Showing papers by "Kim A. Eagle published in 2003"
TL;DR: Across the entire spectrum of ACS and in general clinical practice, this model provides excellent ability to assess the risk for death and can be used as a simple nomogram to estimate risk in individual patients.
Abstract: Background Management of acute coronary syndromes (ACS) should be guided by an estimate of patient risk. Objective To develop a simple model to assess the risk for in-hospital mortality for the entire spectrum of ACS treated in general clinical practice. Methods A multivariable logistic regression model was developed using 11 389 patients (including 509 in-hospital deaths) with ACS with and without ST-segment elevation enrolled in the Global Registry of Acute Coronary Events (GRACE) from April 1, 1999, through March 31, 2001. Validation data sets included a subsequent cohort of 3972 patients enrolled in GRACE and 12 142 in the Global Use of Strategies to Open Occluded Coronary Arteries IIb (GUSTO-IIb) trial. Results The following 8 independent risk factors accounted for 89.9% of the prognostic information: age (odds ratio [OR], 1.7 per 10 years), Killip class (OR, 2.0 per class), systolic blood pressure (OR, 1.4 per 20-mm Hg decrease), ST-segment deviation (OR, 2.4), cardiac arrest during presentation (OR, 4.3), serum creatinine level (OR, 1.2 per 1-mg/dL [88.4-µmol/L] increase), positive initial cardiac enzyme findings (OR, 1.6), and heart rate (OR, 1.3 per 30-beat/min increase). The discrimination ability of the simplified model was excellent with c statistics of 0.83 in the derived database, 0.84 in the confirmation GRACE data set, and 0.79 in the GUSTO-IIb database. Conclusions Across the entire spectrum of ACS and in general clinical practice, this model provides excellent ability to assess the risk for death and can be used as a simple nomogram to estimate risk in individual patients.
2,053Â citations
TL;DR: This comprehensive review is organized in two parts, with a focus on the etiology, natural history, and classification (with vascular staging) of aortic wall disease in Part I and emphasis on therapeutic management and follow-up in Part II.
Abstract: Cardiovascular disease is the leading cause of death in most Western societies and is increasing steadily in many developing countries. Aortic diseases constitute an emerging share of the burden. New diagnostic imaging modalities, longer life expectancy in general, longer exposure to elevated blood pressure, and the proliferation of modern noninvasive imaging modalities have all contributed to the growing awareness of acute and chronic aortic syndromes. Despite recent progress in recognition of both the epidemiological problem and diagnostic and therapeutic advances, the cardiology community and the medical community in general are far from comfortable in understanding the spectrum of aortic syndromes and defining an optimal pathway to manage aortic diseases.1–13 This comprehensive review is organized in two parts, with a focus on the etiology, natural history, and classification (with vascular staging) of aortic wall disease in Part I and emphasis on therapeutic management and follow-up in Part II. Both parts may help to better integrate the complexities of acute aortic syndromes.
587Â citations
TL;DR: Insight is provided into current-day profiles and outcomes of acute type B aortic dissection and factors associated with increased in-hospital mortality should be identified and taken into consideration for risk stratification and decision-making.
Abstract: Background— Clinical profiles and outcomes of patients with acute type B aortic dissection have not been evaluated in the current era. Methods and Results— Accordingly, we analyzed 384 patients (65±13 years, males 71%) with acute type B aortic dissection enrolled in the International Registry of Acute Aortic Dissection (IRAD). A majority of patients had hypertension and presented with acute chest/back pain. Only one-half showed abnormal findings on chest radiograph, and almost all patients had computerized tomography (CT), transesophageal echocardiography, magnetic resonance imaging (MRI), and/or aortogram to confirm the diagnosis. In-hospital mortality was 13% with most deaths occurring within the first week. Factors associated with increased in-hospital mortality on univariate analysis were hypotension/shock, widened mediastinum, periaortic hematoma, excessively dilated aorta (≥6 cm), in-hospital complications of coma/altered consciousness, mesenteric/limb ischemia, acute renal failure, and surgical man...
546Â citations
TL;DR: Compared with older patients with AoD, young patients have unique risk factors for dissection: Marfan syndrome, bicuspid aortic valves, and larger aorta dimensions.
419Â citations
TL;DR: This comprehensive review is organized in two parts, with focus on etiology, natural history, and classification (with vascular staging) of aortic wall disease in Part I and emphasis on therapeutic management and follow-up in Part II.
Abstract: Cardiovascular disease is the leading cause of death in most Western societies and is increasing steadily in many developing countries. Aortic diseases constitute an emerging share of the burden. New diagnostic imaging modalities, longer life expectancy in general, longer exposure to elevated blood pressure, and the proliferation of modern noninvasive imaging modalities have all contributed to the growing awareness of acute and chronic aortic syndromes. Despite recent progress in recognition of both the epidemiological problem and diagnostic and therapeutic advances, the cardiology community and the medical community in general are far from comfortable in understanding the spectrum of aortic syndromes and defining an optimal pathway to manage aortic diseases.1–13 This comprehensive review is organized in two parts, with focus on etiology, natural history, and classification (with vascular staging) of aortic wall disease in Part I and emphasis on therapeutic management and follow-up in Part II. Both parts may help to better integrate the complexities of acute aortic syndromes.
330Â citations
TL;DR: In both DM and non-DM, patients with CAD treated with PD had significantly poorer survival compared with HD, and differences in solute clearance and/or cardiac risk profiles between PD and HD may explain these findings deserves further investigation.
Abstract: It is unclear whether peritoneal dialysis (PD) compared with hemodialysis (HD) confers a survival advantage in end-stage renal disease (ESRD) patients with coronary artery disease (CAD). This hypothesis was tested in a national cohort of 107,922 patients starting dialysis therapy between May 1, 1995, and July 31, 1997. Data on patient characteristics were obtained from the Center for Medicare and Medicaid Services Medical Evidence Form (CMS) and linked to mortality data from the United States Renal Data System (USRDS). Patients were classified on the basis of CAD presence and followed until death or the end of 2 yr. Nonproportional Cox regression models estimated the relative risk (RR) of death for patients with and without CAD by dialysis modality using primarily the intent-to-treat but also the as-treated approach. Diabetic patients (DM) and nondiabetic patients (non-DM) were analyzed separately. Among DM, patients with CAD treated with PD had a 23% higher RR (95% CI, 1.12 to 1.34) compared with similar HD patients, whereas patients without CAD receiving PD had a 17% higher RR (CI, 1.08 to 1.26) compared with HD. Among non-DM, patients with CAD treated with PD had a 20% higher RR (CI. 1.10 to 1.32) compared with HD patients, whereas patients without CAD had similar survival on PD or HD (RR = 0.99; CI, 0.93 to 1.05). The mortality risk for new ESRD patients with CAD differed by treatment modality. In both DM and non-DM, patients with CAD treated with PD had significantly poorer survival compared with HD. Whether differences in solute clearance and/or cardiac risk profiles between PD and HD may explain these findings deserves further investigation.
226Â citations
TL;DR: Although GP IIb/IIIa antagonist use in patients with ACS and renal insufficiency resulted in increased bleeding events, its administration was associated with a decreased risk of in-hospital mortality.
177Â citations
TL;DR: Compared with patients with ACS without any AF, previous and new-onset AF are associated with increased hospital morbidity and mortality, however, only new-ONSet AF is an independent predictor of in-hospital adverse events in patients with ACS.
Abstract: Preexisting or new-onset atrial fibrillation (AF) commonly occurs in patients with an acute coronary syndrome (ACS). However, it is currently unknown if previous or new-onset AF confers different risks in these patients. To determine the prognostic significance of new-onset and previous AF in patients with ACS, we evaluated all patients with ACS enrolled in the multinational Global Registry of Acute Coronary Events (GRACE) between April 1999 and September 2001. We compared clinical characteristics, management, and hospital outcomes in patients with ACS and new-onset and previous AF with those without AF. Of a total of 21,785 patients with ACS enrolled in GRACE, 1,700 (7.9%) had previous AF and 1,221 (6.2%) had new-onset AF. Patients with any AF were older, more likely to be women, had more co-morbid conditions, and worse hemodynamic status. Most in-hospital adverse events (reinfarction, shock, pulmonary edema, bleeding, stroke, and mortality) were significantly higher in patients with any AF than those without AF. Only new-onset AF (not previous AF) was an independent predictor of all adverse in-hospital outcomes. We conclude that compared with patients with ACS without any AF, previous and new-onset AF are associated with increased hospital morbidity and mortality. However, only new-onset AF is an independent predictor of in-hospital adverse events in patients with ACS.
151Â citations
TL;DR: The goal of appropriate preoperative evaluation and therapy should be to not only improve immediate periprocedural outcomes but also to improve long term clinical outcome.
Abstract: The prevalence of cardiovascular disease in the United States1 and the number of noncardiac surgical procedures performed are progressively increasing. Preoperative risk assessment is an important step in reducing perioperative morbidity and mortality in patients undergoing noncardiac surgery. Successful perioperative evaluation is best achieved by combining an integrated multidisciplinary approach with good communication between the patient, primary care physician, anesthesiologist, consultant, and surgeon. The goal of appropriate preoperative evaluation and therapy should be to not only improve immediate periprocedural outcomes but also to improve long term clinical outcome.
### Case
A 68-year-old man with diabetes, hyperlipidemia, and lifestyle-limiting claudication requires aorto-bifemoral bypass surgery. He has a history of prior myocardial infarction 6 years ago and has had infrequent episodes of angina since then. His ability to perform physical activity is limited by claudication. He is currently taking aspirin, long-acting nitrates, glyburide, and lovastatin. Does he need further evaluation before his elective surgery? What can be done to minimize his risk of perioperative complications?
#### (1) Assess the Patient’s Clinical Features
The history and physical examination should emphasize identification of markers of cardiac risk and assess the patient’s cardiac status. High-risk cardiac conditions include recent myocardial infarction (MI), decompensated heart failure (HF), unstable angina, symptomatic arrhythmias, and symptomatic valvular heart disease. The patient’s underlying cardiac conditions, although apparently stable at present, may become manifest during perioperative stresses. Such conditions include stable angina, distant MI, prior HF, or moderate valvular disease. One should also identify serious comorbid conditions such as diabetes, stroke, renal insufficiency, and pulmonary disease because these illnesses may also affect periprocedural outcomes. Table 1 lists the factors that increase the risk of perioperative cardiac complications in patients undergoing noncardiac surgery.2
View this table:
TABLE 1. Factors That Increase the Risk of Perioperative Cardiac Complications and Indications for Perioperative β-Blocker Therapy
#### (2) Evaluate Functional Status
The history should assess functional capacity (the ability to …
59Â citations
TL;DR: What has been learned about the process of guideline implementation is reviewed, the major research questions that need to be addressed are laid out, and it is argued that professional societies play a critical role in moving from guideline development to application.
Abstract: Major opportunity exists to better align clinical science and clinical practice. To do so will require efforts not only to develop clinical practice guidelines, but to facilitate their application in practice. The American College of Cardiology operates a program to develop and assess the effectiveness of tools that facilitate the application of guidelines in practice. Here we review what we have learned about the process of guideline implementation, lay out the major research questions that need to be addressed, and argue that professional societies play a critical role in moving from guideline development to application.
46Â citations
TL;DR: The role of systemic hypertension in acute coronary syndrome (ACS) has not been well studied, and at 6-month follow-up, age- and gender-adjusted odds ratios for adverse events were equivalent in hypertensives and normotensives, suggesting no continuing differential treatment benefit in the months after the initial ACS episode.
Abstract: The role of systemic hypertension in acute coronary syndrome (ACS) has not been well studied. We studied consecutive subjects admitted to the University of Michigan Health System (Ann Arbor, Michigan) with symptoms of ACS. Data were collected using a standardized form. This observational study is currently ongoing; we collected data from May 1999 to December 2000 for 979 subjects, 890 of whom also had 6-month follow-up data. Hypertensives represented 64.4% (n = 630) of the total population. In general, hypertensive patients were older than normotensives (66.3 vs 59.9 years, p <0.0001), more often women (38.7% vs 26.9%, p = 0.0002), and had more comorbidities, such as previous myocardial infarction (47.9% vs 33.8%, p <0.0001), congestive heart failure (25.7% vs 12.0%, p <0.0001), and diabetes (36.9% vs 17.8%, p <0.0001). At admission, hypertensives had higher systolic blood pressure. Hypertensives had fewer electrocardiographic abnormalities indicating ischemic changes (67.9% vs 76.3%, p = 0.01) and had fewer incident of acute myocardial infarction (AMI) (70.7% vs 76.1%, p = 0.07) than normotensives. There was consistency over different levels of admission systolic blood pressure. Hypertensives received more oral cardiovascular drugs, and had undergone more invasive procedures. The lower rate of AMI in hypertensives seemed to be related to the higher frequency of a history of percutaneous coronary intervention and coronary artery bypass grafting. However, at 6-month follow-up, age- and gender-adjusted odds ratios for adverse events were equivalent in hypertensives and normotensives, suggesting no continuing differential treatment benefit for hypertensives in the months after the initial ACS episode.
TL;DR: Developing and fostering a collaborative culture allowed hospital teams to avoid barriers or overcome them successfully based on others' experiences and collectively solve problems, and it shortened the learning curve and accelerated QI.
TL;DR: In patients with troponin-negative acute coronary syndromes, creatine kinase (CK)-MB elevation predicts a significantly higher risk of death and major acute cardiac events compared with CK-MB negative patients.
Abstract: In patients with troponin-negative acute coronary syndromes, creatine kinase (CK)-MB elevation predicts a significantly higher risk of death and major acute cardiac events compared with CK-MB negative patients. This risk is accentuated in troponin-negative, CK-MB positive patients who do not demonstrate ST elevation by electrocardiogram.
TL;DR: It is documented that patients with thoracic aortic dissections are at risk to harbor or develop a later AAA, and this finding supports the tenet that abdominal CTs or ultrasound scanning should be mandatory in the follow-up of patients with known thoraco-aortic dissection.
TL;DR: Extracardiac vascular disease is associated with an increased risk of in-hospital mortality and other complications after coronary interventions, independent from other co-morbidities and baseline characteristics.
Abstract: Extracardiac vascular disease is associated with an increased risk of in-hospital mortality and other complications after coronary interventions, independent from other co-morbidities and baseline characteristics. The underlying cause of this significant association is unclear, but it warrants further investigation in an attempt to improve outcome in this high-risk cohort.
TL;DR: The presence of extracardiac vascular disease was found to be associated with a significantly higher risk for late mortality and cerebrovascular disease was less common but was related with a trend towards worse survival.
Abstract: Patients with extracardiac vascular disease were identified from 2,372 consecutive percutaneous coronary intervention (PCI) cases performed between 1997 and 2001. After multivariate adjustment, we found the presence of extracardiac vascular disease to be associated with a significantly higher risk for late mortality (hazard ratio [HR] 1.4, 95% confidence interval [CI] 1.0 to 2.0, p = 0.029). When extracardiac vascular disease was separated into cerebrovascular disease and peripheral vascular disease, cerebrovascular disease was less common but was associated with a trend towards worse survival.
Journal Article•
TL;DR: Risk adjustment appears to be a valid tool for assessing the effectiveness of cost reduction and quality improvement efforts in percutaneous coronary intervention efforts independently from changes in case mix, despite an increase in case complexity and utilization of new technology.
Abstract: OBJECTIVE To describe cost reduction and quality improvement efforts in our percutaneous coronary intervention (PCI) program and how risk adjustment was used to assess the effects of these changes. STUDY DESIGN Single center registry analysis. PATIENTS AND METHODS Data were collected on 2158 PCIs performed between July 1, 1994, and June 30, 1997. Of these, 1126 PCIs reflected care provided after implementation of competitive bidding for catheterization lab supplies, and efforts to reduce the use of postprocedure heparin and to implement early arterial sheaths removal (postbidding period). Hospital costs were estimated using a microcost accounting method. In-hospital mortality rates during the 2 time periods were compared using standardized mortality ratio estimated with a previously validated risk adjustment model for in-hospital mortality. RESULTS Compared with the prebidding period, the postbidding period was characterized by a significantly higher utilization of new technology (coronary stents and atherectomy devices 46% vs 25%; abciximab 19.1% vs 3.7, P<.01), and an overall increase in case complexity. Despite these changes, the average and median postbidding cost per case was dollars 1223 and dollars 1444 lower, respectively, than in the prebidding period. After adjustment for comorbidities, procedure variables, complications, and length of hospital stay, multivariate regression modeling identified the postbidding period as an independent predictor of lower hospital costs (P<.001) with an estimated adjusted cost savings of dollars 460. These cost savings were associated with trends toward a lower observed mortality rate, a higher predicted mortality rate, and a significantly lower standardized mortality ratio (SMR .71; 95% CI 0.48-0.9; P<.05). CONCLUSION Despite an increase in case complexity and utilization of new technology, cost reductions can be achieved through competitive bidding for supplies and modifications of periprocedure care. Risk adjustment appears to be a valid tool for assessing the effectiveness of these efforts independently from changes in case mix.
TL;DR: The increasing trend toward the use of low-molecular weight heparin as a protective anticoagulant for atrial fibrillation is noted, despite the lack of controlled data about its efficacy.
Book•
01 Jan 2003
TL;DR: In this paper, the authors present a comprehensive evaluation of common Cardiovascular Symptoms, including Chest Pain, Chest Fatigue, Stable Angina, and Paroxysmal Supraventricular Tachycardia.
Abstract: Section I. Evaluation of Common Cardiovascular Symptoms Section Editor: Ragavendra R. Baliga Chest Pain ... 1 Thippeswamy H. Murthy and Peter G. Hagan Dyspnea ... 16 Fernando J. Martinez and Keith D. Aaronson Palpitations ... 30 Michael H. Lehmann Edema ... 46 Peter V. Vaitkevicius and Ragavendra R. Baliga Syncope ... 55 Ragavendra R. Baliga and Michael H. Lehmann Approach to Claudication ... 80 Sanjay Rajagopalan and Thomas W. Wakefield Section II. Evaluation and Management of Common Cardiovascular Conditions A. Coronary Artery Disease Section Editors: Eric R. Bates and Richard L. Prager Primary Prevention of Coronary Artery Disease ... 88 Melvyn Rubenfire and Eric R. Bates Secondary Prevention of Coronary Artery Disease ... 113 Claire Duvernoy and Melvyn Rubenfire Stable Angina ... 135 Steven W. Werns Unstable Angina/Non-ST Elevation Myocardial Infarction ... 151 Stanley Chetcuti, Francis D. Pagani, and Eric R. Bates Acute ST Elevation Myocardial Infarction ... 170 Debabrata Mukherjee and Eric R. Bates B. Hypertension Section Editor: Ragavendra R. Baliga Primary Hypertension ... 188 Kenneth A. Jamerson Approach to Secondary Hypertension ... 199 John D. Bisognano C. Congestive Heart Failure Section Editor: Robert J. Cody Heart Failure Due to Left Ventricular Systolic Dysfunction ... 207 Todd M. Koelling and Robert J. Cody Congestive Heart Failure with Preserved Systolic Function ... 239 Ragavendra R. Baliga, Mauro Moscucci, and Robert J. Cody D. Arrhythmias Section Editor: Fred Morady Paroxysmal Supraventricular Tachycardia ... 264 Hakan Oral and Fred Morady Atrial Fibrillation and Atrial Flutter ... 273 Frank Pelosi, Jr., and Fred Morady Ventricular Tachycardia ... 286 Bradley P. Knight and Fred Morady Bradycardia ... 309 Bradley P. Knight and William Kou E. Valvular Heart Disease Section Editor: Mark R. Starling Infective Endocarditis ... 335 Ragavendra R. Baliga and Sunil Das Mitral Regurgitation ... 353 David S. Bach, Mark R. Starling, and Steven F. Bolling Aortic Regurgitation ... 362 David S. Bach, Michael J. Shea, and G. Michael Deeb Mitral Stenosis ... 371 Mani A. Vannan Aortic Stenosis ... 384 Ragavendra R. Baliga, Mauro Moscucci, Michael J. Shea, and G. Michael Deeb Tricuspid/Pulmonary Valve Disease ... 399 Theodore J. Kolias, Julie A. Kovach, and William F. Armstrong F. Pericardial Disease Section Editor: William F. Armstrong Acute Pericarditis/Pericardial Effusion ... 409 Mani A. Vannan and Mauro Moscucci Pericardial Constriction ... 419 Julie A. Kovach and Richard L. Prager G. Aortic and Major Vascular Diseases Section Editors: G. Michael Deeb and James C. Stanley
TL;DR: The investigation showed that an outpatient, emergency department based disease management strategy for new, uncomplicated AF could result in clinically acceptable, cost-effective innovations in AF treatment strategies and LMWH is an example of an agent allowing innovations in disease management strategies.
Abstract: Background: Atrial fibrillation (AF) is the most common sustained arrhythmia and various AF disease management strategies can be utilized.
TL;DR: Clinical trials have documented the benefits of warfarin in atrial fibrillation, angiotensin-converting enzyme (ACE) and the sources of quality deficits are difficult to determine.
Journal Article•
TL;DR: This review focuses on the revised American College of Cardiology/ American Heart Association guidelines for the management of patients presenting with UA/NSTEMI, and concludes that an optimal single strategy encompassing most patients’ needs is not clear.
Abstract: Unstable angina (UA) and non-ST-segment elevation myocardial infarction (NSTEMI) refer to a spectrum of acute severe cardiac disorders characterized by myocardial oxygen demand and supply mismatch, caused by atherosclerotic coronary artery disease. Patients presenting with acute coronary syndromes represent a major medical problem, accounting for 2.5 million hospitalizations and 500,000 deaths annually in the United States alone. Of these, 1.5 million have a final diagnosis of UA, and myocardial infarction (ST-segment and non-ST-segment elevation) accounts for the remaining 1 million. The management of UA/NSTEMI presents a challenge to the cardiologist because treatment strategies continue to evolve. A number of trials have now assessed the safety and efficacy of early revascularization strategies in the treatment of patients with UA/NSTEMI, whereas others have focused on pharmacologic adjunctive therapy. An optimal single strategy encompassing most patients’ needs is not clear. This review focuses on the revised American College of Cardiology/ American Heart Association guidelines for the management of patients presenting with UA/NSTEMI.