Eugene Braunwald

Bio: Eugene Braunwald is an academic researcher from Brigham and Women's Hospital. The author has contributed to research in topics: Myocardial infarction & TIMI. The author has an hindex of 230, co-authored 1711 publications receiving 264576 citations. Previous affiliations of Eugene Braunwald include Boston University & University of California, San Francisco.

Severe Mitral Regurgitation Following Acute Myocardial Infarction and Ruptured Papillary Muscle Hemodynamic Findings and Results of Operative Treatment in Four Patients

Abstract: The results of operative treatment are described in four patients who sustained myocardial infarctions and in whom ruptured left ventricular papillary muscles caused severe mitral regurgitation. All were men between 51 and 69 years of age, and the intervals between myocardial infarction and operation were 3 to 15 months. Each patient manifested severe congestive heart failure. All were in sinus rhythm and had an apical holosystolic murmur and an atrial gallop sound. Three of the four had severe pulmonary hypertension (60 to 80 mm Hg systolic), grossly elevated mean left atrial pressure, and v waves 37 to 45 mm Hg. In all the cardiac index was abnormally low (average 1.8 L/min/m2). In all four patients the mitral valve was replaced with a 2M Starr-Edwards prosthesis. In two of the excised valves, one head of the posterior papillary muscle was infarcted and had ruptured, and in the other two the anterior papillary muscle was similarly involved. All patients survived, and all have derived distinct symptomati...

A Proposed Model for Initial Assessment and Management of Acute Heart Failure Syndromes

Abstract: ACUTE HEART FAILURE SYNDROMES (AHFS) HAVE BEEN defined as new-onset or recurrence of worsening signs and symptoms of HF necessitating urgent or emergency management. More than 1 million hospital admissions occur annually for AHFS both in the United States and in Europe. Initial management of AHFS has changed little over the last decades. Although patients with AHFS experience symptomatic improvement during hospitalization, the postdischarge rehospitalization rate and mortality within 60 to 90 days remain as high as 30% and 15%, respectively. An algorithm is needed for evaluation of AHFS at presentation, given the heterogeneity of this patient population. The ultimate clinical value of any conceptual framework depends on its capacity to improve use of diagnostic and therapeutic modes and to guide design of clinical trials. Three phases of AHFS have been suggested: (1) urgent treatment and stabilization (most often occurring in the emergency department); (2) in-hospital management; and (3) the postdischarge “vulnerable” period. In this Commentary, we focus on assessment and management of AHFS during phase 1.

The smoker's paradox: insights from the angiographic substudies of the TIMI trials.

Abstract: Background: Despite increased risk for coronary artery disease and acute myocardial infarction (AMI), smokers have a paradoxically lower mortality after thrombolysis for AMI than non-smokers. We determined the clinical risk profiles and coronary flow characteristics of patients in the TIMI trials according to smoking status, focusing on microvascular flow. Methods: Among 2,573 patients in the TIMI 4, 10A, 10B and TIMI 14 trials, epicardial flow post-thrombolysis was measured using angiographic TIMI flow grades and the corrected TIMI frame count (CTFC). Microvascular flow was measured by TIMI Myocardial Perfusion Grade (TMPG) and, in TIMI 14, the percentage of ST segment resolution. Results: Clinically, the mean age (54 vs. 62 years), the prevalence of diabetes mellitus (11% vs. 16%) and hypertension (26% vs. 40%), and the 30-day mortality (2.6% vs. 6.2%) were lower among smokers than non-smokers (all p ≤ 0.001). Angiographically, single-vessel disease (48% vs. 40%) and non-left anterior descending infarct arteries (65.4% vs. 60.8%) were more common among smokers (both p ≤ 0.01). Epicardial TIMI grade 3 flow was achieved more often in smokers than non-smokers (61% vs. 56%) and the CTFC was faster (34 vs. 37 frames/sec, both p ≤ 0.01), especially in LAD lesions. However, the frequency of normal microvascular flow (TMPG 3) was similar among smokers and non-smokers (24% vs. 29%, p = 0.16), as was the frequency of complete ST segment resolution (50% vs. 46%, p = 0.29). Conclusions: Smokers have lower mortality after AMI than non-smokers, due in large part to lower clinical risk profiles and faster epicardial flow. Differences in tissue-level perfusion do not appear to contribute to lower mortality in smokers. Abbreviated Abstract. After acute MI, active smokers have lower acute mortality than non-smokers that appears to be largely explained by their healthier risk profiles, less extensive coronary disease, and faster epicardial blood flow after thrombolysis. Microvascular injury does not appear to play a major role in the lower mortality risk among smokers.

Evaluation of the AccuTnI Cardiac Troponin I Assay for Risk Assessment in Acute Coronary Syndromes

Abstract: Effective risk assessment guides appropriate triage and therapy for patients with suspected unstable angina or non-ST-elevation myocardial infarction (MI) (1)(2). Cardiac biomarkers play a valuable role in risk stratification in non-ST-elevation acute coronary syndromes (NSTE ACS). In particular, the cardiac troponins have been identified as the preferred biomarkers for this purpose (1). Clinical application of cardiac troponin I (cTnI) has been complicated by a lack of standardization across the multiple commercially available assays, which has produced substantial variation in the reported clinical decision limits. As such, clinical appraisal of the prognostic performance of each cTnI assay is important to providing an evidence-based guide to its use for risk assessment. The most recent generation cTnI assay from Beckman Coulter (AccuTnITM) uses antibodies directed at a stable region (amino acids 30–110) of the NH2 terminus of cTnI and delivers very good analytic performance (3)(4). We evaluated this assay for the assessment of the short-term risk of death and recurrent ischemic events among patients with suspected NSTE ACS enrolled in the Orbofiban in Patients with Unstable Coronary Syndromes (OPUS)-Thrombolysis in Myocardial Infarction (TIMI) 16 trial. OPUS-TIMI 16 was a multicenter, randomized, parallel-group trial comparing an oral glycoprotein IIb/IIIa inhbitor with placebo for patients with ACS. The design and results of OPUS-TIMI 16 have been reported (5). The protocol was approved by the Institutional Review Board of each participating hospital, and all patients signed written informed consent. Patients were included if they presented within 72 h of symptom onset and had at least one of the following: dynamic electrocardiographic changes; increased cardiac markers; history of coronary artery disease; or age ≥65 with diabetes or vascular disease. Patients were randomized to placebo or one of two orbofiban doses. The present substudy was conducted in all patients with NSTE ACS …

The Seventh Report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure: the JNC 7 report.

Abstract: "The Seventh Report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure" provides a new guideline for hypertension prevention and management. The following are the key messages(1) In persons older than 50 years, systolic blood pressure (BP) of more than 140 mm Hg is a much more important cardiovascular disease (CVD) risk factor than diastolic BP; (2) The risk of CVD, beginning at 115/75 mm Hg, doubles with each increment of 20/10 mm Hg; individuals who are normotensive at 55 years of age have a 90% lifetime risk for developing hypertension; (3) Individuals with a systolic BP of 120 to 139 mm Hg or a diastolic BP of 80 to 89 mm Hg should be considered as prehypertensive and require health-promoting lifestyle modifications to prevent CVD; (4) Thiazide-type diuretics should be used in drug treatment for most patients with uncomplicated hypertension, either alone or combined with drugs from other classes. Certain high-risk conditions are compelling indications for the initial use of other antihypertensive drug classes (angiotensin-converting enzyme inhibitors, angiotensin-receptor blockers, β-blockers, calcium channel blockers); (5) Most patients with hypertension will require 2 or more antihypertensive medications to achieve goal BP (<140/90 mm Hg, or <130/80 mm Hg for patients with diabetes or chronic kidney disease); (6) If BP is more than 20/10 mm Hg above goal BP, consideration should be given to initiating therapy with 2 agents, 1 of which usually should be a thiazide-type diuretic; and (7) The most effective therapy prescribed by the most careful clinician will control hypertension only if patients are motivated. Motivation improves when patients have positive experiences with and trust in the clinician. Empathy builds trust and is a potent motivator. Finally, in presenting these guidelines, the committee recognizes that the responsible physician's judgment remains paramount.

Cochrane Handbook for Systematic Reviews of Interventions

Abstract: The Cochrane Handbook for Systematic Reviews of Interventions is the official document that describes in detail the process of preparing and maintaining Cochrane systematic reviews on the effects of healthcare interventions.

Atherosclerosis — An Inflammatory Disease

Abstract: Atherosclerosis is an inflammatory disease. Because high plasma concentrations of cholesterol, in particular those of low-density lipoprotein (LDL) cholesterol, are one of the principal risk factors for atherosclerosis,1 the process of atherogenesis has been considered by many to consist largely of the accumulation of lipids within the artery wall; however, it is much more than that. Despite changes in lifestyle and the use of new pharmacologic approaches to lower plasma cholesterol concentrations,2,3 cardiovascular disease continues to be the principal cause of death in the United States, Europe, and much of Asia.4,5 In fact, the lesions of atherosclerosis represent . . .

Lifetime Prevalence and Age-of-Onset Distributions of DSM-IV Disorders in the National Comorbidity Survey Replication

Abstract: Context Little is known about lifetime prevalence or age of onset of DSM-IV disorders. Objective To estimate lifetime prevalence and age-of-onset distributions of DSM-IV disorders in the recently completed National Comorbidity Survey Replication. Design and Setting Nationally representative face-to-face household survey conducted between February 2001 and April 2003 using the fully structured World Health Organization World Mental Health Survey version of the Composite International Diagnostic Interview. Participants Nine thousand two hundred eighty-two English-speaking respondents aged 18 years and older. Main Outcome Measures Lifetime DSM-IV anxiety, mood, impulse-control, and substance use disorders. Results Lifetime prevalence estimates are as follows: anxiety disorders, 28.8%; mood disorders, 20.8%; impulse-control disorders, 24.8%; substance use disorders, 14.6%; any disorder, 46.4%. Median age of onset is much earlier for anxiety (11 years) and impulse-control (11 years) disorders than for substance use (20 years) and mood (30 years) disorders. Half of all lifetime cases start by age 14 years and three fourths by age 24 years. Later onsets are mostly of comorbid conditions, with estimated lifetime risk of any disorder at age 75 years (50.8%) only slightly higher than observed lifetime prevalence (46.4%). Lifetime prevalence estimates are higher in recent cohorts than in earlier cohorts and have fairly stable intercohort differences across the life course that vary in substantively plausible ways among sociodemographic subgroups. Conclusions About half of Americans will meet the criteria for a DSM-IV disorder sometime in their life, with first onset usually in childhood or adolescence. Interventions aimed at prevention or early treatment need to focus on youth.

Seventh Report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure

Abstract: The National High Blood Pressure Education Program presents the complete Seventh Report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure. Like its predecessors, the purpose is to provide an evidence-based approach to the prevention and management of hypertension. The key messages of this report are these: in those older than age 50, systolic blood pressure (BP) of greater than 140 mm Hg is a more important cardiovascular disease (CVD) risk factor than diastolic BP; beginning at 115/75 mm Hg, CVD risk doubles for each increment of 20/10 mm Hg; those who are normotensive at 55 years of age will have a 90% lifetime risk of developing hypertension; prehypertensive individuals (systolic BP 120-139 mm Hg or diastolic BP 80-89 mm Hg) require health-promoting lifestyle modifications to prevent the progressive rise in blood pressure and CVD; for uncomplicated hypertension, thiazide diuretic should be used in drug treatment for most, either alone or combined with drugs from other classes; this report delineates specific high-risk conditions that are compelling indications for the use of other antihypertensive drug classes (angiotensin-converting enzyme inhibitors, angiotensin-receptor blockers, beta-blockers, calcium channel blockers); two or more antihypertensive medications will be required to achieve goal BP (<140/90 mm Hg, or <130/80 mm Hg) for patients with diabetes and chronic kidney disease; for patients whose BP is more than 20 mm Hg above the systolic BP goal or more than 10 mm Hg above the diastolic BP goal, initiation of therapy using two agents, one of which usually will be a thiazide diuretic, should be considered; regardless of therapy or care, hypertension will be controlled only if patients are motivated to stay on their treatment plan. Positive experiences, trust in the clinician, and empathy improve patient motivation and satisfaction. This report serves as a guide, and the committee continues to recognize that the responsible physician's judgment remains paramount.