
Abstract
OBJECTIVES This study sought to analyze the impact of the American College of Cardiology, American Heart Association, and Heart Rhythm Society (ACC/AHA/HRS) guidelines for cardiac resynchronization therapy with defibrillator (CRT-D) update on utilization and efficacy of CRT-D. BACKGROUND In September 2012, the ACC/AHA/HRS guidelines for CRT-D were modified to include left bundle branch block (LBBB) as a Class I indication. METHODS The IBM Watson MarketScan Database was queried between January 1, 2003, and December 31, 2018, for CRT-D implants or upgrades. The primary outcome was heart failure (HF) hospitalization following left ventricular lead implant. Secondary outcomes included all-cause mortality and device-related lead revision. RESULTS A total of 27,238 patients were analyzed: 18,384 pre-update and 8,854 post-update. Mean age was 69 ± 11 years, 73% men, and 98% with history of HF hospitalization. The proportion of patients with LBBB increased from 29% to 55% (P < 0.001) after the update. Patients receiving CRT-D post-update demonstrated a greater prevalence of comorbidities, including atrial fibrillation (47% vs 40%; P < 0.001), diabetes mellitus (45% vs 39%; P < 0.001), chronic kidney disease (24% vs 15%; P < 0.001), and HF hospitalization in the year before CRT-D (40% vs 37%; P < 0.001). Despite greater baseline comorbidities, HF hospitalization significantly declined post-update (HR: 0.89; P < 0.001). Multivariate predictors of reduced HF hospitalization included angiotensin receptor neprilysin inhibitor prescription (HR: 0.48; P < 0.001) and presence of LBBB (HR: 0.71; P < 0.001). All-cause mortality was not significantly different between the 2 groups, and fewer lead revisions were noted post-update (0.6% vs 1.7%; P < 0.001). CONCLUSIONS The revised 2012 guidelines led to an increased proportion of LBBB patients receiving CRT-D at the population-level. This change was associated with reduced HF hospitalization, despite broadening therapy to patients with more comorbid conditions.
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Affiliation(s)
- Ahmad B Allaw
- Center for Arrhythmia Care, Heart and Vascular Institute, The University of Chicago Pritzker School of Medicine, Chicago, Illinois, USA
| | - Suneet Mittal
- Department of Cardiology, Valley Health System, Ridgewood, New Jersey, USA
| | - Faisal M Merchant
- Division of Cardiology, Section of Cardiac Electrophysiology, Emory University School of Medicine, Atlanta, Georgia, USA
| | - Stephanie A Besser
- Center for Arrhythmia Care, Heart and Vascular Institute, The University of Chicago Pritzker School of Medicine, Chicago, Illinois, USA
| | - Andrew D Beaser
- Center for Arrhythmia Care, Heart and Vascular Institute, The University of Chicago Pritzker School of Medicine, Chicago, Illinois, USA
| | - Zaid Aziz
- Center for Arrhythmia Care, Heart and Vascular Institute, The University of Chicago Pritzker School of Medicine, Chicago, Illinois, USA
| | - Cevher Ozcan
- Center for Arrhythmia Care, Heart and Vascular Institute, The University of Chicago Pritzker School of Medicine, Chicago, Illinois, USA
| | - Hemal M Nayak
- Center for Arrhythmia Care, Heart and Vascular Institute, The University of Chicago Pritzker School of Medicine, Chicago, Illinois, USA
| | - Roderick Tung
- Center for Arrhythmia Care, Heart and Vascular Institute, The University of Chicago Pritzker School of Medicine, Chicago, Illinois, USA
| | - Gaurav A Upadhyay
- Center for Arrhythmia Care, Heart and Vascular Institute, The University of Chicago Pritzker School of Medicine, Chicago, Illinois, USA.
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11
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Wang S, Patel H, Miller T, Ameyaw K, Narang A, Chauhan D, Anand S, Anyanwu E, Besser SA, Kawaji K, Liu XP, Lang RM, Mor-Avi V, Patel AR. AI Based CMR Assessment of Biventricular Function: Clinical Significance of Intervendor Variability and Measurement Errors. JACC Cardiovasc Imaging 2022; 15:413-427. [PMID: 34656471 PMCID: PMC8917993 DOI: 10.1016/j.jcmg.2021.08.011] [Citation(s) in RCA: 15] [Impact Index Per Article: 7.5] [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: 12/17/2020] [Revised: 08/09/2021] [Accepted: 08/17/2021] [Indexed: 12/30/2022]
Abstract
OBJECTIVES The aim of this study was to determine whether left ventricular ejection fraction (LVEF) and right ventricular ejection fraction (RVEF) and left ventricular mass (LVM) measurements made using 3 fully automated deep learning (DL) algorithms are accurate and interchangeable and can be used to classify ventricular function and risk-stratify patients as accurately as an expert. BACKGROUND Artificial intelligence is increasingly used to assess cardiac function and LVM from cardiac magnetic resonance images. METHODS Two hundred patients were identified from a registry of individuals who underwent vasodilator stress cardiac magnetic resonance. LVEF, LVM, and RVEF were determined using 3 fully automated commercial DL algorithms and by a clinical expert (CLIN) using conventional methodology. Additionally, LVEF values were classified according to clinically important ranges: <35%, 35% to 50%, and ≥50%. Both ejection fraction values and classifications made by the DL ejection fraction approaches were compared against CLIN ejection fraction reference. Receiver-operating characteristic curve analysis was performed to evaluate the ability of CLIN and each of the DL classifications to predict major adverse cardiovascular events. RESULTS Excellent correlations were seen for each DL-LVEF compared with CLIN-LVEF (r = 0.83-0.93). Good correlations were present between DL-LVM and CLIN-LVM (r = 0.75-0.85). Modest correlations were observed between DL-RVEF and CLIN-RVEF (r = 0.59-0.68). A >10% error between CLIN and DL ejection fraction was present in 5% to 18% of cases for the left ventricle and 23% to 43% for the right ventricle. LVEF classification agreed with CLIN-LVEF classification in 86%, 80%, and 85% cases for the 3 DL-LVEF approaches. There were no differences among the 4 approaches in associations with major adverse cardiovascular events for LVEF, LVM, and RVEF. CONCLUSIONS This study revealed good agreement between automated and expert-derived LVEF and similarly strong associations with outcomes, compared with an expert. However, the ability of these automated measurements to accurately classify left ventricular function for treatment decision remains limited. DL-LVM showed good agreement with CLIN-LVM. DL-RVEF approaches need further refinements.
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Affiliation(s)
- Shuo Wang
- University of Chicago, Chicago, Illinois,Beijing Chao-Yang Hospital, Capital Medical University, Beijing, China
| | - Hena Patel
- University of Chicago, Chicago, Illinois
| | | | | | | | | | | | | | | | - Keigo Kawaji
- University of Chicago, Chicago, Illinois,Illinois Institute of Technology, Chicago, Illinois
| | - Xing-Peng Liu
- Beijing Chao-Yang Hospital, Capital Medical University, Beijing, China
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12
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Chauhan D, Anyanwu E, Goes J, Besser SA, Anand S, Madduri R, Getty N, Kelle S, Kawaji K, Mor-Avi V, Patel AR. Comparison of machine learning and deep learning for view identification from cardiac magnetic resonance images. Clin Imaging 2022; 82:121-126. [PMID: 34813989 PMCID: PMC8849564 DOI: 10.1016/j.clinimag.2021.11.013] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2021] [Accepted: 11/03/2021] [Indexed: 02/03/2023]
Abstract
BACKGROUND Artificial intelligence is increasingly utilized to aid in the interpretation of cardiac magnetic resonance (CMR) studies. One of the first steps is the identification of the imaging plane depicted, which can be achieved by both deep learning (DL) and classical machine learning (ML) techniques without user input. We aimed to compare the accuracy of ML and DL for CMR view classification and to identify potential pitfalls during training and testing of the algorithms. METHODS To train our DL and ML algorithms, we first established datasets by retrospectively selecting 200 CMR cases. The models were trained using two different cohorts (passively and actively curated) and applied data augmentation to enhance training. Once trained, the models were validated on an external dataset, consisting of 20 cases acquired at another center. We then compared accuracy metrics and applied class activation mapping (CAM) to visualize DL model performance. RESULTS The DL and ML models trained with the passively-curated CMR cohort were 99.1% and 99.3% accurate on the validation set, respectively. However, when tested on the CMR cases with complex anatomy, both models performed poorly. After training and testing our models again on all 200 cases (active cohort), validation on the external dataset resulted in 95% and 90% accuracy, respectively. The CAM analysis depicted heat maps that demonstrated the importance of carefully curating the datasets to be used for training. CONCLUSIONS Both DL and ML models can accurately classify CMR images, but DL outperformed ML when classifying images with complex heart anatomy.
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Affiliation(s)
- Daksh Chauhan
- University of Chicago, Chicago, IL, United States of America
| | - Emeka Anyanwu
- Department of Medicine, University of Chicago, Chicago, IL, United States of America
| | - Jacob Goes
- Illinois Institute of Technology, Chicago, IL, United States of America
| | - Stephanie A Besser
- Department of Medicine, University of Chicago, Chicago, IL, United States of America
| | | | - Ravi Madduri
- Data Science and Learning Department, Argonne National Laboratory, Lemont, IL, United States of America
| | - Neil Getty
- Illinois Institute of Technology, Chicago, IL, United States of America; Data Science and Learning Department, Argonne National Laboratory, Lemont, IL, United States of America
| | - Sebastian Kelle
- Department of Internal Medicine/Cardiology German Heart Center, Berlin, Germany
| | - Keigo Kawaji
- Illinois Institute of Technology, Chicago, IL, United States of America
| | - Victor Mor-Avi
- Department of Medicine, University of Chicago, Chicago, IL, United States of America
| | - Amit R Patel
- Department of Medicine, University of Chicago, Chicago, IL, United States of America; Department of Radiology, University of Chicago, Chicago, IL, United States of America.
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13
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Wilson WW, Chua RFM, Wei P, Besser SA, Tung EL, Kolak M, Tabit CE. Association Between Acute Exposure to Crime and Individual Systolic Blood Pressure. Am J Prev Med 2022; 62:87-94. [PMID: 34538556 PMCID: PMC8973828 DOI: 10.1016/j.amepre.2021.06.017] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/17/2021] [Revised: 06/03/2021] [Accepted: 06/08/2021] [Indexed: 01/03/2023]
Abstract
INTRODUCTION Hypertension is associated with adverse cardiovascular outcomes and is geographically concentrated in urban underserved neighborhoods. This study examines the temporal-spatial association between individual exposure to violent crime and blood pressure. METHODS A retrospective observational cohort study analyzed 39,211 patients with 227,595 blood pressure measurements from 2014 to 2016 at 3 outpatient clinics at an academic medical center in Chicago. Patients were included in the study if they had documentation of blood pressure in the medical record and resided in census tracts with >1,000 observations. Geocoded violent crime events were obtained from the Chicago Police Department. Individual-level exposure was defined on the basis of spatial and temporal buffers around each patient's home. Spatial buffers included 100-, 250-, 500-, and 1,000-meter disc radii, and temporal buffers included 7, 30, and 60 days preceding each outpatient appointment. Systolic blood pressure measurements (mmHg) were abstracted from the electronic health record. Analysis was performed in 2019-2020. RESULTS For each violent crime event within 100 meters from home, systolic blood pressure increased by 0.14 mmHg within 7 days of exposure compared with 0.08 mmHg at 30 days of exposure. In analyses stratified by neighborhood cluster, systolic blood pressure increased by 0.37 mmHg among patients in the suburban affluent cluster relative to that among those in an extreme poverty cluster for the same spatial and temporal buffer. CONCLUSIONS Exposure to a violent crime event was associated with increased blood pressure, with gradient effects by both distance and time from exposure.
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Affiliation(s)
- W Wyatt Wilson
- Department of Medicine, The University of Chicago, Chicago, Illinois
| | - Rhys F M Chua
- Department of Medicine, The University of Chicago, Chicago, Illinois; Section of Cardiology, The University of Chicago, Chicago, Illinois
| | - Peng Wei
- Department of Medicine, The University of Chicago, Chicago, Illinois; Section of Cardiology, The University of Chicago, Chicago, Illinois
| | - Stephanie A Besser
- Department of Medicine, The University of Chicago, Chicago, Illinois; Section of Cardiology, The University of Chicago, Chicago, Illinois
| | - Elizabeth L Tung
- Department of Medicine, The University of Chicago, Chicago, Illinois; Section of General Medicine, The University of Chicago, Chicago, Illinois
| | - Marynia Kolak
- Center for Spatial Data Science, The University of Chicago, Chicago, Illinois
| | - Corey E Tabit
- Department of Medicine, The University of Chicago, Chicago, Illinois; Section of Cardiology, The University of Chicago, Chicago, Illinois.
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14
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Belkin MN, Alenghat FJ, Besser SA, Pinney SP, Grinstein J. Improved Prognostic Performance of Cardiac Power Output With Right Atrial Pressure: A Subanalysis of the ESCAPE Trial. J Card Fail 2021; 28:866-869. [PMID: 34774746 DOI: 10.1016/j.cardfail.2021.11.001] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/29/2021] [Revised: 10/24/2021] [Accepted: 11/02/2021] [Indexed: 10/19/2022]
Abstract
BACKGROUND The initial derivation of cardiac power output (CPO) included the difference between mean arterial pressure (MAP) and right atrial pressure (RAP) in the numerator, before multiplying by cardiac output (CO). We hypothesized that the inclusion of RAP (CPO-RAP) would enhance the prognostic performance of this parameter in those with an elevated RAP. METHODS AND RESULTS We obtained patient-level data from the ESCAPE trial via the Biolincc database. Participants with full final hemodynamics were included in the analysis. The CPO-RAP was calculated as [(MAP - RAP) × CO)]/451 Watts (W), and the CPO was calculated as (MAP × CO)/451. The primary outcome was freedom from left ventricular assist device, heart transplant, or death at 6 months. Included participants (n = 157) were a median of 58 years of age (interquartile range [IQR] 49-67 years), 27% were women, and 59% had ischemic cardiomyopathy. The median CPO was 0.70 W (IQR 0.50-0.90 W), and the median CPO-RAP was 0.62 W (IQR 0.47-0.79 W). In univariable logistic regressions, the CPO was not associated with the primary outcome (odds ratio 0.32, 95% confidence interval 0.08-1.29, P = .11), but the CPO-RAP was (odds ratio 0.10, 95% confidence interval 0.02-0.54, P < .01). In Kaplan-Meier analyses, there were no significant difference in outcomes with CPO (76% vs 64%, P = .08), but for CPO-RAP, there were significant differences in outcomes (81% vs 63%, P = .01). When further delineating CPO-RAP by RAP above or below the median, there was no significant difference in the outcome for participants with a RAP 8 or less (94% vs 79%, P = .07), but a significant difference in participants with a RAP of more than 8 mm Hg (66% vs 45%, P < .05). CONCLUSIONS The inclusion of RAP resulted in a significant association with the primary outcome; CPO alone was not.
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Affiliation(s)
- Mark N Belkin
- From the University of Chicago Medicine, Section of Cardiology, Chicago, Illinois
| | - Francis J Alenghat
- From the University of Chicago Medicine, Section of Cardiology, Chicago, Illinois
| | - Stephanie A Besser
- From the University of Chicago Medicine, Section of Cardiology, Chicago, Illinois
| | - Sean P Pinney
- From the University of Chicago Medicine, Section of Cardiology, Chicago, Illinois
| | - Jonathan Grinstein
- From the University of Chicago Medicine, Section of Cardiology, Chicago, Illinois.
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15
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Upadhyay GA, Henry M, Genovese D, Desai P, Lattell J, Wey H, Besser SA, Aziz Z, Beaser AD, Ozcan C, Nayak HM, Lang RM, Tung R. Impact of physiological pacing on functional mitral regurgitation in systolic dysfunction: Initial echocardiographic remodeling findings after His bundle pacing. Heart Rhythm O2 2021; 2:446-454. [PMID: 34667959 PMCID: PMC8505206 DOI: 10.1016/j.hroo.2021.07.007] [Citation(s) in RCA: 4] [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] [Subscribe] [Scholar Register] [Indexed: 11/11/2022] Open
Abstract
Background Although His bundle pacing (HBP) has been shown to improve left ventricular ejection fraction (LVEF), its impact on mitral regurgitation (MR) remains uncertain. Objectives The aim of this study was to evaluate change in functional MR after HBP in patients with left ventricular (LV) systolic dysfunction. Methods Paired echocardiograms were retrospectively assessed in patients with reduced LVEF (<50%) undergoing HBP for pacing or resynchronization. The primary outcomes assessed were change in MR, LVEF, LV volumes, and valve geometry pre- and post-HBP. MR reduction was characterized as a decline in ≥1 MR grade post-HBP in patients with ≥grade 3 MR at baseline. Results Thirty patients were analyzed: age 68 ± 15 years, 73% male, LVEF 32% ± 10%, 38% coronary artery disease, 33% history of atrial fibrillation. Baseline QRS was 162 ± 31 ms: 33% left bundle branch block, 37% right bundle branch block, 17% paced, and 13% narrow QRS. Significant reductions in LV end-systolic volume (122 mL [73–152 mL] to 89 mL [71–122 mL], P = .006) and increase in LV ejection fraction (31% [25%–37%] to 39% [30%–49%], P < .001) were observed after HBP. Ten patients had grade 3 or 4 MR at baseline, with reduction in MR observed in 7. In patients with at least grade 3 MR at baseline, reduction in LV volumes, improved mitral valve geometry, and greater LV contractility were associated with MR reduction. Greater reduction in paced QRS width was present in MR responders compared to non-MR responders (-40% vs -25%, P = .04). Conclusions In this initial detailed echocardiographic analysis in patients with LV systolic dysfunction, HBP reduced functional MR through favorable ventricular remodeling.
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Affiliation(s)
- Gaurav A Upadhyay
- Center for Arrhythmia Care, Section of Cardiology, Department of Medicine, Pritzker School of Medicine, The University of Chicago Medicine, Chicago, Illinois
| | - Michael Henry
- Cardiac Imaging Center, Section of Cardiology, Department of Medicine, Pritzker School of Medicine, The University of Chicago Medicine, Chicago, Illinois
| | - Davide Genovese
- Cardiac Imaging Center, Section of Cardiology, Department of Medicine, Pritzker School of Medicine, The University of Chicago Medicine, Chicago, Illinois.,Department of Cardiac, Thoracic and Vascular Sciences, University of Padua, Padua, Italy
| | - Parth Desai
- Center for Arrhythmia Care, Section of Cardiology, Department of Medicine, Pritzker School of Medicine, The University of Chicago Medicine, Chicago, Illinois
| | - Jonathan Lattell
- Center for Arrhythmia Care, Section of Cardiology, Department of Medicine, Pritzker School of Medicine, The University of Chicago Medicine, Chicago, Illinois
| | - Hannah Wey
- Center for Arrhythmia Care, Section of Cardiology, Department of Medicine, Pritzker School of Medicine, The University of Chicago Medicine, Chicago, Illinois
| | - Stephanie A Besser
- Center for Arrhythmia Care, Section of Cardiology, Department of Medicine, Pritzker School of Medicine, The University of Chicago Medicine, Chicago, Illinois
| | - Zaid Aziz
- Center for Arrhythmia Care, Section of Cardiology, Department of Medicine, Pritzker School of Medicine, The University of Chicago Medicine, Chicago, Illinois
| | - Andrew D Beaser
- Center for Arrhythmia Care, Section of Cardiology, Department of Medicine, Pritzker School of Medicine, The University of Chicago Medicine, Chicago, Illinois
| | - Cevher Ozcan
- Center for Arrhythmia Care, Section of Cardiology, Department of Medicine, Pritzker School of Medicine, The University of Chicago Medicine, Chicago, Illinois
| | - Hemal M Nayak
- Center for Arrhythmia Care, Section of Cardiology, Department of Medicine, Pritzker School of Medicine, The University of Chicago Medicine, Chicago, Illinois
| | - Roberto M Lang
- Cardiac Imaging Center, Section of Cardiology, Department of Medicine, Pritzker School of Medicine, The University of Chicago Medicine, Chicago, Illinois
| | - Roderick Tung
- Center for Arrhythmia Care, Section of Cardiology, Department of Medicine, Pritzker School of Medicine, The University of Chicago Medicine, Chicago, Illinois
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Singh N, Singh A, Besser SA, Lang RM, Mor-Avi V, Kosuri S, Bishop MR, DeCara JM. Echocardiographic predictors of new-onset atrial arrhythmias in patients undergoing hematopoietic stem cell transplantation. Int J Cardiol 2021; 339:225-231. [PMID: 34174337 DOI: 10.1016/j.ijcard.2021.06.038] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/13/2021] [Revised: 06/08/2021] [Accepted: 06/18/2021] [Indexed: 10/21/2022]
Abstract
BACKGROUND Atrial arrhythmias following hematopoietic stem cell transplantation (HSCT) have been associated with increased length of stay, need for intensive care, and increased mortality within one-year post-transplant. We sought to identify echocardiographic parameters that may predict the development of new atrial arrhythmias post-HSCT. METHODS We performed a retrospective chart review of 753 consecutive patients who underwent HSCT at the University of Chicago from January 2015 through December 2019. Patients with baseline echocardiogram within 6 months prior to transplantation were included. Those with prior transplants, history of atrial arrhythmias, or unavailable echocardiographic images were excluded, resulting in 187 patients included for final analysis. Baseline clinical and demographic variables, as well as echocardiographic parameters, were compared between patients who developed new atrial arrhythmias post-HSCT versus those who did not. RESULTS Of the 187 patients included for analysis, 25 (13%) developed new atrial arrhythmias, with 13 of these occurring within 30 days of transplantation. Despite no significant difference in left atrial (LA) end-systolic volume between those with and without new arrhythmia following HSCT (OR 1.04; 95% CI 0.91-1.09, p = 0.233), univariable analysis demonstrated that patients who developed atrial arrhythmias had reduced LA function, as reflected by lower LA emptying fraction (OR 0.94; 95% CI 0.91-0.98, p = 0.003) and lower LA reservoir strain (OR 0.95; 95% CI 0.92-0.99, p = 0.009). CONCLUSIONS Echocardiographic indices of LA function, namely LA emptying fraction and LA reservoir strain, can identify patients at risk for developing new atrial arrhythmias post-HSCT, prior to the development of morphologic changes in the LA.
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Affiliation(s)
- Nikhil Singh
- Section of Cardiology, Department of Medicine, UChicago Medicine, Chicago, IL 60636, USA
| | - Amita Singh
- Section of Cardiology, Department of Medicine, UChicago Medicine, Chicago, IL 60636, USA
| | - Stephanie A Besser
- Section of Cardiology, Department of Medicine, UChicago Medicine, Chicago, IL 60636, USA
| | - Roberto M Lang
- Section of Cardiology, Department of Medicine, UChicago Medicine, Chicago, IL 60636, USA
| | - Victor Mor-Avi
- Section of Cardiology, Department of Medicine, UChicago Medicine, Chicago, IL 60636, USA
| | - Satyajit Kosuri
- Section of Hematology/Oncology, Department of Medicine, UChicago Medicine, Chicago, IL 60637, USA
| | - Michael R Bishop
- Section of Hematology/Oncology, Department of Medicine, UChicago Medicine, Chicago, IL 60637, USA
| | - Jeanne M DeCara
- Section of Cardiology, Department of Medicine, UChicago Medicine, Chicago, IL 60636, USA.
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17
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Kong N, Chua RFM, Besser SA, Heelan L, Nathan S, Spiegel TF, van Wijk XMR, Tabit CE. A retrospective analysis of high sensitivity cardiac troponin-T ranges in non-myocardial infarction emergency department visits. BMC Cardiovasc Disord 2021; 21:283. [PMID: 34098902 PMCID: PMC8186234 DOI: 10.1186/s12872-021-02089-0] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/09/2021] [Accepted: 05/24/2021] [Indexed: 11/10/2022] Open
Abstract
Introduction Current evidence suggests that high sensitivity cardiac troponin-T (hs-cTnT) values differ based on sex, race, age, and kidney function. However, most studies examining the relationship of hs-cTnT and these individual factors are in healthy participants, leading to difficulty in interpreting hs-cTnT values in the Emergency Department (ED) setting. We seek to examine the relationship between hs-cTnT values and sex, race, age, and kidney function in a contemporary, urban academic setting. Methods ED visits from June 2018 through April 2019 with at least 1 hs-cTnT and no diagnosis of acute myocardial infarction (AMI) at an academic medical center in the south side of Chicago were retrospectively analyzed. Median hs-cTnT values were stratified by sex (male or female), race (African American or Caucasian), age, estimated glomerular filtration rate (eGFR), and stage of chronic kidney disease. Results
9679 encounters, representing 7989 distinct patients, were included for analysis (age 58 ± 18 years, 59% female, 85% black). Males had significantly higher median hs-cTnT values than females (16 [8–34] vs. 9 [6–22] ng/L, p < 0.001), African Americans had a significantly lower median value than Caucasians (10 [6–24] vs. 15 [6–29] ng/L, p < 0.001), and those with atrial fibrillation (27 [16–48] vs. 9 [6–19] ng/L, p < 0.001) and heart failure (28 [14–48] vs. 8 [6–15] ng/L, p < 0.001) had higher median values than those without. Median hs-cTnT values increased significantly with increased age and decreased eGFR. All relationships continued to be significant even after multivariable regression of sex, age, race, eGFR, presence of atrial fibrillation, and presence of heart failure (p < 0.01). Conclusions Analysis of hs-cTnT in non-AMI patients during ED encounters showed that males have higher values than females, African Americans have lower values than Caucasians, those with atrial fibrillation and heart failure have higher values than those without, and that older age and lower eGFR were associated with higher median values.
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Affiliation(s)
- Nathan Kong
- Department of Medicine, The University of Chicago, Chicago, IL, USA
| | - Rhys F M Chua
- Department of Medicine, Section of Cardiology, The University of Chicago, 5841 South Maryland Avenue, MC6080, Chicago, IL, 60637, USA
| | - Stephanie A Besser
- Department of Medicine, Section of Cardiology, The University of Chicago, 5841 South Maryland Avenue, MC6080, Chicago, IL, 60637, USA
| | - Louise Heelan
- Department of Data Science and Analytics, The University of Chicago Medicine, Chicago, IL, USA
| | - Sandeep Nathan
- Department of Medicine, Section of Cardiology, The University of Chicago, 5841 South Maryland Avenue, MC6080, Chicago, IL, 60637, USA
| | - Thomas F Spiegel
- Department of Medicine, Section of Emergency Medicine, The University of Chicago, Chicago, IL, USA
| | | | - Corey E Tabit
- Department of Medicine, Section of Cardiology, The University of Chicago, 5841 South Maryland Avenue, MC6080, Chicago, IL, 60637, USA.
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Belkin MN, Alenghat FJ, Besser SA, Nguyen AB, Chung BB, Smith BA, Kalantari S, Sarswat N, Blair JEA, Kim GH, Pinney SP, Grinstein J. Aortic pulsatility index predicts clinical outcomes in heart failure: a sub-analysis of the ESCAPE trial. ESC Heart Fail 2021; 8:1522-1530. [PMID: 33595923 PMCID: PMC8006667 DOI: 10.1002/ehf2.13246] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/02/2020] [Revised: 01/19/2021] [Accepted: 01/23/2021] [Indexed: 01/24/2023] Open
Abstract
AIMS Aortic pulsatility index (API), calculated as (systolic-diastolic blood pressure)/pulmonary capillary wedge pressure (PCWP), is a novel haemodynamic measurement representing both cardiac filling pressures and contractility. We hypothesized that API would better predict clinical outcomes than traditional haemodynamic metrics of cardiac function. METHODS AND RESULTS The Evaluation Study of Congestive Heart Failure and Pulmonary Artery Catheterization Effectiveness (ESCAPE) trial individual-level data were used. Routine haemodynamic measurements, including Fick cardiac index (CI), and the advanced haemodynamic metrics of API, cardiac power output (CPO), and pulmonary artery pulsatility index (PAPI) were calculated after final haemodynamic-monitored optimization. The primary outcome was a composite endpoint of death or need for orthotopic heart transplant (OHT) or left ventricular assist device (LVAD) at 6 months. A total of 433 participants were enrolled in the ESCAPE trial of which 145 had final haemodynamic data. Final API measurements predicted the primary outcome, OR 0.47 (95% CI 0.32-0.70, P < 0.001), while CI, CPO, and PAPI did not. Receiver operator characteristic analyses of final advanced haemodynamic measurements indicated API best predicted the primary outcome with a cutoff of 2.9 (sensitivity 76.2%, specificity 55.3%, correctly classified 61.4%, area-under-the-curve 0.71), compared with CPO, CI, and PAPI. Kaplan-Meier analyses indicated API ≥ 2.9 was associated with greater freedom from the primary outcome (83.5%), compared with API < 2.9 (58.4%), P = 0.001. While PAPI was also significantly associated, CI and CPO were not. CONCLUSIONS The novel haemodynamic measurement API better predicted clinical outcomes in the ESCAPE trial when compared with traditional invasive haemodynamic metrics of cardiac function.
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Affiliation(s)
- Mark N Belkin
- University of Chicago Medicine, Section of Cardiology, Chicago, IL, USA
| | | | | | - Ann B Nguyen
- University of Chicago Medicine, Section of Cardiology, Chicago, IL, USA
| | - Ben B Chung
- University of Chicago Medicine, Section of Cardiology, Chicago, IL, USA
| | - Bryan A Smith
- University of Chicago Medicine, Section of Cardiology, Chicago, IL, USA
| | - Sara Kalantari
- University of Chicago Medicine, Section of Cardiology, Chicago, IL, USA
| | - Nitasha Sarswat
- University of Chicago Medicine, Section of Cardiology, Chicago, IL, USA
| | - John E A Blair
- University of Chicago Medicine, Section of Cardiology, Chicago, IL, USA
| | - Gene H Kim
- University of Chicago Medicine, Section of Cardiology, Chicago, IL, USA
| | - Sean P Pinney
- University of Chicago Medicine, Section of Cardiology, Chicago, IL, USA
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19
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Singh A, Chen W, Patel HN, Alvi N, Kawaji K, Besser SA, Tung R, Zou J, Lang RM, Mor-Avi V, Patel AR. Impact of Wideband Late Gadolinium Enhancement Cardiac Magnetic Resonance Imaging on Device-Related Artifacts in Different Implantable Cardioverter-Defibrillator Types. J Magn Reson Imaging 2021; 54:1257-1265. [PMID: 33742522 DOI: 10.1002/jmri.27608] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/03/2020] [Revised: 03/05/2021] [Accepted: 03/10/2021] [Indexed: 02/05/2023] Open
Abstract
BACKGROUND Late gadolinium enhancement (LGE) imaging in patients with implantable cardioverter-defibrillators (ICD) is limited by device-related artifacts (DRA). The use of wideband (WB) LGE protocols improves LGE images, but their efficacy with different ICD types is not well known. PURPOSE To assess the effects of WB LGE imaging on DRA in different non-MR conditional ICD subtypes. STUDY TYPE Retrospective. POPULATION A total of 113 patients undergoing cardiac magnetic resonance imaging with three ICD subtypes: transvenous (TV-ICD, N = 48), cardiac-resynchronization therapy device (CRT-D, N = 48), and subcutaneous (S-ICD, N = 17). FIELD STRENGTH/SEQUENCE 5 T scanner, standard LGE, and WB LGE imaging with a phase-sensitive inversion recovery segmented gradient echo sequence. ASSESSMENT DRA burden was defined as the number of artifact-positive short-axis LGE slices as percentage of the total number of short-axis slices covering the left ventricle from based to apex, and was determined for WB and standard LGE studies for each patient. Additionally, artifact area on each slice was quantified. STATISTICAL TESTS Shapiro-Wilks, Kruskal-Wallis analysis of variance, Dunn tests with Bonferroni correction, and Mann-Whitney U-test. RESULTS In patients with TV-ICD, DRA burden was significantly reduced and nearly eliminated with WB LGE compared to standard LGE imaging (median [interquartile range]: 0 [0-7]% vs. 18 [0-50]%, P < 0.05), but WB imaging had less of an impact on DRA in the CRT-D (8 [0-23]% vs. 16 [0-45]%, p = 0.12) and S-ICD (60 [15-71]% vs. 67 [50-92]%, P = 0.09) patients. Residual DRA was significantly greater (P < 0.05) for S-ICD compared to other device types with WB LGE imaging, despite the generators of all three ICD types having similar proximity to the heart. The area of S-ICD associated DRA was smaller with WB LGE (P < 0.001) than with standard LGE imaging and the artifacts had different characteristics (dark signal void instead of a bright hyperenhancement artifact). DATA CONCLUSION Although WB LGE imaging reduced the burden of DRA caused by S-ICD, the residual artifact was greater than that observed with TV-ICD and CRT-D devices. Further developments are needed to better resolve S-ICD artifacts. LEVEL OF EVIDENCE 1 TECHNICAL EFFICACY: STAGE: 5.
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Affiliation(s)
- Amita Singh
- Department of Medicine, Section of Cardiology, University of Chicago Medicine, Chicago, Illinois, USA
| | - Wensu Chen
- Department of Medicine, Section of Cardiology, University of Chicago Medicine, Chicago, Illinois, USA.,Cardiology Department, First Affiliated Hospital, Nanjing Medical University, Nanjing, China
| | - Hena N Patel
- Department of Medicine, Section of Cardiology, University of Chicago Medicine, Chicago, Illinois, USA
| | - Nazia Alvi
- Department of Medicine, Section of Cardiology, University of Chicago Medicine, Chicago, Illinois, USA
| | - Keigo Kawaji
- Department of Medicine, Section of Cardiology, University of Chicago Medicine, Chicago, Illinois, USA.,Department of Biomedical Engineering, Illinois Institute of Technology, Chicago, Illinois, USA
| | - Stephanie A Besser
- Department of Medicine, Section of Cardiology, University of Chicago Medicine, Chicago, Illinois, USA
| | - Roderick Tung
- Department of Medicine, Section of Cardiology, University of Chicago Medicine, Chicago, Illinois, USA
| | - Jiangang Zou
- Cardiology Department, First Affiliated Hospital, Nanjing Medical University, Nanjing, China
| | - Roberto M Lang
- Department of Medicine, Section of Cardiology, University of Chicago Medicine, Chicago, Illinois, USA
| | - Victor Mor-Avi
- Department of Medicine, Section of Cardiology, University of Chicago Medicine, Chicago, Illinois, USA
| | - Amit R Patel
- Department of Medicine, Section of Cardiology, University of Chicago Medicine, Chicago, Illinois, USA
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20
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Ozcan C, Allan T, Besser SA, de la Pena A, Blair J. The relationship between coronary microvascular dysfunction, atrial fibrillation and heart failure with preserved ejection fraction. Am J Cardiovasc Dis 2021; 11:29-38. [PMID: 33815917 PMCID: PMC8012292] [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] [Subscribe] [Scholar Register] [Received: 11/14/2020] [Accepted: 12/21/2020] [Indexed: 06/12/2023]
Abstract
OBJECTIVE Coronary microvascular dysfunction (CMD) is a new frontier in cardiovascular disease and an important contributor to myocardial ischemia. A high prevalence of CMD is shown in heart failure, however, the cause-and-effect relationship between CMD and atrial fibrillation (AF) is unknown. We hypothesize that CMD is associated with AF and increases susceptibility to the co-existence of AF and heart failure with preserved ejection fraction (HFpEF). METHODS Our study examined the relationship between CMD, AF, and HFpEF in all patients who underwent invasive coronary physiology studies for assessment of chest pain or dyspnea. CMD was defined as impaired coronary flow reserve (CFR) without obstructive coronary disease. RESULTS A total of 80 patients (mean age 60±12 years, 68.8% female, median follow up of 2.2 years) were studied. Patients with AF (61%) or HFpEF (62%), or both (71%) were more likely to have CMD than those patients without these conditions. Of the patients with AF and abnormal CFR, 91% had HFpEF. CMD was a predictor of AF with concomitant HFpEF (OR 4.38, P=0.02). Our clinical outcome analysis demonstrated that patients with CMD, AF or HFpEF had lower survival free of HF hospitalization than those patients without (P<0.05). AF (OR 5.5, P=0.02), diabetes, older age, female gender, and higher heart rate were predictors of CMD. CONCLUSION CMD is highly prevalent in patients with AF with or without HFpEF. CMD is associated with poor clinical outcomes and the co-existence of AF and HFpEF. Understanding of the association between CMD and AF is important for developing an effective treatment strategy and the risk stratification for the prevention of AF in patients with CMD and vice versa.
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Affiliation(s)
- Cevher Ozcan
- Department of Medicine, University of Chicago5841 S. Maryland Avenue, MC 6080, Chicago, IL 60637, USA
- Section of Cardiology, Department of Medicine, University of Chicago5841 S. Maryland Avenue, MC 6080, Chicago, IL 60637, USA
| | - Tess Allan
- Pritzker School of Medicine, University of Chicago5841 S. Maryland Avenue, MC 6080, Chicago, IL 60637, USA
| | - Stephanie A Besser
- Department of Medicine, University of Chicago5841 S. Maryland Avenue, MC 6080, Chicago, IL 60637, USA
- Section of Cardiology, Department of Medicine, University of Chicago5841 S. Maryland Avenue, MC 6080, Chicago, IL 60637, USA
| | - Anthony de la Pena
- Department of Medicine, University of Chicago5841 S. Maryland Avenue, MC 6080, Chicago, IL 60637, USA
| | - John Blair
- Department of Medicine, University of Chicago5841 S. Maryland Avenue, MC 6080, Chicago, IL 60637, USA
- Section of Cardiology, Department of Medicine, University of Chicago5841 S. Maryland Avenue, MC 6080, Chicago, IL 60637, USA
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21
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Anchan R, Venturini J, Larsen P, Lee L, Fernandez C, Besser SA, Kalathiya R, Paul J, Blair J, Nathan S. Safe and rapid radial hemostasis achieved using a novel topical hemostatic patch: Results of a first-in-human pilot study using hydrophobically modified polysaccharide-chitosan. Catheter Cardiovasc Interv 2021; 99:786-794. [PMID: 33576564 DOI: 10.1002/ccd.29529] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/13/2020] [Accepted: 01/17/2021] [Indexed: 11/11/2022]
Abstract
BACKGROUND The transradial approach (TRA) for catheter interventions decreases vascular complications and bleeding versus transfemoral approach. Reducing time to hemostasis and preventing radial artery occlusion (RAO) following TRA are important and incompletely realized aspirations. OBJECTIVES This first-in-human study sought to evaluate the efficacy of a novel, topically applied compound (hydrophobically modified polysaccharide-chitosan, hm-P) plus minimal required pneumatic compression, to achieve rapid radial arterial hemostasis in post-TRA procedures compared with de facto standards. MATERIALS AND METHODS About 50 adult patients undergoing 6 French diagnostic TRA procedures were prospectively enrolled. At procedure completion, a topical hm-P impregnated patch was placed over the dermotomy and TR Band (TRB) compression was applied to the access site. This patch was used as part of a novel rapid deflation protocol with a primary outcome of time to hemostasis. Photographic and vascular ultrasound evaluation of the radial artery was performed to evaluate the procedural site. RESULTS Time to hemostasis was 40.5 min (IQR: 38-50 min) with the majority of patients (n = 39, 78%) not requiring reinflation. Patients with bleeding requiring TRB reinflation were more likely to have low body weight and liver dysfunction, with absence of hypertension and LV dysfunction. The rate of RAO was 0% with predischarge radial artery patency documented in all patients using vascular ultrasound. One superficial hematoma was noted. No late bleeding events or cutaneous reactions were reported in the study follow-up. CONCLUSIONS Topical application of hm-P in conjunction with pneumatic compression was safe and resulted in rapid and predictable hemostasis at the arterial puncture site.
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Affiliation(s)
- Rajeev Anchan
- Section of Cardiology, Department of Medicine, University of Chicago Medicine, Chicago, Illinois, USA
| | - Joseph Venturini
- Section of Cardiology, Department of Medicine, University of Chicago Medicine, Chicago, Illinois, USA
| | - Paul Larsen
- Section of Cardiology, Department of Medicine, University of Chicago Medicine, Chicago, Illinois, USA
| | - Linda Lee
- Section of Cardiology, Department of Medicine, University of Chicago Medicine, Chicago, Illinois, USA
| | - Christopher Fernandez
- Section of Cardiology, Department of Medicine, University of Chicago Medicine, Chicago, Illinois, USA
| | - Stephanie A Besser
- Section of Cardiology, Department of Medicine, University of Chicago Medicine, Chicago, Illinois, USA
| | - Rohan Kalathiya
- Section of Cardiology, Department of Medicine, University of Chicago Medicine, Chicago, Illinois, USA
| | - Jonathan Paul
- Section of Cardiology, Department of Medicine, University of Chicago Medicine, Chicago, Illinois, USA
| | - John Blair
- Section of Cardiology, Department of Medicine, University of Chicago Medicine, Chicago, Illinois, USA
| | - Sandeep Nathan
- Section of Cardiology, Department of Medicine, University of Chicago Medicine, Chicago, Illinois, USA
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22
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Anyanwu EC, Chua RFM, Besser SA, Sun D, Liao JK, Tabit CE. SALAD-BAAR: A numerical risk score for hospital admission or emergency department presentation in ambulatory patients with cardiovascular disease. Clin Cardiol 2021; 44:193-199. [PMID: 33277922 PMCID: PMC7852175 DOI: 10.1002/clc.23525] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/07/2020] [Revised: 11/23/2020] [Accepted: 11/27/2020] [Indexed: 12/21/2022] Open
Abstract
BACKGROUND While many interventions to reduce hospital admissions and emergency department (ED) visits for patients with cardiovascular disease have been developed, identifying ambulatory cardiac patients at high risk for admission can be challenging. HYPOTHESIS A computational model based on readily accessible clinical data can identify patients at risk for admission. METHODS Electronic health record (EHR) data from a tertiary referral center were used to generate decision tree and logistic regression models. International Classification of Disease (ICD) codes, labs, admissions, medications, vital signs, and socioenvironmental variables were used to model risk for ED presentation or hospital admission within 90 days following a cardiology clinic visit. Model training and testing were performed with a 70:30 data split. The final model was then prospectively validated. RESULTS A total of 9326 patients and 46 465 clinic visits were analyzed. A decision tree model using 75 patient characteristics achieved an area under the curve (AUC) of 0.75 and a logistic regression model achieved an AUC of 0.73. A simplified 9-feature model based on logistic regression odds ratios achieved an AUC of 0.72. A further simplified numerical score assigning 1 or 2 points to each variable achieved an AUC of 0.66, specificity of 0.75, and sensitivity of 0.58. Prospectively, this final model maintained its predictive performance (AUC 0.63-0.60). CONCLUSION Nine patient characteristics from routine EHR data can be used to inform a highly specific model for hospital admission or ED presentation in cardiac patients. This model can be simplified to a risk score that is easily calculated and retains predictive performance.
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Affiliation(s)
- Emeka C Anyanwu
- Section of Cardiology, Department of Medicine, University of Chicago, Chicago, Illinois, USA
| | - Rhys F M Chua
- Section of Cardiology, Department of Medicine, University of Chicago, Chicago, Illinois, USA
| | - Stephanie A Besser
- Section of Cardiology, Department of Medicine, University of Chicago, Chicago, Illinois, USA
| | - Deyu Sun
- Section of Cardiology, Department of Medicine, University of Chicago, Chicago, Illinois, USA
| | - James K Liao
- Section of Cardiology, Department of Medicine, University of Chicago, Chicago, Illinois, USA
| | - Corey E Tabit
- Section of Cardiology, Department of Medicine, University of Chicago, Chicago, Illinois, USA
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23
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Obuobi S, Chua RFM, Besser SA, Tabit CE. Social determinants of health and hospital readmissions: can the HOSPITAL risk score be improved by the inclusion of social factors? BMC Health Serv Res 2021; 21:5. [PMID: 33397379 PMCID: PMC7780407 DOI: 10.1186/s12913-020-05989-7] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/02/2020] [Accepted: 12/01/2020] [Indexed: 12/04/2022] Open
Abstract
Background The HOSPITAL Risk Score (HRS) predicts 30-day hospital readmissions and is internationally validated. Social determinants of health (SDOH) such as low socioeconomic status (SES) affect health outcomes and have been postulated to affect readmission rates. We hypothesized that adding SDOH to the HRS could improve its predictive accuracy. Methods Records of 37,105 inpatient admissions at the University of Chicago Medical Center were reviewed. HRS was calculated for each patient. Census tract-level SDOH then were combined with the HRS and the performance of the resultant “Social HRS” was compared against the HRS. Patients then were assigned to 1 of 7 typologies defined by their SDOH and a balanced dataset of 14,235 admissions was sampled from the larger dataset to avoid over-representation by any 1 sociodemographic group. Principal component analysis and multivariable linear regression then were performed to determine the effect of SDOH on the HRS. Results The c-statistic for the HRS predicting 30-day readmission was 0.74, consistent with published values. However, the addition of SDOH to the HRS did not improve the c-statistic (0.71). Patients with unfavorable SDOH (no high-school, limited English, crowded housing, disabilities, and age > 65 yrs) had significantly higher HRS (p < 0.05 for all). Overall, SDOH explained 0.2% of the HRS. Conclusion At an urban tertiary care center, the addition of census tract-level SDOH to the HRS did not improve its predictive power. Rather, the effects of SDOH are already reflected in the HRS. Supplementary Information The online version contains supplementary material available at 10.1186/s12913-020-05989-7.
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Affiliation(s)
- Shirlene Obuobi
- Department of Medicine, University of Chicago, Chicago, IL, USA
| | - Rhys F M Chua
- Section of Cardiology, Department of Medicine, Chicago, IL, USA
| | | | - Corey E Tabit
- Section of Cardiology, Department of Medicine, Chicago, IL, USA.
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Tung R, Raiman M, Liao H, Zhan X, Chung FP, Nagel R, Hu H, Jian J, Shatz DY, Besser SA, Aziz ZA, Beaser AD, Upadhyay GA, Nayak HM, Nishimura T, Xue Y, Wu S. Simultaneous Endocardial and Epicardial Delineation of 3D Reentrant Ventricular Tachycardia. J Am Coll Cardiol 2020; 75:884-897. [PMID: 32130924 DOI: 10.1016/j.jacc.2019.12.044] [Citation(s) in RCA: 90] [Impact Index Per Article: 22.5] [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: 11/24/2019] [Revised: 12/12/2019] [Accepted: 12/16/2019] [Indexed: 02/08/2023]
Abstract
BACKGROUND Mechanisms of scar-related ventricular tachycardia (VT) are largely based on computational and animal models that portray a 2-dimensional view. OBJECTIVES The authors sought to delineate the human VT circuit with a 3-dimensional perspective from recordings obtained by simultaneous endocardial and epicardial mapping. METHODS High-resolution mapping was performed during 97 procedures in 89 patients with structural heart disease. Circuits were characterized by systematic isochronal analysis to estimate the dimensions of the isthmus and extent of the exit region recorded on both myocardial surfaces. RESULTS A total of 151 VT morphologies were mapped, of which 83 underwent simultaneous endocardial and epicardial mapping; 17% of circuits activated in a 2-dimensional plane, restricted to 1 myocardial surface. Three-dimensional activation patterns with nonuniform transmural propagation were observed in 61% of circuits with only 4% showing transmurally uniform activation, and 18% exhibiting focal activation patterns consistent with mid-myocardial reentry. The dimensions of the central isthmus were 17 mm (12 to 28 mm) × 10 mm (9 to 19 mm) with 55% exhibiting a minimal dimension of <1.5 cm. QRS activation was transmural in 63% and located 43 mm (34 to 52 mm) from the central isthmus. On the basis of 6 proposed definitions for epicardial VT, the prevalence of an epicardial circuit ranged from 21% to 80% in ischemic cardiomyopathy and 28% to 77% in nonischemic cardiomyopathy. CONCLUSIONS A 2D perspective oversimplifies the electrophysiological circuit responsible for reentrant human VT and simultaneous endocardial and epicardial mapping facilitates inferences about mid-myocardial activation. Intricate activation patterns are frequently observed on both myocardial surfaces, and the epicardium is functionally involved in the majority of circuits. Human reentry may exist within isthmus dimensions smaller than 1 cm, whereas QRS activation is often transmural and remote from the critical isthmus target. A 3-dimensional perspective of the VT circuit may enhance the precision of ablative therapy and may support a greater role for adjunctive strategies and technology to address arrhythmogenic tissue harbored in the mid-myocardium and subepicardium.
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Affiliation(s)
- Roderick Tung
- University of Chicago Medicine, Center for Arrhythmia Care, Division of Cardiology, Department of Medicine, Pritzker School of Medicine, Chicago, Illinois; Guangdong Provincial People's Hospital, Guangdong Academy of Medical Sciences, Guangzhou, China.
| | | | - Hongtao Liao
- Guangdong Provincial People's Hospital, Guangdong Academy of Medical Sciences, Guangzhou, China
| | - Xianzhang Zhan
- Guangdong Provincial People's Hospital, Guangdong Academy of Medical Sciences, Guangzhou, China
| | - Fa Po Chung
- Taipei Veterans General Hospital, Taipei, Taiwan
| | | | - Hongde Hu
- West China Hospital, Sichuan University, Chengdu, China
| | - Jiang Jian
- West China Hospital, Sichuan University, Chengdu, China
| | - Dalise Y Shatz
- University of Chicago Medicine, Center for Arrhythmia Care, Division of Cardiology, Department of Medicine, Pritzker School of Medicine, Chicago, Illinois
| | - Stephanie A Besser
- University of Chicago Medicine, Center for Arrhythmia Care, Division of Cardiology, Department of Medicine, Pritzker School of Medicine, Chicago, Illinois
| | - Zaid A Aziz
- University of Chicago Medicine, Center for Arrhythmia Care, Division of Cardiology, Department of Medicine, Pritzker School of Medicine, Chicago, Illinois
| | - Andrew D Beaser
- University of Chicago Medicine, Center for Arrhythmia Care, Division of Cardiology, Department of Medicine, Pritzker School of Medicine, Chicago, Illinois
| | - Gaurav A Upadhyay
- University of Chicago Medicine, Center for Arrhythmia Care, Division of Cardiology, Department of Medicine, Pritzker School of Medicine, Chicago, Illinois
| | - Hemal M Nayak
- University of Chicago Medicine, Center for Arrhythmia Care, Division of Cardiology, Department of Medicine, Pritzker School of Medicine, Chicago, Illinois
| | - Takuro Nishimura
- University of Chicago Medicine, Center for Arrhythmia Care, Division of Cardiology, Department of Medicine, Pritzker School of Medicine, Chicago, Illinois
| | - Yumei Xue
- Guangdong Provincial People's Hospital, Guangdong Academy of Medical Sciences, Guangzhou, China
| | - Shulin Wu
- Guangdong Provincial People's Hospital, Guangdong Academy of Medical Sciences, Guangzhou, China
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25
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Singh N, Anchan RK, Besser SA, Belkin MN, Cruz MD, Lee L, Yu D, Mehta N, Nguyen AB, Alenghat FJ. High sensitivity Troponin-T for prediction of adverse events in patients with COVID-19. Biomarkers 2020; 25:626-633. [PMID: 32981387 PMCID: PMC7711742 DOI: 10.1080/1354750x.2020.1829056] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/09/2020] [Accepted: 09/13/2020] [Indexed: 12/11/2022]
Abstract
BACKGROUND High sensitivity cardiac troponin-T (hs-TnT) has been associated with mortality in patients hospitalized with COVID-19. We aimed to determine if hs-TnT levels and their timing are independent predictors of adverse events in these patients. DESIGN Retrospective chart review was performed for all patients hospitalized at our institution between 23 March 2020 and 13 April 2020 who were found to be COVID-19-positive. Clinical, demographic, and laboratory variables including initial and peak hs-TnT were recorded. Univariable and multivariable analyses were completed for a primary composite endpoint of in-hospital death, intubation, need for critical care, or cardiac arrest. RESULTS In the 276 patients analysed, initial hs-TnT above the median (≥17 ng/L) was associated with increased length of stay, need for vasoactive medications, and death, along with the composite endpoint (OR 3.92, p < 0.001). Multivariable analysis demonstrated that elevated initial hs-TnT was independently associated with the primary endpoint (OR 2.92, p = 0.01). Late-peaking hs-TnT (OR 2.19 for each additional day until peak, p < 0.001) was also independently associated with the composite endpoint. CONCLUSIONS In patients hospitalized with COVID-19, hs-TnT identifies patients at high risk for adverse in-hospital events, and trends of hs-TnT over time, particularly during the first day, provide additional prognostic information.
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Affiliation(s)
- Nikhil Singh
- Section of Cardiology, Department of Medicine, University of Chicago Medical Center, Chicago, IL, 60637, USA
| | - Rajeev K. Anchan
- Section of Cardiology, Department of Medicine, University of Chicago Medical Center, Chicago, IL, 60637, USA
| | - Stephanie A. Besser
- Section of Cardiology, Department of Medicine, University of Chicago Medical Center, Chicago, IL, 60637, USA
| | - Mark N. Belkin
- Section of Cardiology, Department of Medicine, University of Chicago Medical Center, Chicago, IL, 60637, USA
| | - Mark D. Cruz
- Section of Cardiology, Department of Medicine, University of Chicago Medical Center, Chicago, IL, 60637, USA
| | - Linda Lee
- Section of Cardiology, Department of Medicine, University of Chicago Medical Center, Chicago, IL, 60637, USA
| | - Dongbo Yu
- Section of Cardiology, Department of Medicine, University of Chicago Medical Center, Chicago, IL, 60637, USA
| | - Natasha Mehta
- Section of Cardiology, Department of Medicine, University of Chicago Medical Center, Chicago, IL, 60637, USA
| | - Ann B. Nguyen
- Section of Cardiology, Department of Medicine, University of Chicago Medical Center, Chicago, IL, 60637, USA
| | - Francis J. Alenghat
- Section of Cardiology, Department of Medicine, University of Chicago Medical Center, Chicago, IL, 60637, USA
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26
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Nayak HM, Aziz ZA, Kwasnik A, Lee E, Shatz DY, Tenorio R, Besser SA, Beaser AD, Ozcan C, Upadhyay GA, Tung R. Indirect and Direct Evidence for 3-D Activation During Left Atrial Flutter. JACC Clin Electrophysiol 2020; 6:1812-1823. [DOI: 10.1016/j.jacep.2020.09.022] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2020] [Revised: 09/16/2020] [Accepted: 09/17/2020] [Indexed: 11/28/2022]
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27
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Vohra AS, Chua RFM, Besser SA, Alcain CF, Basnet S, Battle B, Coplan MJ, Liao JK, Tabit CE. Community Health Workers Reduce Rehospitalizations and Emergency Department Visits for Low-Socioeconomic Urban Patients With Heart Failure. Crit Pathw Cardiol 2020; 19:139-145. [PMID: 32209825 PMCID: PMC7679953 DOI: 10.1097/hpc.0000000000000220] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/10/2023]
Abstract
BACKGROUND Low-socioeconomic, urban, minority patients with heart failure (HF) often have unique barriers to care. Community health workers (CHWs) are specially trained laypeople who serve as liaisons between underserved communities and the health system. It is not known whether CHWs improve outcomes in low-socioeconomic, urban, minority patients with HF. HYPOTHESIS CHWs reduce rehospitalizations, emergency department (ED) visits, and healthcare costs for low-socioeconomic urban patients with HF. METHODS Patients admitted with acute decompensated HF were assigned to receive weekly visits by CHW after discharge. Patients were propensity score matched with controls who received usual care. HF-related rehospitalizations, ED visits, and inpatient costs were compared for 12 months following index admission versus the same period before. RESULTS Twenty-eight patients who received weekly visits from a CHW for 12 months after discharge were matched with 28 control patients who did not receive CHWs. Patients who received a CHW had a 75% decrease in HF-related ED visits (0.71 vs. 0.18 visits per patient, P < 0.001), an 89% decrease in HF-related readmissions (0.64 vs. 0.07 admissions per patient, P < 0.005), and a significant decrease in inpatient cost for HF-related visits. In controls receiving usual care, there was no significant change in hospitalizations, ED visits, or costs. CONCLUSIONS In conclusion, CHWs are associated with reduced rehospitalizations, ED visits, and inpatient costs in low-socioeconomic, urban, minority patients with HF. CHWs may be a cost-effective method to reduce health care utilization and improve outcomes for this population.
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Affiliation(s)
- Adam S. Vohra
- Department of Medicine, The University of Chicago, Chicago, IL
| | - Rhys F. M. Chua
- Section of Cardiology, Department of Medicine, The University of Chicago, Chicago, IL
| | - Stephanie A. Besser
- Section of Cardiology, Department of Medicine, The University of Chicago, Chicago, IL
| | - Charina F. Alcain
- Section of Cardiology, Department of Medicine, The University of Chicago, Chicago, IL
| | - Sweta Basnet
- Urban Health Initiative, The University of Chicago Medicine, Chicago, IL
| | - Brenda Battle
- Urban Health Initiative, The University of Chicago Medicine, Chicago, IL
| | - Mitchell J. Coplan
- Section of Cardiology, Department of Medicine, The University of Chicago, Chicago, IL
| | - James K. Liao
- Section of Cardiology, Department of Medicine, The University of Chicago, Chicago, IL
| | - Corey E. Tabit
- Section of Cardiology, Department of Medicine, The University of Chicago, Chicago, IL
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28
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Beaser AD, Aziz Z, Besser SA, Jones CI, Jameria Z, Kannan A, Upadhyay GA, Broman MT, Ozcan C, Tung R, Nayak HM. Characterization of Lead Adherence Using Intravascular Ultrasound to Assess Difficulty of Transvenous Lead Extraction. Circ Arrhythm Electrophysiol 2020; 13:e007726. [DOI: 10.1161/circep.119.007726] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background:
Clinical factors associated with development of intravascular lead adherence (ILA) are unreliable predictors. Because vascular injury in the superior vena cava-right atrium during transvenous lead extraction is more likely to occur in segments with higher degrees of ILA, reliable and accurate assessment of ILA is warranted. We hypothesized that intravascular ultrasound (IVUS) could accurately visualize and quantify ILA and degree of ILA correlates with transvenous lead extraction difficulty.
Methods:
Serial imaging of leads occurred before transvenous lead extraction using IVUS. ILA areas were classified as high or low grade. Degree of extraction difficulty was assessed using 2 metrics and correlated with ILA grade. Lead extraction difficulty was calculated for each patient and compared with IVUS findings.
Results:
One hundred fifty-eight vascular segments in 60 patients were analyzed: 141 (89%) low grade versus 17 (11%) high grade. Median extraction time (low=0 versus high grade=97 seconds,
P
<0.001) and median laser pulsations delivered (low=0 versus high grade=5852,
P
<0.001) were significantly higher in high-grade segments. Most patients with low lead extraction difficulty score had low ILA grades. Eighty-six percentage of patients with high lead extraction difficulty score had low IVUS grade, and the degree of transvenous lead extraction difficulty was similar to patients with low IVUS grades and lead extraction difficulty scores.
Conclusions:
IVUS is a feasible imaging modality that may be useful in characterizing ILA in the superior vena cava-right atrium region. An ILA grading system using imaging correlates with extraction difficulty. Most patients with clinical factors associated with higher extraction difficulty may exhibit lower ILA and extraction difficulty based on IVUS imaging.
Graphic Abstract:
A
graphic abstract
is available for this article.
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Affiliation(s)
- Andrew D. Beaser
- Department of Medicine, Section of Cardiology, University of Chicago Pritzker School of Medicine, IL
| | - Zaid Aziz
- Department of Medicine, Section of Cardiology, University of Chicago Pritzker School of Medicine, IL
| | - Stephanie A. Besser
- Department of Medicine, Section of Cardiology, University of Chicago Pritzker School of Medicine, IL
| | - Christopher I. Jones
- Department of Medicine, Section of Cardiology, University of Chicago Pritzker School of Medicine, IL
| | - Zenith Jameria
- Department of Medicine, Section of Cardiology, University of Chicago Pritzker School of Medicine, IL
| | - Arun Kannan
- Department of Medicine, Section of Cardiology, University of Chicago Pritzker School of Medicine, IL
| | - Gaurav A. Upadhyay
- Department of Medicine, Section of Cardiology, University of Chicago Pritzker School of Medicine, IL
| | - Michael T. Broman
- Department of Medicine, Section of Cardiology, University of Chicago Pritzker School of Medicine, IL
| | - Cevher Ozcan
- Department of Medicine, Section of Cardiology, University of Chicago Pritzker School of Medicine, IL
| | - Roderick Tung
- Department of Medicine, Section of Cardiology, University of Chicago Pritzker School of Medicine, IL
| | - Hemal M. Nayak
- Department of Medicine, Section of Cardiology, University of Chicago Pritzker School of Medicine, IL
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29
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Ai L, Liu L, wu R, Sitikov A, Harrison D, Besser SA, Fang Y, Liao JK, Wu R. Abstract 525: Adult Inducible Deletion of Endothelial Hypoxia-inducible Factor-2α Exaggerates Myocardial Infarction Induced Heart Failure and Cardiac Microvascular Barrier Dysfunction. Circ Res 2020. [DOI: 10.1161/res.127.suppl_1.525] [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:
Myocardial ischemia occurs during myocardial infarction results in the stabilization of Hypoxia-inducible factors (HIFs). Hif2α expresses profoundly in vascular endothelial cells (EC), and its embryonic deletion increases vessel permeability. It has been shown that HIF2a is protective from renal and pulmonary injury. However, the direct role of ecHIF2α in ischemia heart disease is unknown. We hypothesized that ecHIF2a expression in response to myocardial infarction (MI) protects cardiac barrier dysfunction and against heart failure.
Methods and Results:
We generated the Inducible endothelial-specific knockout mice (ecHIF2a
-/-
) by crossing Hif2a
flox/flox
mice with Cre ERT2 mice under the VE-cadherin promoter. Followed with MI, ecHIF2a
-/-
mice displayed worsened cardiac function determined by echocardiography, and they had increased mortality as compared to the controls. In vitro, we used primary mouse cardiac microvascular endothelial cells (mCMVEC) from ecHIF2a
-/-
mouse hearts. We found that under hypoxia condition or 1mM Dimethyloxalylglycine treatment, the deficiency of HIF2a in the mCMVEC increased endothelial permeability determined by trans-endothelial electrical resistance. The knocking down of HIF2a in HUVECs induced by a HIF2a siRNA led to impaired tube formation accessed by the significant reduction in total node counts, junctions, meshes, and full tube length compared to control-siRNA treated cells. HIF2α deletion and hypoxia both reduced endothelial cell migration, and interestingly, the retarded HIF2α-/- ECs migration seems to be independent of hypoxia. Moreover, apoptosis assay showed that ecHIF2a
-/-
ECs increased cell early apoptotic stage compared to WT in hypoxic conditions, but not in normoxia indicating the critical role of HIF2α in ECs survival during cardiac ischemia. Finally, several increased markers of inflammation, such as ICAM-1 and VCAM-1, are associated with HIF2a deletion.
Conclusion:
These data revealed an essential role of HIF2α in protecting cardiac remodeling in response to MI, which might through promoting endothelial cell migration, barrier function, as well as vascularization. Thus, HIF2α is a potential therapeutic target in the treatment of ischemic heart disease.
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Affiliation(s)
| | | | | | | | | | | | - Yun Fang
- Univeristy of Chicago, chicago, IL
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30
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Nishimura T, Beaser AD, Aziz ZA, Upadhyay GA, Ozcan C, Raiman M, Shatz DY, Besser SA, Shatz NA, Nayak HM, Tung R. Periaortic ventricular tachycardia in structural heart disease: Evidence of localized reentrant mechanisms. Heart Rhythm 2020; 17:1271-1279. [PMID: 32325198 DOI: 10.1016/j.hrthm.2020.04.018] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [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: 02/25/2020] [Revised: 03/31/2020] [Accepted: 04/05/2020] [Indexed: 10/24/2022]
Abstract
BACKGROUND The mechanisms for scar-related ventricular tachycardia (VT) originating from the periaortic region remain incompletely characterized. OBJECTIVE The purpose of this study was to map the circuits responsible for periaortic VT in high resolution. METHODS Cases with periaortic VT (2016-2020) were analyzed to characterize the substrate and mechanisms with multielectrode mapping. Periaortic VT was defined as low-voltage and/or deceleration zones within 2 cm of the left ventriculoaortic junction with a corresponding critical site during VT. RESULTS Forty-nine periaortic monomorphic VTs were analyzed in 30 patients (25% of all patients with nonischemic cardiomyopathy). Isolated periaortic substrate was observed in 27% of patients, with 73% having concomitant scar, most commonly in the mid-septum (47%). Deceleration zones were equally prevalent on the septal and lateral portions of the periaortic region (87% vs 73%; P = .19). During activation mapping of VT (tachycardia cycle length 392 ± 105 ms), localized reentrant patterns of activation (14 mm [10-17 mm] × 10 mm [7-14 mm]) were demonstrated in 63% and 37% of VTs showed centrifugal activation, consistent with a focal breakout pattern. Ninety-three percent of VTs fulfilled criteria for a reentrant mechanism. Sixty-five percent of reentrant circuits had endocardial activation gaps within the tachycardia cycle length (3-dimensional circuitry), which were associated with higher rates of recurrence as compared with 2-dimensional complete circuits at 1 year (73% vs 37%; P = .028). CONCLUSION Periaortic VTs were observed in 25% of patients with nonischemic cardiomyopathy and scar-related VT. For the first time, localized reentry confined to this anatomically challenging region was demonstrated as the predominant mechanism by high-resolution circuit activation mapping.
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Affiliation(s)
- Takuro Nishimura
- Center for Arrhythmia Care, Pritzker School of Medicine, The University of Chicago Medicine, Chicago, Illinois
| | - Andrew D Beaser
- Center for Arrhythmia Care, Pritzker School of Medicine, The University of Chicago Medicine, Chicago, Illinois
| | - Zaid A Aziz
- Center for Arrhythmia Care, Pritzker School of Medicine, The University of Chicago Medicine, Chicago, Illinois
| | - Gaurav A Upadhyay
- Center for Arrhythmia Care, Pritzker School of Medicine, The University of Chicago Medicine, Chicago, Illinois
| | - Cevher Ozcan
- Center for Arrhythmia Care, Pritzker School of Medicine, The University of Chicago Medicine, Chicago, Illinois
| | | | - Dalise Y Shatz
- Center for Arrhythmia Care, Pritzker School of Medicine, The University of Chicago Medicine, Chicago, Illinois
| | - Stephanie A Besser
- Center for Arrhythmia Care, Pritzker School of Medicine, The University of Chicago Medicine, Chicago, Illinois
| | | | - Hemal M Nayak
- Center for Arrhythmia Care, Pritzker School of Medicine, The University of Chicago Medicine, Chicago, Illinois
| | - Roderick Tung
- Center for Arrhythmia Care, Pritzker School of Medicine, The University of Chicago Medicine, Chicago, Illinois.
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31
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Anyanwu E, Chua RF, Besser SA, Kolak M, Tung EL, Liao J, Tabit C. SALAD-BAAR: A NUMERICAL RISK SCORE FOR ADMISSION OR ER PRESENTATION IN AMBULATORY CARDIOLOGY PATIENTS. J Am Coll Cardiol 2020. [DOI: 10.1016/s0735-1097(20)32568-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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32
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Wilson WW, Chua R, Wei P, Besser SA, Tung EL, Kolak M, Tabit C. ACUTE EFFECTS OF VIOLENT CRIME ON BLOOD PRESSURE IN CHICAGO. J Am Coll Cardiol 2020. [DOI: 10.1016/s0735-1097(20)32471-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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33
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Tung EL, Chua RFM, Besser SA, Lindau ST, Kolak M, Anyanwu EC, Liao JK, Tabit CE. Association of Rising Violent Crime With Blood Pressure and Cardiovascular Risk: Longitudinal Evidence From Chicago, 2014-2016. Am J Hypertens 2019; 32:1192-1198. [PMID: 31414132 DOI: 10.1093/ajh/hpz134] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/16/2019] [Revised: 07/23/2019] [Accepted: 08/13/2019] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND The purpose of this study was to examine the longitudinal association between rising violent crime and elevated blood pressure (BP). METHODS We analyzed 217,816 BP measurements from 17,783 adults during a temporal surge in violent crime in Chicago (2014-2016). Serial observations were abstracted from the electronic health record at an academic medical center and paired to the City of Chicago Police Data Portal. The violent crime rate (VCR) was calculated as the number of violent crimes per 1,000 population per year for each census tract. Longitudinal multilevel regression models were implemented to assess elevated BP (systolic BP ≥ 140 mm Hg or diastolic BP ≥ 90 mm Hg) as a function of the VCR, adjusting for patient characteristics, neighborhood characteristics, and time effects. Secondary dependent measures included elevated heart rate, obesity, missed outpatient appointments, all-cause hospital admissions, and cardiovascular hospital admissions. RESULTS At baseline, the median VCR was 41.3 (interquartile range: 15.2-66.8), with a maximum rise in VCR of 59.1 over the 3-year surge period. A 20-unit rise in the VCR was associated with 3% higher adjusted odds of having elevated BP (95% confidence interval [CI]: 1.01-1.06), 8% higher adjusted odds of missing an outpatient appointment (95% CI: 1.03-1.13), and 6% higher adjusted odds of having a cardiovascular-related hospital admission (95% CI: 1.01-1.12); associations were not significant for elevated heart rate and obesity. CONCLUSION Rising violent crime was associated with increased BP during a temporal crime surge.
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Affiliation(s)
- Elizabeth L Tung
- Section of General Internal Medicine, Department of Medicine, University of Chicago, Chicago, Illinois, USA
- Center for Health and the Social Sciences, University of Chicago, Chicago, Illinois, USA
- Chicago Center for Diabetes Translation Research, University of Chicago, Chicago, Illinois, USA
| | - Rhys F M Chua
- Section of Cardiology, Department of Medicine, University of Chicago, Chicago, Illinois, USA
| | - Stephanie A Besser
- Section of Cardiology, Department of Medicine, University of Chicago, Chicago, Illinois, USA
| | - Stacy Tessler Lindau
- Department of Obstetrics and Gynecology, University of Chicago, Chicago, Illinois, USA
- Department of Medicine-Geriatrics, University of Chicago, Chicago, Illinois, USA
- MacLean Center on Clinical Medical Ethics, University of Chicago, Chicago, Illinois, USA
- Comprehensive Cancer Center, University of Chicago, Chicago, Illinois, USA
| | - Marynia Kolak
- Center for Spatial Data Science, University of Chicago, Chicago, Illinois, USA
| | - Emeka C Anyanwu
- Section of Cardiology, Department of Medicine, University of Chicago, Chicago, Illinois, USA
| | - James K Liao
- Section of Cardiology, Department of Medicine, University of Chicago, Chicago, Illinois, USA
| | - Corey E Tabit
- Section of Cardiology, Department of Medicine, University of Chicago, Chicago, Illinois, USA
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34
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Aziz Z, Shatz D, Raiman M, Upadhyay GA, Beaser AD, Besser SA, Shatz NA, Fu Z, Jiang R, Nishimura T, Liao H, Nayak HM, Tung R. Targeted Ablation of Ventricular Tachycardia Guided by Wavefront Discontinuities During Sinus Rhythm. Circulation 2019; 140:1383-1397. [DOI: 10.1161/circulationaha.119.042423] [Citation(s) in RCA: 79] [Impact Index Per Article: 15.8] [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:
Accurate and expedited identification of scar regions most prone to reentry is needed to guide ventricular tachycardia (VT) ablation. We aimed to prospectively assess outcomes of VT ablation guided primarily by the targeting of deceleration zones (DZ) identified by propagational analysis of ventricular activation during sinus rhythm.
Methods:
Patients with scar-related VT were prospectively enrolled in the University of Chicago VT Ablation Registry between 2016 and 2018. Isochronal late activation maps annotated to the latest local electrogram deflection were created with high-density multielectrode mapping catheters. Targeted ablation of DZ (>3 isochrones within 1cm radius) was performed, prioritizing later activated regions with maximal isochronal crowding. When possible, activation mapping of VT was performed, and successful ablation sites were compared with DZ locations for mechanistic correlation. Patients were prospectively followed for VT recurrence and mortality.
Results:
One hundred twenty patients (median age 65 years [59-71], 15% female, 50% nonischemic, median ejection fraction 31%) underwent 144 ablation procedures for scar-related VT. 57% of patients had previous ablation and epicardial access was employed in 59% of cases. High-density mapping during baseline rhythm was performed (2518 points [1615-3752] endocardial, 5049±2580 points epicardial) and identified an average of 2±1 DZ, which colocalized to successful termination sites in 95% of cases. The median total radiofrequency application duration was 29 min (21-38 min) to target DZ, representing ablation of 18% of the low-voltage area. At 12±10 months, 70% freedom from VT recurrence (80% in ischemic cardiomyopathy and 63% in nonischemic cardiomyopathy) was achieved. The overall survival rate was 87%.
Conclusions:
A novel voltage-independent high-density mapping display can identify the functional substrate for VT during sinus rhythm and guide targeted ablation, obviating the need for extensive radiofrequency delivery. Regions with isochronal crowding during the baseline rhythm were predictive of VT termination sites, providing mechanistic evidence that deceleration zones are highly arrhythmogenic, functioning as niduses for reentry.
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Affiliation(s)
- Zaid Aziz
- Center for Arrhythmia Care, Pritzker School of Medicine, Department of Medicine, Division of Cardiology, University of Chicago, IL (Z.A., D.S., M.R., G.A.U., A.B., S.A.B., Z.F., R.J., T.N., H.L, H.M.N., R.T.)
| | - Dalise Shatz
- Center for Arrhythmia Care, Pritzker School of Medicine, Department of Medicine, Division of Cardiology, University of Chicago, IL (Z.A., D.S., M.R., G.A.U., A.B., S.A.B., Z.F., R.J., T.N., H.L, H.M.N., R.T.)
| | - Michael Raiman
- Center for Arrhythmia Care, Pritzker School of Medicine, Department of Medicine, Division of Cardiology, University of Chicago, IL (Z.A., D.S., M.R., G.A.U., A.B., S.A.B., Z.F., R.J., T.N., H.L, H.M.N., R.T.)
- Abbott, Abbott Park, IL (M.R., N.A.S.)
| | - Gaurav A Upadhyay
- Center for Arrhythmia Care, Pritzker School of Medicine, Department of Medicine, Division of Cardiology, University of Chicago, IL (Z.A., D.S., M.R., G.A.U., A.B., S.A.B., Z.F., R.J., T.N., H.L, H.M.N., R.T.)
| | - Andrew D. Beaser
- Center for Arrhythmia Care, Pritzker School of Medicine, Department of Medicine, Division of Cardiology, University of Chicago, IL (Z.A., D.S., M.R., G.A.U., A.B., S.A.B., Z.F., R.J., T.N., H.L, H.M.N., R.T.)
| | - Stephanie A. Besser
- Center for Arrhythmia Care, Pritzker School of Medicine, Department of Medicine, Division of Cardiology, University of Chicago, IL (Z.A., D.S., M.R., G.A.U., A.B., S.A.B., Z.F., R.J., T.N., H.L, H.M.N., R.T.)
| | | | - Zihuan Fu
- Center for Arrhythmia Care, Pritzker School of Medicine, Department of Medicine, Division of Cardiology, University of Chicago, IL (Z.A., D.S., M.R., G.A.U., A.B., S.A.B., Z.F., R.J., T.N., H.L, H.M.N., R.T.)
| | - Ruhong Jiang
- Center for Arrhythmia Care, Pritzker School of Medicine, Department of Medicine, Division of Cardiology, University of Chicago, IL (Z.A., D.S., M.R., G.A.U., A.B., S.A.B., Z.F., R.J., T.N., H.L, H.M.N., R.T.)
| | - Takuro Nishimura
- Center for Arrhythmia Care, Pritzker School of Medicine, Department of Medicine, Division of Cardiology, University of Chicago, IL (Z.A., D.S., M.R., G.A.U., A.B., S.A.B., Z.F., R.J., T.N., H.L, H.M.N., R.T.)
| | - Hongtao Liao
- Center for Arrhythmia Care, Pritzker School of Medicine, Department of Medicine, Division of Cardiology, University of Chicago, IL (Z.A., D.S., M.R., G.A.U., A.B., S.A.B., Z.F., R.J., T.N., H.L, H.M.N., R.T.)
| | - Hemal M. Nayak
- Center for Arrhythmia Care, Pritzker School of Medicine, Department of Medicine, Division of Cardiology, University of Chicago, IL (Z.A., D.S., M.R., G.A.U., A.B., S.A.B., Z.F., R.J., T.N., H.L, H.M.N., R.T.)
| | - Roderick Tung
- Center for Arrhythmia Care, Pritzker School of Medicine, Department of Medicine, Division of Cardiology, University of Chicago, IL (Z.A., D.S., M.R., G.A.U., A.B., S.A.B., Z.F., R.J., T.N., H.L, H.M.N., R.T.)
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Narang N, Chung B, Nguyen A, Kalathiya RJ, Laffin LJ, Holzhauser L, Ebong IA, Besser SA, Imamura T, Smith BA, Kalantari S, Raikhelkar J, Sarswat N, Kim GH, Jeevanandam V, Burkhoff D, Sayer G, Uriel N. Discordance Between Clinical Assessment and Invasive Hemodynamics in Patients With Advanced Heart Failure. J Card Fail 2019; 26:128-135. [PMID: 31442494 DOI: 10.1016/j.cardfail.2019.08.004] [Citation(s) in RCA: 29] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/04/2019] [Revised: 08/04/2019] [Accepted: 08/07/2019] [Indexed: 11/18/2022]
Abstract
BACKGROUND Historically, invasive hemodynamic guidance was not superior compared to clinical assessment in patients admitted with acute decompensated heart failure (ADHF). This study assessed the accuracy of clinical assessment vs invasive hemodynamics in patients with ADHF. METHODS AND RESULTS We conducted a prospective cohort study of patients admitted with ADHF. Prior to right-heart catheterization (RHC), physicians categorically predicted right atrial pressure, pulmonary capillary wedge pressure, cardiac index and hemodynamic profile (wet/dry, warm/cold) based on physical examination and clinical data evaluation (warm = cardiac index > 2.2 L/min/m2; wet = pulmonary capillary wedge pressure > 18 mmHg). We collected 218 surveys (of 83 cardiology fellows, 55 attending cardiologists, 45 residents, 35 interns) evaluating 97 patients. Of those patients, 46% were receiving inotropes prior to RHC. The positive and negative predictive values of clinical assessment compared to RHC for the cold and wet subgroups were 74.7% and 50.4%. The accuracy of categorical prediction was 43.6% for right atrial pressure, 34.4% for pulmonary capillary wedge pressure and 49.1% for cardiac index, and accuracy did not differ by clinician (P > 0.05 for all). Interprovider agreement was 44.4%. Therapeutic changes following RHC occurred in 71.1% overall (P < 0.001). CONCLUSIONS Clinical assessment of patients with advanced heart failure presenting with ADHF has low accuracy across all training levels, with exaggerated rates of misrecognition of the most high-risk patients.
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Affiliation(s)
- Nikhil Narang
- Department of Medicine, Section of Cardiology, University of Chicago Medical Center, 5841 S. Maryland Avenue MC 2016, Chicago, Illinois 60637
| | - Ben Chung
- Department of Medicine, Section of Cardiology, University of Chicago Medical Center, 5841 S. Maryland Avenue MC 2016, Chicago, Illinois 60637
| | - Ann Nguyen
- Department of Medicine, Section of Cardiology, University of Chicago Medical Center, 5841 S. Maryland Avenue MC 2016, Chicago, Illinois 60637
| | - Rohan J Kalathiya
- Department of Medicine, Section of Cardiology, University of Chicago Medical Center, 5841 S. Maryland Avenue MC 2016, Chicago, Illinois 60637
| | - Luke J Laffin
- Department of Cardiovascular Medicine, Cleveland Clinic Foundation, 9500 Euclid Avenue, Mail Code JB1, Cleveland, Ohio 44195
| | - Luise Holzhauser
- Department of Medicine, Section of Cardiology, University of Chicago Medical Center, 5841 S. Maryland Avenue MC 2016, Chicago, Illinois 60637
| | - Imo A Ebong
- Department of Medicine, Section of Cardiology, University of Chicago Medical Center, 5841 S. Maryland Avenue MC 2016, Chicago, Illinois 60637
| | - Stephanie A Besser
- Department of Medicine, Section of Cardiology, University of Chicago Medical Center, 5841 S. Maryland Avenue MC 2016, Chicago, Illinois 60637
| | - Teruhiko Imamura
- Department of Medicine, Section of Cardiology, University of Chicago Medical Center, 5841 S. Maryland Avenue MC 2016, Chicago, Illinois 60637
| | - Bryan A Smith
- Department of Medicine, Section of Cardiology, University of Chicago Medical Center, 5841 S. Maryland Avenue MC 2016, Chicago, Illinois 60637
| | - Sara Kalantari
- Department of Medicine, Section of Cardiology, University of Chicago Medical Center, 5841 S. Maryland Avenue MC 2016, Chicago, Illinois 60637
| | - Jayant Raikhelkar
- Department of Medicine, Section of Cardiology, Columbia University Medical Center, 622 W. 168th St PH10-203A New York, NY 10032
| | - Nitasha Sarswat
- Department of Medicine, Section of Cardiology, University of Chicago Medical Center, 5841 S. Maryland Avenue MC 2016, Chicago, Illinois 60637
| | - Gene H Kim
- Department of Medicine, Section of Cardiology, University of Chicago Medical Center, 5841 S. Maryland Avenue MC 2016, Chicago, Illinois 60637
| | - Valluvan Jeevanandam
- Department of Surgery, Section of Cadiac Surgery, University of Chicago Medical Center, 5841 S. Maryland Avenue MC 2016, Chicago, Illinois 60637
| | - Daniel Burkhoff
- Columbia University Medical Center and Cardiovascular Research Foundation, 1700 Broadway, 9th floor, New York, NY 10019
| | - Gabriel Sayer
- Department of Medicine, Section of Cardiology, Columbia University Medical Center, 622 W. 168th St PH10-203A New York, NY 10032
| | - Nir Uriel
- Department of Medicine, Section of Cardiology, Columbia University Medical Center, 622 W. 168th St PH10-203A New York, NY 10032.
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Erley J, Genovese D, Tapaskar N, Alvi N, Rashedi N, Besser SA, Kawaji K, Goyal N, Kelle S, Lang RM, Mor-Avi V, Patel AR. Echocardiography and cardiovascular magnetic resonance based evaluation of myocardial strain and relationship with late gadolinium enhancement. J Cardiovasc Magn Reson 2019; 21:46. [PMID: 31391036 PMCID: PMC6686365 DOI: 10.1186/s12968-019-0559-y] [Citation(s) in RCA: 49] [Impact Index Per Article: 9.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/04/2019] [Accepted: 07/01/2019] [Indexed: 01/15/2023] Open
Abstract
OBJECTIVES We sought to: (1) determine the agreement in cardiovascular magnetic resonance (CMR) and speckle tracking echocardiography (STE) derived strain measurements, (2) compare their reproducibility, (3) determine which approach is best related to CMR late gadolinium enhancement (LGE). BACKGROUND While STE-derived strain is routinely used to assess left ventricular (LV) function, CMR strain measurements are not yet standardized. Strain can be measured using dedicated pulse sequences (strain-encoding, SENC), or post-processing of cine images (feature tracking, FT). It is unclear whether these measurements are interchangeable, and whether strain can be used as an alternative to LGE. METHODS Fifty patients underwent 2D echocardiography and 1.5 T CMR. Global longitudinal strain (GLS) was measured by STE (Epsilon), FT (NeoSoft) and SENC (Myocardial Solutions) and circumferential strain (GCS) by FT and SENC. RESULTS GLS showed good inter-modality agreement (r-values: 0.71-0.75), small biases (< 1%) but considerable limits of agreement (- 7 to 8%). The agreement between the CMR techniques was better for GLS than GCS (r = 0.81 vs 0.67; smaller bias). Repeated measurements showed low intra- and inter-observer variability for both GLS and GCS (intraclass correlations 0.86-0.99; coefficients of variation 3-13%). LGE was present in 22 (44%) of patients. Both SENC- and FT-derived GLS and GCS were associated with LGE, while STE-GLS was not. Irrespective of CMR technique, this association was stronger for GCS (AUC 0.77-0.78) than GLS (AUC 0.67-0.72) and STE-GLS (AUC = 0.58). CONCLUSION There is good inter-technique agreement in strain measurements, which were highly reproducible, irrespective of modality or analysis technique. GCS may better reflect the presence of underlying LGE than GLS.
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Affiliation(s)
- Jennifer Erley
- Department of Internal Medicine / Cardiology, German Heart Center, Berlin, Germany
| | - Davide Genovese
- Department of Medicine, University of Chicago Medical Center, 5758 S. Maryland Avenue, MC9067, Chicago, IL 60637 USA
- Department of Cardiac, Thoracic and Vascular Sciences, University of Padua, Padua, Italy
| | - Natalie Tapaskar
- Department of Medicine, University of Chicago Medical Center, 5758 S. Maryland Avenue, MC9067, Chicago, IL 60637 USA
| | - Nazia Alvi
- Department of Medicine, University of Chicago Medical Center, 5758 S. Maryland Avenue, MC9067, Chicago, IL 60637 USA
- Department of Cardiology, Riverside Medical Center, Kankakee, IL USA
| | - Nina Rashedi
- Department of Medicine, University of Chicago Medical Center, 5758 S. Maryland Avenue, MC9067, Chicago, IL 60637 USA
| | - Stephanie A. Besser
- Department of Medicine, University of Chicago Medical Center, 5758 S. Maryland Avenue, MC9067, Chicago, IL 60637 USA
| | - Keigo Kawaji
- Department of Medicine, University of Chicago Medical Center, 5758 S. Maryland Avenue, MC9067, Chicago, IL 60637 USA
- Department of Biomedical Engineering, Illinois Institute of Technology, Chicago, IL USA
| | - Neha Goyal
- Department of Medicine, University of Chicago Medical Center, 5758 S. Maryland Avenue, MC9067, Chicago, IL 60637 USA
| | - Sebastian Kelle
- Department of Internal Medicine / Cardiology, German Heart Center, Berlin, Germany
- Department of Internal Medicine/Cardiology, Charité Campus Virchow Klinikum, Berlin, Germany
- DZHK (German Center for Cardiovascular Research), Partner Site Berlin, Berlin, Germany
| | - Roberto M. Lang
- Department of Medicine, University of Chicago Medical Center, 5758 S. Maryland Avenue, MC9067, Chicago, IL 60637 USA
| | - Victor Mor-Avi
- Department of Medicine, University of Chicago Medical Center, 5758 S. Maryland Avenue, MC9067, Chicago, IL 60637 USA
| | - Amit R. Patel
- Department of Medicine, University of Chicago Medical Center, 5758 S. Maryland Avenue, MC9067, Chicago, IL 60637 USA
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Kishiki K, Singh A, Narang A, Gomberg-Maitland M, Goyal N, Maffessanti F, Besser SA, Mor-Avi V, Lang RM, Addetia K. Impact of Severe Pulmonary Arterial Hypertension on the Left Heart and Prognostic Implications. J Am Soc Echocardiogr 2019; 32:1128-1137. [PMID: 31278050 DOI: 10.1016/j.echo.2019.05.008] [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] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/22/2018] [Revised: 04/05/2019] [Accepted: 05/06/2019] [Indexed: 11/19/2022]
Abstract
BACKGROUND Severe pulmonary arterial hypertension (sPAH) results in a dilated and dysfunctional right ventricle (RV) together with a small left ventricle (LV) with preserved systolic function. RV size and function parameters have an established association with poor prognosis in sPAH. We sought to determine the impact of RV geometry and function on LV mechanics and its relationship with mortality. METHODS We studied 114 patients (54 ± 13 years) with sPAH, normal LV ejection fraction (LVEF), and complete two-dimensional transthoracic echocardiograms (TTE) and compared them with 70 normal controls of similar age and gender distribution. TTE measurements of atrial sizes, ventricular volumes and function, tricuspid and mitral regurgitation (TR, MR), and LV diastolic function were performed. Speckle-tracking strain was measured in all four chambers, including LV global longitudinal strain (GLS). Cox proportional hazards regression with forward selection was performed to determine the associations between measured indices and mortality over a 20-month follow-up period. Kaplan-Meier curves were generated for variables most associated with death. RESULTS Compared with controls, sPAH patients had greater TR severity and right-chamber size with worse function. Of note, LVEF was normal in both groups. Left atrial peak strain and LV GLS were reduced in sPAH, with greater reductions in nonsurvivors. In multivariate analysis, right atrial volume index (hazard ratio [HR] = 1.02 [CI, 1.01-1.04], P < .01), RV free-wall strain (HR = 1.08; CI [1.01-1.15]; P = .03), and LV GLS (HR = 1.11 [CI, 1.01-1.22]; P = .04) were independently associated with mortality. CONCLUSIONS Although PAH is predominantly a right heart disease, in our cohort of sPAH with normal LVEF, LV GLS was independently associated with death in addition to RV and right atrial abnormalities. These findings indicate that the role of left heart dysfunction in sPAH may be underappreciated in clinical practice.
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Affiliation(s)
- Kanako Kishiki
- Section of Cardiology, Department of Medicine, University of Chicago, Chicago, Illinois
| | - Amita Singh
- Section of Cardiology, Department of Medicine, University of Chicago, Chicago, Illinois
| | - Akhil Narang
- Section of Cardiology, Department of Medicine, University of Chicago, Chicago, Illinois
| | | | - Neha Goyal
- Section of Cardiology, Department of Medicine, University of Chicago, Chicago, Illinois
| | - Francesco Maffessanti
- Institute of Computational Sciences, Università della Svizzera Italiana, Lugano, Switzerland
| | - Stephanie A Besser
- Section of Cardiology, Department of Medicine, University of Chicago, Chicago, Illinois
| | - Victor Mor-Avi
- Section of Cardiology, Department of Medicine, University of Chicago, Chicago, Illinois
| | - Roberto M Lang
- Section of Cardiology, Department of Medicine, University of Chicago, Chicago, Illinois
| | - Karima Addetia
- Section of Cardiology, Department of Medicine, University of Chicago, Chicago, Illinois.
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Mazzone S, Chua RF, Besser SA, Nathan S, Shah AP, Liao JK, Tabit CE. Abstract 150: Early Administration of Ticagrelor in Patients with Non-ST Segment Elevation Myocardial Infarction is Associated with Improved Survival. Circ Cardiovasc Qual Outcomes 2019. [DOI: 10.1161/hcq.12.suppl_1.150] [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:
Dual antiplatelet therapy (aspirin plus clopidogrel/ticagrelor - DAPT) is a mainstay treatment for NSTEMI. However, studies suggest that early administration of clopidogrel may not confer significant benefit over later administration. As the time to peak plasma concentration is much shorter for ticagrelor (1-2 hours) vs. clopidogrel (8-12 hours), we hypothesized that earlier administration of ticagrelor may confer survival benefit over later administration.
Methods:
Patients treated for NSTEMI at our center using DAPT, January 2012 through May 2017, between 18 and 90 years old, were retrospectively identified. Patients who left the hospital against medical advice, were discharged to hospice, or were already treated with DAPT or an anticoagulant at the time of presentation were excluded. Patients who received ticagrelor ≤ 2 hours from arrival were matched with similar patients who received ticagrelor > 2 hours from arrival using 30 clinical and demographic variables. Patients who received clopidogrel were matched similarly. We then compared survival for 500 days using a log rank test.
Results:
349 patients met the inclusion criteria. Of these, 18 received ticagrelor within 2 hours and 41 received clopidogrel within 2 hours. These were matched with 18 and 41 control patients, respectively, who received ticagrelor/clopidogrel > 2 hours from arrival. As shown in Figure 1a, patients who received ticagrelor ≤ 2 hours from arrival had significantly lower 500-day mortality than patients who received ticagrelor > 2 hours from arrival (0.0% vs. 27.7%; p=0.017). There was no difference in mortality between the early and late clopidogrel groups (Figure 1b).
Conclusion:
In the ticagrelor era, early administration of DAPT with ticagrelor (within 2 hours of arrival) may be associated with improved mortality in patients with NSTEMI, an effect not seen with clopidogrel. Larger studies investigating the impact of door to DAPT time in patients with NSTEMI are needed.
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Erley J, Tapaskar N, Alvi N, Rashedi N, Genovese D, Besser SA, Kelle S, Kawaji K, Goyal N, Lang R, Mor-Avi V, Patel A. NON-CONTRAST CARDIAC MAGNETIC RESONANCE BASED DETECTION OF MYOCARDIAL DAMAGE USING MYOCARDIAL STRAIN ANALYSIS. J Am Coll Cardiol 2019. [DOI: 10.1016/s0735-1097(19)32273-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Guo J, Nayak HM, Besser SA, Beaser A, Aziz Z, Broman M, Ozcan C, Tung R, Upadhyay GA. Impact of Atrial Fibrillation Ablation on Recurrent Hospitalization: A Nationwide Cohort Study. JACC Clin Electrophysiol 2018; 5:330-339. [PMID: 30898236 DOI: 10.1016/j.jacep.2018.10.015] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/23/2018] [Revised: 09/28/2018] [Accepted: 10/25/2018] [Indexed: 01/20/2023]
Abstract
OBJECTIVES This study assessed the impact of atrial fibrillation (AF) ablation on hospitalization and antiarrhythmic drug use in the community setting. BACKGROUND Despite the widespread increase in the use of catheter ablation to treat AF in the United States, the impact of ablation on arrhythmic, cardiovascular, and noncardiovascular hospitalizations remains unclear. METHODS The national prospectively acquired Truven Health MarketScan data set (January 1, 2008 to December 31, 2014) was used to identify patients who underwent first time AF ablation with uninterrupted enrollment for 24 months (12 months pre-ablation and 12 months post-ablation). Multivariate logistic regression was used to determine predictors of hospitalization. RESULTS Of 5,238 patients who underwent AF ablation for the first time, 2,720 patients with uninterrupted enrollment were analyzed (age 60 ± 10 years; 29% were women, 79% had hypertension, and 23% had heart failure [HF]). AF ablation was associated with significantly reduced all-cause hospitalization from 1,669 hospitalizations in the year before ablation to 1,034 hospitalizations in the year after ablation, which was driven primarily by a 56% reduction in arrhythmic hospitalization. Nonarrhythmic cardiovascular hospitalizations also declined through a 43% drop off in HF hospitalizations. Noncardiovascular hospitalization rates did not significantly change. Age younger than 55 years (odds ratio [OR]: 1.43; p < 0.001), obstructive sleep apnea (OR: 1.38; p < 0.001), and HF (OR: 1.29; p = 0.024) were multivariate predictors for decreased arrhythmic hospitalization. Rates of antiarrhythmic drug use also significantly declined post-procedure by 37.5% (p < 0.001). CONCLUSIONS In this nationwide cohort, AF ablation was associated with significant decreases in arrhythmic and nonarrhythmic cardiovascular hospitalizations, which was driven by reductions in hospitalization for AF and HF.
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Affiliation(s)
- Jia Guo
- Center for Arrhythmia Care, Heart and Vascular Center, The University of Chicago Pritzker School of Medicine, The University of Chicago Medicine, Chicago, Illinois
| | - Hemal M Nayak
- Center for Arrhythmia Care, Heart and Vascular Center, The University of Chicago Pritzker School of Medicine, The University of Chicago Medicine, Chicago, Illinois
| | - Stephanie A Besser
- Center for Arrhythmia Care, Heart and Vascular Center, The University of Chicago Pritzker School of Medicine, The University of Chicago Medicine, Chicago, Illinois
| | - Andrew Beaser
- Center for Arrhythmia Care, Heart and Vascular Center, The University of Chicago Pritzker School of Medicine, The University of Chicago Medicine, Chicago, Illinois
| | - Zaid Aziz
- Center for Arrhythmia Care, Heart and Vascular Center, The University of Chicago Pritzker School of Medicine, The University of Chicago Medicine, Chicago, Illinois
| | - Michael Broman
- Center for Arrhythmia Care, Heart and Vascular Center, The University of Chicago Pritzker School of Medicine, The University of Chicago Medicine, Chicago, Illinois
| | - Cevher Ozcan
- Center for Arrhythmia Care, Heart and Vascular Center, The University of Chicago Pritzker School of Medicine, The University of Chicago Medicine, Chicago, Illinois
| | - Roderick Tung
- Center for Arrhythmia Care, Heart and Vascular Center, The University of Chicago Pritzker School of Medicine, The University of Chicago Medicine, Chicago, Illinois
| | - Gaurav A Upadhyay
- Center for Arrhythmia Care, Heart and Vascular Center, The University of Chicago Pritzker School of Medicine, The University of Chicago Medicine, Chicago, Illinois.
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Abstract
INTRODUCTION Evaluating the applicability of a clinical trial to a specific patient is difficult. A novel framework, the Trial Score, was created to quantify the generalizability of a trial's result based on participants' baseline characteristics and not on the trial's inclusion and exclusion criteria. METHODS For each Systolic Blood Pressure Intervention Trial (SPRINT) participant, the Euclidean distance in six-dimensional space from the theoretical "average" participant was calculated to produce an individual Trial Score that incorporates multiple distinct continuous-variable baseline characteristics. We prospectively defined the "data-rich," "data-limited," and "data-free" zones as Trial Scores < 90th percentile, the 90th-97.5th percentile, and >97.5th percentile, respectively. Trial Scores were then calculated for National Health and Nutrition Examination Survey participants to map data zones of the general population. Individual participant data from the Action to Control Cardiovascular Risk in Diabetes blood pressure trial (ACCORD-BP) was used to test if participants further from the average SPRINT participant behave differently than the overall SPRINT results. RESULTS The National Health and Nutrition Examination Survey cohort and the ACCORD-BP trial demonstrate large percentages of participants in SPRINT's data-free and data-limited zones. Time-to-event rates seen with intensive and standard blood pressure control in SPRINT were the same as ACCORD-BP participants within SPRINT's data-rich zone (hazard ratio 0.97, p = 0.84 and hazard ratio 0.95, p = 0.70). However, these rates were significantly different than those of ACCORD-BP participants outside SPRINT's data-rich zone (hazard ratio 0.64, p < 0.01 and hazard ratio 0.77, p < 0.01). CONCLUSIONS ACCORD-BP participants with SPRINT Trial Scores in the 90th percentile or below have similar event rates to SPRINT participants in both the intensive and standard blood pressure groups. Quantifying the difference between an individual patient and the average clinical trial participant holds promise as a tool to more precisely determine applicability of a specific trial to individual patients.
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Affiliation(s)
- Luke J Laffin
- 1 Department of Cardiovascular Medicine, Cleveland Clinic Foundation, USA
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Nguyen AB, Lourenço L, Chung BB, Imamura T, Rodgers D, Besser SA, Murks C, Riley T, Powers J, Raikhelkar J, Kalantari S, Sarswat N, Jeevanandam V, Kim G, Sayer G, Uriel N. Increase in short-term risk of rejection in heart transplant patients receiving granulocyte colony-stimulating factor. J Heart Lung Transplant 2018; 37:1322-1328. [PMID: 30174163 DOI: 10.1016/j.healun.2018.06.009] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2017] [Revised: 04/05/2018] [Accepted: 06/20/2018] [Indexed: 11/16/2022] Open
Abstract
BACKGROUND Neutropenia is a significant adverse event after heart transplantation (HT) and increases infection risk. Granulocyte colony-stimulating factor (G-CSF) is commonly used in patients with neutropenia. In this work, we assessed the adverse effects of G-CSF treatment in the setting of a university hospital. METHODS Data on HT patients from January 2008 to July 2016 were reviewed. Patients who received G-CSF were identified and compared with patients without a history of therapy. Baseline characteristics, rejection episodes, and outcomes were collected. Data were analyzed by incidence rates, time to rejection and survival were analyzed using Kaplan-Meier curves, and odds ratios were generated using logistic regression analysis. RESULTS Two hundred twenty-two HT patients were studied and 40 (18%) received G-CSF for a total of 85 total neutropenic events (0.79 event/patient year). There were no differences in baseline characteristics between the groups. In the 3 months after G-CSF, the incidence rate of rejection was 0.067 event/month. In all other time periods considered free of G-CSF effect, the incidence rate was 0.011 event/month. This rate was similar to the overall incidence rate in the non-GCSF group, which was 0.010 event/month. There was a significant difference between the incidence rates in the G-CSF group at 0 to 3 months after G-CSF administration and the non-GCSF group (p = 0.04), but not for the other time periods (p = 0.5). Freedom from rejection in the 3 months after G-CSF administration was 87.5% compared with 97.5% in the non-GCSF group (p = 0.006). CONCLUSIONS G-CSF administration was found to be associated with significant short-term risk of rejection. This suggests the need for increased surveillance during this time period.
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Affiliation(s)
- Ann B Nguyen
- Department of Medicine, Section of Cardiology, The University of Chicago Medicine, Chicago, Illinois, USA.
| | - Laura Lourenço
- Department of Pharmacy Services, The University of Chicago Medicine, Chicago, Illinois, USA
| | - Ben Bow Chung
- Department of Medicine, Section of Cardiology, The University of Chicago Medicine, Chicago, Illinois, USA
| | - Teruhiko Imamura
- Department of Medicine, Section of Cardiology, The University of Chicago Medicine, Chicago, Illinois, USA
| | - Daniel Rodgers
- Department of Medicine, Section of Cardiology, The University of Chicago Medicine, Chicago, Illinois, USA
| | - Stephanie A Besser
- Department of Medicine, Section of Cardiology, The University of Chicago Medicine, Chicago, Illinois, USA
| | - Catherine Murks
- Department of Medicine, Section of Cardiology, The University of Chicago Medicine, Chicago, Illinois, USA
| | - Tiana Riley
- Department of Medicine, Section of Cardiology, The University of Chicago Medicine, Chicago, Illinois, USA
| | - JoDel Powers
- Department of Medicine, Section of Cardiology, The University of Chicago Medicine, Chicago, Illinois, USA
| | - Jayant Raikhelkar
- Department of Medicine, Section of Cardiology, The University of Chicago Medicine, Chicago, Illinois, USA
| | - Sara Kalantari
- Department of Medicine, Section of Cardiology, The University of Chicago Medicine, Chicago, Illinois, USA
| | - Nitasha Sarswat
- Department of Medicine, Section of Cardiology, The University of Chicago Medicine, Chicago, Illinois, USA
| | - Valluvan Jeevanandam
- Department of Surgery, Section of Cardiac and Thoracic Surgery, The University of Chicago Medicine, Chicago, Illinois, USA
| | - Gene Kim
- Department of Medicine, Section of Cardiology, The University of Chicago Medicine, Chicago, Illinois, USA
| | - Gabriel Sayer
- Department of Medicine, Section of Cardiology, The University of Chicago Medicine, Chicago, Illinois, USA
| | - Nir Uriel
- Department of Medicine, Section of Cardiology, The University of Chicago Medicine, Chicago, Illinois, USA
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Medvedofsky D, Maffessanti F, Weinert L, Tehrani DM, Narang A, Addetia K, Mediratta A, Besser SA, Maor E, Patel AR, Spencer KT, Mor-Avi V, Lang RM. 2D and 3D Echocardiography-Derived Indices of Left Ventricular Function and Shape: Relationship With Mortality. JACC Cardiovasc Imaging 2017; 11:1569-1579. [PMID: 29153577 DOI: 10.1016/j.jcmg.2017.08.023] [Citation(s) in RCA: 33] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/01/2017] [Revised: 08/23/2017] [Accepted: 08/24/2017] [Indexed: 01/28/2023]
Abstract
OBJECTIVES This study hypothesized that left ventricular (LV) ejection fraction (EF) and global longitudinal strain (GLS) derived from 3-dimensional echocardiographic (3DE) images would better predict mortality than those obtained by 2-dimensional echocardiographic (2DE) measurements, and that 3DE-based LV shape analysis may have added prognostic value. BACKGROUND Previous studies have shown that both LVEF and GLS derived from 2DE images predict mortality. Recently, 3DE measurements of these parameters were found to be more accurate and reproducible because of independence of imaging plane and geometric assumptions. Also, 3DE analysis offers an opportunity to accurately quantify LV shape. METHODS We retrospectively studied 416 inpatients (60 ± 18 years of age) referred for transthoracic echocardiography between 2006 and 2010, who had good-quality 2DE and 3DE images were available. Mortality data through 2016 were collected. Both 2DE and 3DE images were analyzed to measure LVEF and GLS. Additionally, 3DE-derived LV endocardial surface information was analyzed to obtain global shape indices (sphericity and conicity) and regional curvature (anterior, septal, inferior, lateral walls). Cardiovascular (CV) mortality risks related to these indices were determined using Cox regression. RESULTS Of the 416 patients, 208 (50%) died, including 114 (27%) CV-related deaths over a mean follow-up period of 5 ± 3 years. Cox regression revealed that age and body surface area, all 4 LV function indices (2D EF, 3D EF, 2D GLS, 3D GLS), and regional shape indices (septal and inferior wall curvatures) were independently associated with increased risk of CV mortality. GLS was the strongest prognosticator of CV mortality, superior to EF for both 2DE and 3DE analyses, and 2D EF was the weakest among the 4 functional indices. A 1% decrease in GLS magnitude was associated with an 11.3% increase in CV mortality risk. CONCLUSIONS GLS predicts mortality better than EF by both 3DE and 2DE analysis, whereas 3D EF is a better predictor than 2D EF. Also, LV shape indices provide additional risk assessment.
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Affiliation(s)
- Diego Medvedofsky
- Department of Medicine, University of Chicago Medical Center, Chicago, Illinois
| | - Francesco Maffessanti
- Center for Computational Medicine in Cardiology, Institute of Computational Sciences, Università della Svizzera Italiana, Lugano, Switzerland
| | - Lynn Weinert
- Department of Medicine, University of Chicago Medical Center, Chicago, Illinois
| | - David M Tehrani
- Department of Medicine, University of Chicago Medical Center, Chicago, Illinois
| | - Akhil Narang
- Department of Medicine, University of Chicago Medical Center, Chicago, Illinois
| | - Karima Addetia
- Department of Medicine, University of Chicago Medical Center, Chicago, Illinois
| | - Anuj Mediratta
- Department of Medicine, University of Chicago Medical Center, Chicago, Illinois
| | - Stephanie A Besser
- Department of Medicine, University of Chicago Medical Center, Chicago, Illinois
| | - Elad Maor
- Leviev Heart Institute, The Chaim Sheba Medical Center, Tel HaShomer, Israel
| | - Amit R Patel
- Department of Medicine, University of Chicago Medical Center, Chicago, Illinois
| | - Kirk T Spencer
- Department of Medicine, University of Chicago Medical Center, Chicago, Illinois
| | - Victor Mor-Avi
- Department of Medicine, University of Chicago Medical Center, Chicago, Illinois
| | - Roberto M Lang
- Department of Medicine, University of Chicago Medical Center, Chicago, Illinois.
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Laffin LJ, Besser SA, Alenghat FJ. Abstract P130: A Map of SPRINT’s Data-free Zone. Hypertension 2017. [DOI: 10.1161/hyp.70.suppl_1.p130] [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] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
120 mmHg is an optimal SBP goal according to the SPRINT trial. However, certain inclusion and exclusion criteria cloud its broad applicability. It is critical to understand which patients are well represented and reasonable candidates for intensive BP goals. Using only trial inclusion and exclusion criteria diminishes the fact that subjects are unevenly distributed across these criteria. A patient may fit study constraints, yet be poorly represented. Conversely, a patient may be excluded based on a parameter, and declared an inhabitant of a "data-free zone," yet in other respects resemble the trial population.
We defined and mapped the "data-rich, data-limited, and data -free zones" of SPRINT based on subjects’ baseline characteristics and not on inclusion and exclusion criteria. For each participant (n=9245), a z-score was computed for 6 variables: age, SBP, glucose, non-HDL-C, creatinine, and BMI. Standardized coefficients from multivariable logistic regression, based on SPRINT’s primary end-point, were used to weigh variables. Summary Scores (SS) were generated for each subject to scale with the Euclidean distance of participants from the theoretical "average patient" in six dimensional space.
A SS of 0.56 represents the 90th percentile and 0.74 represents the 97.5th. These were chosen as borders between the data-rich, data-limited, and data-free zones. SS were then calculated for 2007-14 NHANES participants with age >35, SBP≥130, and HbA1c<7. The NHANES population mapped onto SPRINT data zones shows a landscape of applicability by race and sex (Figure).
Defining data zones based on patient characteristics holds promise to refine the applicability of trial results.
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