Showing papers by "Kim A. Eagle published in 2005"
TL;DR: In this paper, the authors assessed differences in practice patterns, comorbidities, and in-hospital event rates, by age and type of acute coronary syndrome (ACS).
523 citations
TL;DR: The International Registry of Acute Aortic Dissection experience confirms that patient selection plays an important role in determining surgical outcomes in patients with acute type A aortic dissection and knowledge of significant risk factors for operative mortality can contribute to better management and a more defined risk assessment in patients affected by acute type C aorta dissection.
514 citations
TL;DR: This report reviews the etiology, pathophysiology, clinical presentation, outcomes, and therapeutic approaches to acute aortic syndromes and summarizes the most clinically relevant issues as “take home points” (THPs) to affirm their importance in the diagnosis and management of this disorder.
Abstract: Acute aortic syndromes (AAS) comprise a group of potentially lethal conditions that require prompt recognition, diagnosis as well as acute medical stabilization and surgical intervention. The purpose of this article is to review the relevant variants of AAS presentation, as well as diagnostic and management issues, including adequate long-term medical therapy and follow-up imaging. In this context, the American College of Cardiology and the American Heart Association recently published guidelines on the management of thoracic aortic disease, drawing greater attention to these processes.
499 citations
TL;DR: The American College of Cardiology (ACC) and the American Heart Association (AHA) have developed a multifaceted strategy to facilitate the process of improving clinical care.
435 citations
TL;DR: The IRAD data demonstrate a 5.7% prevalence of IMH in patients with acute aortic syndromes, and like classic AD, IMH is a highly lethal condition when it involves the ascending aorta and surgical therapy should be considered, but this condition is less critical when limited to the arch or descending aorti.
Abstract: Background— The definition, prevalence, outcomes, and appropriate treatment strategies for acute intramural hematoma (IMH) continue to be debated. Methods and Results— We studied 1010 patients with acute aortic syndromes who were enrolled in the International Registry of Aortic Dissection (IRAD) to delineate the prevalence, presentation, management, and outcomes of acute IMH by comparing these patients with those with classic aortic dissection (AD). Fifty-eight (5.7%) patients had IMH, and this cohort tended to be older (68.7 versus 61.7 years; P<0.001) and more likely to have distal aortic involvement (60.3% versus 35.3%; P<0.001) compared with 952 patients with AD. Patients with IMH described more severe initial pain than did those with AD but were less likely to have ischemic leg pain, pulse deficits, or aortic valve insufficiency; moreover, they required a longer time to diagnosis and more diagnostic tests. Overall mortality of IMH was similar to that of classic AD (20.7% versus 23.9%; P=0.57), as was...
401 citations
TL;DR: The methodology by which the American College of Cardiology and the American Heart Association approach creating performance measures and devising techniques for quantifying those aspects of care that directly reflect the quality of cardiovascular care is described.
Abstract: The ability to quantify the quality of cardiovascular care critically depends on the translation of recommendations for high-quality care into the measurement of that care. As payers and regulatory agencies increasingly seek to quantify healthcare quality, the implications of the measurement process on practicing physicians are likely to grow. This statement describes the methodology by which the American College of Cardiology and the American Heart Association approach creating performance measures and devising techniques for quantifying those aspects of care that directly reflect the quality of cardiovascular care. Methods for defining target populations, identifying dimensions of care, synthesizing the literature, and operationalizing the process of selecting measures are proposed. It is hoped that new sets of measures will be created through the implementation of this approach, and consequently, through the use of such measurement sets in the context of quality improvement efforts, the quality of cardiovascular care will improve.
324 citations
TL;DR: In this article, the impact of the American College of Cardiology's Guidelines Applied in Practice (GAP) project for acute myocardial infarction (AMI) care, encompassing 33 acute-care hospitals in southeastern Michigan, on rates of mortality in Medicare patients treated in Michigan was evaluated.
227 citations
TL;DR: There are significant differences in case mix between patients undergoing PCI in Michigan and New York that result in marked differences in unadjusted mortality rates.
176 citations
TL;DR: These findings support the current strategy of directing patients with suspected acute coronary syndrome to the nearest hospital with acute care facilities, irrespective of the availability of a catheterisation laboratory, and argue against early routine transfer of these patients to tertiary care hospitals with interventional facilities.
Abstract: Objective To investigate the relation between access to a cardiac catheterisation laboratory and clinical outcomes in patients admitted to hospital with suspected acute coronary
129 citations
TL;DR: The Global Registry of Acute Coronary Events risk score appears to be a useful risk stratification tool that identifies high-risk patients for whom more aggressive treatment is warranted.
Abstract: In the prospective, multicenter Canadian Acute Coronary Syndromes Registry, in-hospital revascularization was independently associated with better 1-year survival only among patients with high-risk non-ST-elevation acute coronary syndromes stratified by the Global Registry of Acute Coronary Events risk score; similar benefits were not observed in the low- and intermediate-risk groups. The Global Registry of Acute Coronary Events risk score appears to be a useful risk stratification tool that identifies high-risk patients for whom more aggressive treatment is warranted.
118 citations
TL;DR: The relationship between operator volume and in-hospital mortality is no longer significant, but the relationship between volume and any adverse outcome is still present and high volume operators had better outcomes than low volume operators in low-risk and high-risk patients.
TL;DR: CPA determination is superior to CCS, IMT, and CRP in its ability to reduce the likelihood of clinically significant underlying CAD in patients of varying cardiac risk.
Abstract: Objective— Coronary calcium score (CCS), carotid plaque area (CPA), intima-media thickness (IMT), and C-reactive protein (CRP) are independent predictors of cardiovascular prognosis. Although each test may enhance risk stratification, their comparative abilities to screen for underlying coronary stenoses in individual patients is less established.
Methods and Results— Forty-two patients who had a 16-slice coronary computed tomography angiogram (CTA) performed were invited to have CPA, IMT, and CRP measured. CPA was defined as the sum of all the cross-sectional areas of each plaque >1 mm in diameter found in all carotid vessels bilaterally. CCS and the number plus degree of stenotic coronary arteries were determined by CTA. The presence of clinically significant coronary artery disease (CAD) was defined as the existence of any stenosis ≥50%. CTA identified clinically significant CAD in 43% of the patients. CPA >0 was more sensitive (72%) and specific (58%) than a CCS >0 (58% and 55%) for identifying CAD. A “clean” carotid artery (CPA=0) provides a superior negative predictive value (74%) and likelihood ratio of a negative test (0.48) than all other studies, in particular versus a CCS=0 (65% and 0.72). The areas under the receiver-operator curves for CPA and CCS in relation to any CAD were similar (0.640 versus 0.675). Carotid IMT and CRP performed poorly compared with CPA and CCS. For detecting CAD in only the left main or left anterior descending artery, the negative predictive value and likelihood ratio of a negative test remained superior for CPA (87% and 0.33) compared with CCS (80% and 0.56). In our population with a prevalence of these coronary lesions of 30%, the post-test probability in any patient with a negative CPA result is reduced to 10%.
Conclusion— CPA determination is superior to CCS, IMT, and CRP in its ability to reduce the likelihood of clinically significant underlying CAD in patients of varying cardiac risk.
TL;DR: Determining beliefs about illness and medication may be helpful in developing interventions aimed at improving adherence after ACS, as not all patients continue their drugs or take them exactly as prescribed.
Abstract: BACKGROUNDNonadherence to medication may lead to poor medical outcomes.OBJECTIVETo describe medication-taking behavior of patients with a history of acute coronary syndromes (ACS) for 4 classes of drugs and determine the relationship between self-reported adherence and patient characteristics.METHODSConsenting patients with the diagnosis of ACS were interviewed by telephone approximately 10 months after discharge. The survey elicited data characterizing the patient, current medication regimens, beliefs about drug therapy, reasons for discontinuing medications, and adherence. The survey included the Beliefs About Medicine Questionnaire providing 4 scales: Specific Necessity, Specific Concerns, General Harm, and General Overuse, and the Medication Adherence Scale (MAS). Multivariate regression was used to determine the independent variables with the strongest association to the MAS. A p value ≤0.05 was considered significant for all analyses.RESULTSTwo hundred eight patients were interviewed. Mean ± SD age ...
TL;DR: In this article, the authors identify patient and health care factors which are related to the use of medical treatments that comprise quality measures and assess the relation of these measures with mortality and identify factors associated with failure to use proven treatments, including high-risk groups that would derive particular benefit from effective therapies.
TL;DR: Level of responses to EQ‐5D items and the EQ VAS score were significantly better for patients with very mild/mild perceived disease severity compared to severe/very severe, for patientswith lower comorbidity, for Patients with lower symptom responses, and for patientsWith a higher cardiac-related functioning.
Abstract: Objective: To analyze the construct validity of the EQ‐5D in patients with acute coronary syndromes (ACS).Methods: All ACS-diagnosed patients discharged from a university-affiliated hospital during...
TL;DR: In general, patients who returned written consent forms during the post-HIPAA period were older, were more likely to be married, and had lower mortality rates at 6 months, compared with other patients with acute coronary syndrome.
Abstract: Background Implementation of the Health Insurance Portability and Accountability Act (HIPAA) Privacy Rule has the potential to affect data collection in outcomes research. Methods To examine the extent to which data collection may be affected by the HIPAA Privacy Rule, we used a quasi-experimental pretest-posttest study design to assess participation rates with informed consent in 2 cohorts of patients eligible for the University of Michigan Acute Coronary Syndrome registry. The pre-HIPAA period included telephone interviews conducted at 6 months that sought verbal informed consent from patients. In the post-HIPAA period, informed consent forms were mailed to ask for permission to call to conduct a telephone interview. The primary outcome measure was the percentage of patients who provided consent. Incremental costs associated with the post-HIPAA period were also assessed. Results The pre-HIPAA period included 1221 consecutive patients with acute coronary syndrome, and the post-HIPAA period included 967 patients. Consent for follow-up declined from 96.4% in the pre-HIPAA period to 34.0% in the post-HIPAA period (P Conclusions The HIPAA Privacy Rule significantly decreases the number of patients available for outcomes research and introduces selection bias in data collection for patient registries.
TL;DR: The results and knowledge gleaned from these projects show the best practices relative to guidelines applied consistently at the bedside in the three American College of Cardiology Acute Myocardial Infarction Guidelines Applied in Practice demonstration projects.
TL;DR: There is a significant difference in the number of AAD events occurring during the different seasons of the year, with highest incidence in winter and lowest incidence in summer, suggesting that the relative change in temperature, rather than absolute temperature, and/or endogenous annual rhythms are critical mechanistic factors.
Abstract: We recently reported the existence of a higher risk of acute aortic dissection (AAD) during the winter months. However, it is not known whether this winter peak is affected by climate. To address this issue, we evaluated data from 969 AAD patients who were enrolled at various sites around the globe and who were participating in the International Registry of Acute Aortic Dissection (IRAD). We found a significant (p = 0.001; chi2 test) difference in the number of AAD events occurring during the different seasons of the year, with highest incidence in winter (28.4%) and lowest incidence in summer (19.9%). Furthermore, the winter peak was evident in both cold and temperate climate settings, suggesting that the relative change in temperature, rather than absolute temperature, and/or endogenous annual rhythms are critical mechanistic factors.
TL;DR: This article reviews the existing literature on the effectiveness of PPAR-gamma agonists in patients with either overt diabetes or a prediabetic state and demonstrates that insulin sensitizers such as thiazolidinediones appear to be associated with better clinical outcomes compared to insulin providers in diabetic patients presenting with acute coronary syndromes.
Abstract: The peroxisome proliferator-activated receptors (PPARs) are nuclear fatty acid receptors, which contain a type II zinc finger DNA binding motif and a hydrophobic ligand binding pocket. These receptors are thought to play an important role in metabolic diseases such as obesity, insulin resistance, and coronary artery disease. Three subtypes of PPAR receptors have been described: PPARalpha, PPARdelta/beta, and PPARgamma. PPARalpha is found in the liver, muscle, kidney, and heart. In the liver, its role is to up-regulate genes involved in fatty acid uptake (beta-oxidation and omega-oxidation). PPARdelta/beta is involved in fatty acid oxidation in muscle. PPARgamma has high expression in fat, low expression in the liver, and very low expression in the muscle. The thiazolidinediones (TZD) are synthetic ligands of PPARgamma. By activating a number of genes in tissues, PPARgamma increases glucose and lipid uptake, increases glucose oxidation, decreases free fatty acid concentration, and decreases insulin resistance. There is a sound rationale for the use of TZDs in patients with type 2 diabetes mellitus and promising preliminary data in patients with patients with pre-diabetes. In patients with type 2 diabetes, thiazolidinediones had been shown to decrease mean HbA(1c)by 1.5% and lower HbA(1c) to less than 7% in 30% of patients. Decreased muscle insulin resistance primarily mediates the glucose lowering effect. In addition, there are several nonhypoglycemic effects of TZDs which may be beneficial to both diabetics and patients with pre-diabetes. These include effects on lipid metabolism, blood pressure, endothelial function, atherosclerotic plaque, coagulation, and albuminuria. In a pilot study, we recently demonstrated that insulin sensitizers such as thiazolidinediones appear to be associated with better clinical outcomes compared to insulin providers in diabetic patients presenting with acute coronary syndromes. In another study, we showed that the prediabetic state is a marker for worse prognosis in patients with acute coronary syndromes. In this article, we review the existing literature on the effectiveness of PPAR-gamma agonists in patients with either overt diabetes or a prediabetic state.
TL;DR: It was concluded that hypotension that occurred in >25% of patients who had acute aortic dissection was associated with a much higher rate of in-hospital adverse events and factors associated with hypotension were identified.
Abstract: To evaluate the clinical characteristics, risk factors, and outcomes of hypotension in unselected patients who had acute aortic dissection (AAD), we studied 1,073 such patients who were enrolled in the International Registry of Acute Aortic Dissection between 1996 and 2001. Hypotension was noted in 313 patients (29.2%) who had AAD (46.0% on admission). Multivariate logistic regression identified age ≥70 years (odds ratio [OR] 2.0, 95% confidence interval [CI] 1.4 to 2.9), type A dissection (referent type B AAD; OR 2.1, 95% CI 1.4 to 3.2), neurologic deficit (OR 3.8, 95% CI 2.2 to 6.6), syncope (OR 2.9, 95% CI 1.8 to 4.7), aortic regurgitation requiring valve surgery (OR 1.9, 95% CI 1.1 to 3.3), cardiac tamponade (OR 5.1, 95% CI 3.0 to 8.8), and new Q-wave or ST-segment deviation on an electrocardiogram (OR 1.6, 95% CI 1.1 to 2.4) as independent associations of hypotension (c statistic 0.78). Hospital complications (neurologic deficits 22.7% vs 12.0%, altered mental status 26.1% vs 4.4%, myocardial ischemia 14.6% vs 6.9%, mesenteric ischemia 6.9% vs 2.6%, or limb ischemia 14.6% vs 6.9%, and death 55.0% vs 10.3%) occurred more frequently in patients who had hypotension than in those who did not (p 25% of patients who had AAD was associated with a much higher rate of in-hospital adverse events. Our study also identified factors associated with hypotension in patients who had AAD.
TL;DR: While highest incidence of AAD occurred in the morning and winter, clinical events were similar during the four different periods of the 24 h periods, and the χ2 test for goodness of fit was used to evaluate non‐uniformity of the time of day and time of year for critical in‐hospital clinical events, including death.
Abstract: The risk of acute aortic dissection (AAD) exhibits chronobiological variations with peak onset in the morning and in winter. However, it is not known whether the time of day or season of the year of the AAD affects clinical outcomes. We studied 1,032 patients enrolled in the International Registry of Acute Aortic Dissection from January 1997 to December 2001. For circadian and seasonal analysis, the time and date of symptom onset were available for 741 and 1,007 patients, respectively, and were grouped into four 6 h periods (morning, afternoon, evening, and night) and four seasons (winter, spring, summer, and autumn). The χ2 test for goodness of fit was used to evaluate non‐uniformity of the time of day and time of year for critical in‐hospital clinical events, including death. While highest incidence of AAD occurred in the morning and winter, clinical events (including mortality) were similar during the four different periods of the 24 h (χ2=1.9, p=0.60) and seasonal (χ2=1.2, p=0.75) periods.
TL;DR: Overall patients with aortic dissection are at high risk for an adverse outcome and need to be managed aggressively in hospital and long term with frequent follow-up.
TL;DR: The data suggest that the combination of clopidogrel with a statin has synergistic effects on the clinical outcomes of patients with non-ST-segment elevation ACS.
Abstract: Aims To evaluate clinical outcomes associated with the combined use of clopidogrel and statins vs. clopidogrel alone on a background of aspirin therapy in patients with the spectrum of acute coronary syndromes (ACS).
Methods and results Utilizing data from the Global Registry of Acute Coronary Events, we studied 15 693 patients admitted with non-ST-segment elevation myocardial infarction (MI) or unstable angina, dividing them according to discharge medications: aspirin alone (group I); aspirin + clopidogrel (group II); aspirin + statin (group III); aspirin + clopidogrel + statin (group IV). Among the groups of patients in whom clopidogrel was used (groups II and IV), group II patients were older, more likely to have prior MI, but less likely to have a history of prior revascularization. In-hospital cardiac catheterization and revascularization rates were similar between groups II and IV. Importantly, Kaplan–Meier analysis showed that the 6 month mortality rate was lower in group IV (log-rank test 22.8, P <0.0001). The hazard ratio for the 6 month mortality rate was adjusted using the Cox proportional hazard model for confounding variables and for propensity score, and the 6 month mortality rate for patients in group IV remained lower compared with those in group II [0.59 (0.41–0.86), P <0.0001].
Conclusion Our data suggest that the combination of clopidogrel with a statin has synergistic effects on the clinical outcomes of patients with non-ST-segment elevation ACS.
TL;DR: Whether men and women with acute coronary syndrome differ in their perceptions of the severity of cardiac-related illness while controlling for the clinical severity of their condition is sought.
TL;DR: To the Editor: Congestive heart failure has long been recognized as a potential complication of aortic dissection (AoD); however, the understanding of the presentation of AoD with concomitant CHF has remained largely restricted to case reports.
TL;DR: Implementation of the ACC/AHA guidelines for cardiac risk assessment prior to noncardiac surgery in an internal medicine preoperative assessment clinic led to a more appropriate use of preoperative stress testing and β-blocker therapy while preserving a low rate of cardiac complications.
Abstract: Background: The American College of Cardiology/American Heart Association (ACC/AHA) publishes recommendations for cardiac assessment of patients undergoing noncardiac surgery with t
TL;DR: High-risk patients are more likely to undergo CABG at low-volume facilities where their risk of dying is higher, and differences in adjusted in-hospital mortality rates between low- and high-volume centers rose as the expected risk of in- hospital death increased.
Abstract: Background The impact of surgical risk on the relationship between hospital volume and outcomes in coronary artery bypass grafting (CABG) is uncertain. We assessed (1) whether in-hospital mortality rates differ across lower- and higher-volume hospitals by expected surgical risk and (2) whether high-risk patients are more likely to undergo CABG at low-volume centers. Methods We used clinical data on 27 355 adults who underwent CABG at 68 hospitals in California between 1997 and 1998. Hospitals were divided into low-volume (n = 44), medium-volume (n = 19), and high-volume (n = 5) categories on the basis of tertiles of annual CABG volume. Using hierarchical logistic regression and log-binomial regression models, we assessed for differences in in-hospital mortality rates across hospital volume categories and the likelihood of CABG being performed in each hospital volume category after adjusting for expected surgical risk. Results Differences in adjusted in-hospital mortality rates between low- and high-volume centers rose as the expected risk of in-hospital death increased: 0.8% vs 0.4% at the 20th risk percentile and 3.8% vs 2.5% at the 80th risk percentile ( P P Conclusion High-risk patients are more likely to undergo CABG at low-volume facilities where their risk of dying is higher.
TL;DR: PVD-QI 2 is a prospective, multicenter observational study designed to improve the quality of care for patients undergoing PVI and to better understand the effectiveness and appropriateness of PVI in improving outcomes of peripheral arterial disease.
TL;DR: Depressive symptoms are common in patients diagnosed with acute coronary syndrome and appear to be related to lower mental health-related quality of life, and the importance of diagnosis and treatment of depression in this population is stressed.
TL;DR: In conclusion, this study provides insight into the profiles, presentation, and outcomes of patients with periaortic hematomas and acute aortic dissections and identifies factors associated with in-hospital mortality in patients with each type of dissections.
Abstract: The clinical profiles, presentation, and outcomes of patients with acute aortic dissections and associated periaortic hematomas on aortic imaging have not been described in a large cohort. This study sought to assess the prognostic implications of periaortic hematomas in patients with aortic dissections and to identify factors associated with in-hospital mortality in patients with periaortic hematomas. The study population was 971 patients with acute aortic dissections enrolled in the International Registry of Acute Aortic Dissection with available imaging data on presentation with the presence or absence of periaortic hematomas. Patients with periaortic hematomas (n = 227, 23.4%) were more likely to be women, to have a history of hypertension and atherosclerosis, and to present early to the hospital. At presentation, they had greater frequencies of shock, cardiac tamponade, coma, and/or altered consciousness. Clinical outcomes were significantly worse in patients with periaortic hematomas, including significantly greater mortality (33% vs 20.3%, p <0.001). A multivariate model demonstrated periaortic hematomas to be an independent predictor of mortality in patients with aortic dissections (odds ratio 1.71, 95% confidence interval 1.15 to 2.54, p = 0.007). In conclusion, this study provides insight into the profiles, presentation, and outcomes of patients with periaortic hematomas and acute aortic dissections. The early identification and aggressive management of patients with periaortic hematomas may potentially improve clinical outcomes.