Showing papers by "Kim A. Eagle published in 2006"
TL;DR: This risk prediction tool uses readily identifiable variables to provide robust prediction of the cumulative six month risk of death or myocardial infarction and can guide patient triage and management across the spectrum of patients with acute coronary syndrome.
Abstract: Objective To develop a clinical risk prediction tool for estimating the cumulative six month risk of death and death or myocardial infarction to facilitate triage and management of patients with acute coronary syndrome.
Design Prospective multinational observational study in which we used multivariable regression to develop a final predictive model, with prospective and external validation.
Setting Ninety four hospitals in 14 countries in Europe, North and South America, Australia, and New Zealand.
Population 43 810 patients (21 688 in derivation set; 22 122 in validation set) presenting with acute coronary syndrome with or without ST segment elevation enrolled in the global registry of acute coronary events (GRACE) study between April 1999 and September 2005.
Main outcome measures Death and myocardial infarction.
Results 1989 patients died in hospital, 1466 died between discharge and six month follow-up, and 2793 sustained a new non-fatal myocardial infarction. Nine factors independently predicted death and the combined end point of death or myocardial infarction in the period from admission to six months after discharge: age, development (or history) of heart failure, peripheral vascular disease, systolic blood pressure, Killip class, initial serum creatinine concentration, elevated initial cardiac markers, cardiac arrest on admission, and ST segment deviation. The simplified model was robust, with prospectively validated C-statistics of 0.81 for predicting death and 0.73 for death or myocardial infarction from admission to six months after discharge. The external applicability of the model was validated in the dataset from GUSTO IIb (global use of strategies to open occluded coronary arteries).
Conclusions This risk prediction tool uses readily identifiable variables to provide robust prediction of the cumulative six month risk of death or myocardial infarction. It is a rapid and widely applicable method for assessing cardiovascular risk to complement clinical assessment and can guide patient triage and management across the spectrum of patients with acute coronary syndrome.
1,273 citations
TL;DR: In this paper, the authors used data from a contemporary registry of acute type B aortic dissection to better understand factors associated with adverse long-term survival, and Cox proportional hazards analysis was performed to identify independent predictors of follow-up mortality.
Abstract: Background— Follow-up survival studies in patients with acute type B aortic dissection have been restricted to a small number of patients in single centers. We used data from a contemporary registry of acute type B aortic dissection to better understand factors associated with adverse long-term survival. Methods and Results— We examined 242 consecutive patients discharged alive with acute type B aortic dissection enrolled in the International Registry of Acute Aortic Dissection (IRAD) between 1996 and 2003. Kaplan-Meier survival curves were constructed, and Cox proportional hazards analysis was performed to identify independent predictors of follow-up mortality. Three-year survival for patients treated medically, surgically, or with endovascular therapy was 77.6±6.6%, 82.8±18.9%, and 76.2±25.2%, respectively (median follow-up 2.3 years, log-rank P=0.61). Independent predictors of follow-up mortality included female gender (hazard ratio [HR],1.99; 95% confidence interval [CI], 1.07 to 3.71; P=0.03), a hist...
663 citations
TL;DR: The American College of Cardiology and the American Heart Association have developed a multi-faceted strategy to facilitate the process of improving clinical care.
Abstract: Preamble......237
Medicine is experiencing an unprecedented focus on quantifying and improving health care quality. The American College of Cardiology (ACC) and the American Heart Association (AHA) have developed a multi-faceted strategy to facilitate the process of improving clinical care. The
368 citations
TL;DR: Insight into current-day clinical profiles and surgical outcomes of ABAD is provided by identifying primary factors that influenced surgical outcome and estimating average surgical mortality for ABAD in the current era.
Abstract: Background— The clinical profiles and outcomes of patients treated surgically for acute type B aortic dissection (ABAD) are often reported for those in small series or for those cared for at a single institution over a long time period, during which a continuous evolution in techniques has occurred. Accordingly, we sought to evaluate the clinical features and surgical results of patients enrolled in the International Registry of Acute Aortic Dissection by identifying primary factors that influenced surgical outcome and estimating average surgical mortality for ABAD in the current era. Methods and Results— A comprehensive analysis of 290 clinical variables and their relation to surgical outcomes for 82 patients who required surgery for ABAD (from a population of 1256 patients; mean±SD age, 60.6±15.0 years; 82.9% male) and who were enrolled in the International Registry of Acute Aortic Dissection was performed. The overall in-hospital mortality was 29.3%. Factors associated with increased surgical mortality based on univariate analysis were preoperative coma or altered consciousness, partial thrombosis of the false lumen, evidence of periaortic hematoma on diagnostic imaging, descending aortic diameter >6 cm, right ventricle dysfunction at surgery, and shorter time from the onset of symptoms to surgery. Factors associated with favorable outcomes included radiating pain, normotension at surgery (systolic blood pressure 100 to 149 mm Hg), and reduced hypothermic circulatory arrest time. The 2 independent predictors of surgical mortality were age >70 years (odds ratio, 4.32; 95% confidence interval, 1.30 to 14.34) and preoperative shock/hypotension (odds ratio, 6.05; 95% confidence interval, 1.12 to 32.49). Conclusions— The present study provides insights into current-day clinical profiles and surgical outcomes of ABAD. Knowledge about different preoperative clinical conditions may help surgeons in making treatment decisions among these high-risk patients.
342 citations
TL;DR: Treatment delays in reperfusion therapy are associated with higher 6-month mortality, but this relationship may be even more critical in patients receiving fibrinolytic therapy.
Abstract: Objective: Treatment delays may result in different clinical outcomes in patients with ST-segment elevation myocardial infarction (STEMI) who receive fibrinolytic therapy vs primary percutaneous coronary intervention (PCI). The aim of this analysis was to examine how treatment delays relate to 6-month mortality in reperfusion-treated patients enrolled in the Global Registry of Acute Coronary Events (GRACE). Design: Prospective, observational cohort study. Setting: 106 hospitals in 14 countries. Patients: 3959 patients who presented with STEMI within 6 h of symptom onset and received reperfusion with either a fibrin-specific fibrinolytic drug or primary PCI. Main outcome measures: 6-month mortality. Methods: Multivariable logistic regression was used to assess the relationship between outcomes and treatment delay separately in each cohort, with time modelled with a quadratic term after adjusting for covariates from the GRACE risk score. Results: A total of 1786 (45.1%) patients received fibrinolytic therapy, and 2173 (54.9%) underwent primary PCI. After multivariable adjustment, longer treatment delays were associated with a higher 6-month mortality in both fibrinolytic therapy and primary PCI patients (p Conclusions: Treatment delays in reperfusion therapy are associated with higher 6-month mortality, but this relationship may be even more critical in patients receiving fibrinolytic therapy.
177 citations
TL;DR: Differences in occurrence of chest pain and left arm pain between men and women are explainable by differences in co-morbidities and history; the higher occurrence of diaphoresis in men and of nausea in women is partly related to maleness or femaleness.
Abstract: This study evaluated symptom similarities and differences between men and women presenting with acute coronary syndromes (ACSs) and determined whether differences in presentation are intrinsic to patient gender or to other factors. This study was a subgroup analysis of patients from an ACS registry. We compared differences in symptom presentation between men and women and analyzed them using binary logistic regression with all variables and 2 × 2 interactions. Patient gender was forced to remain in the models. Women comprised 35% of the 1,941 patients admitted with confirmed ACS. Men were more likely to present with chest pain, left arm pain, or diaphoresis. Nausea was more common in women. Dyspnea did not differ between groups. After binary logistic regression, gender remained a statistically significant predictor of diaphoresis and nausea, but not of chest or left arm pain. We found that differences in occurrence of chest pain and left arm pain between men and women are explainable by differences in co-morbidities and history; the higher occurrence of diaphoresis in men and of nausea in women is partly related to maleness or femaleness. In conclusion, gender should be considered when evaluating patients with symptoms of ACS.
161 citations
TL;DR: Implementation of a regional continuous quality improvement program appears to be associated with enhanced adherence to quality indicators and improved outcomes of PCI, according to nonrandomized, observational data.
Abstract: Background— The objective of this study was to evaluate the association of a continuous quality improvement program with practice and outcome variations of percutaneous coronary intervention (PCI). Methods and Results— Data on consecutive PCI were collected in a consortium of 5 hospitals; 3731 PCIs reflected care provided at baseline (January 1, 1998, to December 31, 1998), and 5901 PCIs reflected care provided after implementation of a continuous quality improvement intervention (January 1, 2002, to December 31, 2002). The intervention included feedback on outcomes, working group meetings, site visits, selection of quality indicators, and use of bedside tools for quality improvement and risk assessment. Postintervention data were compared with baseline and with 10 287 PCIs from 7 hospitals added to the consortium in 2002. Quality indicators included use of preprocedural aspirin or clopidogrel, use of glycoprotein IIb/IIIa receptor blockers and postprocedural heparin, and amount of contrast media per case...
158 citations
TL;DR: The prognostic value of cardiac troponin, beyond that supplied by CK status or important baseline characteristics, assists in the identification of patients with ACS who are at increased risk for death.
106 citations
TL;DR: Patients with prior PAD received less aggressive treatment with proven cardiac medications during hospitalization for an ACS than patients without PAD and Utilization of beneficial medical therapies in patients with PAD before hospitalization with ACS was less than optimal.
79 citations
TL;DR: This pilot study suggests that the acute and subacute phase of both type A and type B aortic dissection is characterized by an increase of MMP-9 plasma levels.
Abstract: ObjectivesAortic dissection is characterized by an acute phase of medial dissection and a subacute-chronic phase of vessel wall repair. Matrix metalloproteinases (MMPs), through degradation of extracellular matrix, may play an important role in these processes. Elevation of MMPs might represent an o
61 citations
TL;DR: The best predictors of increased short-term mortality are ventricular tachycardia and ST-segment deviations, while electrocardiographic markers of poor outcome that were not independent risk factors on multivariate analysis, conflicting findings, and knowledge gaps are discussed.
TL;DR: The GAP program increased the use of evidence-based therapies in male and female patients and may decrease mortality rates at 1 year in patients with AMI; however, the tool was used less often with women.
Abstract: Background Studies have shown that women with acute myocardial infarction (AMI) are less likely to receive evidence-based care compared with men. The American College of Cardiology's AMI Guidelines Applied in Practice (GAP) program has been shown to increase the rates of evidence-based medicine use and reduce mortality in patients with AMI. The objective of this study was to investigate the relative benefits of the GAP program in men and women. Methods By using a predesign-postdesign, standard orders, and a discharge tool to improve evidence-based indicator rates and long-term mortality in patients with AMI in Michigan, this study compared the success of GAP in men vs women. Logistic regression was used to develop predictive models for death at 30 days and 1 year in men and women. Results Use of evidence-based care, including use of β-blockers and aspirin in men and women at hospital discharge and lipid-lowering agent use in men, was higher in the post-GAP sample ( P P =.003). Conclusions The GAP program increased the use of evidence-based therapies in male and female patients. In addition, the GAP discharge tool may decrease mortality rates at 1 year in patients with AMI; however, the tool was used less often with women. Greater use of the GAP discharge tool in women might narrow the post-MI sex mortality gap.
TL;DR: ALI secondary to AoD is predictive of death and visceral ischemia, and endovascular therapy confers excellent limb salvage and allows diagnosis of unsuspected visceral isChemia.
TL;DR: It is likely that the next decade will be characterized by further expansion of primary PCI for acute STEMI in hospitals with cardiac catheterization laboratories, and time to treatment also plays a key role in survival with primary PCI.
Abstract: Over the past decade, primary percutaneous coronary intervention (PCI) has emerged as an effective treatment strategy for acute ST-segment–elevation myocardial infarction (STEMI). Compared with thrombolytic therapy, the benefits of primary PCI include a reduction in the frequency of total stroke and hemorrhagic stroke, a reduction in the frequency of reinfarction, and an increase in the frequency of infarct-related artery patency, resulting in improved in-hospital and long-term survival.1 In addition, the availability of primary PCI provides a valid alternative for patients who have contraindications to thrombolytic therapy. Article p 1079
These observations have led many institutions to select primary PCI as the preferred treatment strategy for patients with acute STEMI. In addition, after the publication of several reports on the safety and efficacy of primary PCI in centers without cardiac surgery on site,2,3 several state regulatory agencies have changed local regulations by allowing primary PCI for acute STEMI in centers without cardiac surgery on site. Thus, it is likely that the next decade will be characterized by further expansion of primary PCI for acute STEMI in hospitals with cardiac catheterization laboratories.
As previously shown for thrombolytic therapy, time to treatment also plays a key role in survival with primary PCI. In the Global Use of Strategies to Open Occluded Arteries in Acute Coronary Syndromes (GUSTO-IIb) substudy,4 the lowest 30-day mortality rate was observed in patients undergoing primary PCI within 60 minutes from presentation to the emergency room, whereas the highest mortality rate was observed in patients undergoing PCI >90 minutes from presentation (1.0% versus 6.4%). Similar compelling data were reported in an analysis of data from the National Registry of Acute Myocardial Infarction (NRMI). In that analysis, which included 27 080 patients, the lowest mortality rate again was observed in patients undergoing PCI within 60 minutes from presentation, …
TL;DR: Treatment with early beta-blocker therapy may have a beneficial impact on hospital and 6-month mortality in all patients, including those presenting with heart failure.
TL;DR: For both primary PCI and thrombolytic therapy, analyses have consistently shown that timely reperfusion remains a key component in improving the survival of patients.
Abstract: It has been 27 years since the initial report of successful reperfusion of occluded coronary arteries with thrombolytic therapy in patients with acute myocardial infarction,1 and 20 years since the initial report of the feasibility and safety of primary percutaneous coronary intervention (PCI) in the same setting.2 During the past decade, primary PCI has gradually emerged as the preferred treatment strategy for acute myocardial infarction with ST-segment elevation.3,4 However, for both primary PCI and thrombolytic therapy, analyses have consistently shown that timely reperfusion remains a key component in improving the survival of patients.5–7 For primary PCI, the standard . . .
TL;DR: In clinical practice, ICDs appear to reduce all-cause and arrhythmic rates of mortality at levels similar to those found in primary prevention trials.
Abstract: Background Implantable cardioverter-defibrillators (ICDs) have been shown in primary prevention efficacy trials to reduce mortality in patients with ischemic heart disease and left ventricular dysfunction. To investigate the generalizabilty of this mortality reduction, we examined the effectiveness of ICDs in clinical practice. Methods We developed a prospective multicenter cohort of 770 patients with ischemic left ventricular dysfunction (ejection fraction ≤35%) and without a history of ventricular arrhythmia, of whom 395 (52%) received ICDs. Mean ± SD follow-up was 27 ± 12 months. We assessed the degree to which ICDs decreased mortality risk using Cox proportional hazards analyses that controlled for clinical predictors of death, receipt of ICD (a propensity score analysis), and predictors of arrhythmic death (including electrophysiologic variables). Results Multivariate Cox analyses showed that those with ICDs had significantly lower all-cause mortality (hazard ratio [HR], 0.53; 95% confidence interval [CI], 0.33-0.86). This mortality reduction was mediated through dramatically lower arrhythmia-related mortality (HR, 0.35; 95% CI, 0.17-0.73), with no significant effect on cardiovascular nonarrhythmic (HR, 0.81; 95% CI, 0.34-1.96) and noncardiovascular (HR, 0.76; 95% CI, 0.29-2.05) mortality. No differences were found between the ICD and non-ICD groups for a composite outcome of all-cause mortality, appropriate ICD shocks, or documented symptomatic ventricular arrhythmia, which suggests that the 2 groups had similar baseline risk for life-threatening arrhythmic events (HR, 0.96; 95% CI, 0.63-1.45). Conclusion In clinical practice, ICDs appear to reduce all-cause and arrhythmic rates of mortality at levels similar to those found in primary prevention trials.
TL;DR: The goal was to identify the highest care priorities for patients with acute coronary syndromes and to incorporate these into the care itself and an optimum timeline and correlations between hospital-specific attributes and greater or lesser success in achieving positive change were identified.
Abstract: The implementation of guidelines into everyday practice does not always seem straightforward. In this primer article, Eagle and colleagues provide a summary of efforts to improve care for acute coronary syndromes in the Guidelines Applied in Practice program in Michigan, highlighting particularly methods that could be transferable to other cardiovascular subspecialties. The American College of Cardiology Acute Myocardial Infarction Guidelines Applied in Practice program in Michigan, USA, was an initiative designed to improve the quality of cardiovascular care by bringing the American College of Cardiology/American Heart Association practice guidelines to the point of care. The program consisted of three different projects, involving a total of 33 hospitals. The program was implemented in five phases—planning, tool implementation, monitoring of tool use, remeasurement and reporting of results—by use of a collaborative model, which included a series of learning sessions for staff members that focused on the five phases. The goal was to identify the highest care priorities for patients with acute coronary syndromes and to incorporate these into the care itself. This aim was achieved with a standardized set of clinical-care tools, such as admission orders and discharge contracts; the use of such tools is associated with improvement in adherence to guidelines. Strategies were, however, tailored to each hospital by local teams. Performance was assessed by the use of tracking tools, which facilitate rapid improvement by enabling key performance indicators founded on the guidelines to be monitored. Using qualitative surveys of the project leaders, we identified an optimum timeline and correlations between hospital-specific attributes and greater or lesser success in achieving positive change. In this review, we describe our experience and identify the most useful strategies for future implementation of such a project.
Journal Article•
TL;DR: Elderly patients presenting with acute coronary syndrome seem to benefit from early statin therapy, and have significantly lower rates of heart failure and pulmonary edema than those who are administered statins at a later stage.
Abstract: OBJECTIVES Elderly patients are less likely to receive statin therapy because of concerns about their side-effects. However, 80% of deaths related to coronary heart disease occur in patients above the age of 65 years. This study evaluated the potential benefit of early administration of statins in elderly patients presenting with an acute coronary syndrome. METHODS This was a prospective cohort study of 774 elderly patients (>65 years) with acute coronary syndrome. The patients were divided into two groups. The first group, consisting of 611 patients, received statins within the first 24 hours of admission, while the second group, consisting of 163 patients, received statins after the first 24 hours. The end points studied included death, heart failure/pulmonary edema, stroke and recurrent myocardial infarction during hospitalization. RESULTS Multivariable logistic regression analysis, adjusting for baseline demographics, co-morbidities and chronic statin therapy, showed that the occurrence of heart failure/pulmonary edema during hospitalization was relatively lower among those who received statins within 24 hours of admission (odds ratio: 0.5, 95% CI: 0.27-0.94, p=0.03). The C statistic for the model was 0.79. CONCLUSION Elderly patients presenting with acute coronary syndrome seem to benefit from early statin therapy, and have significantly lower rates of heart failure and pulmonary edema than those who are administered statins at a later stage.
TL;DR: The importance of accurate preoperative cardiac risk assessment, risk stratification, and modification of risk parameters that guide the framework for optimum perioperative risk reduction strategies is recognized.
Journal Article•
Journal Article•
TL;DR: Chronic kidney disease was independently associated with mortality and major adverse cardiovascular events in a hospital registry of consecutive patients with acute coronary syndrome, adding to the existing body of evidence that more appropriate use of evidence-based medications, particularly statins, may significantly improve clinical outcomes in these highndash;risk patients.
Abstract: BACKGROUND An estimated 11% of the population of the USA has chronic kidney disease. Cardiovascular morbidity and mortality are high among these individuals. We evaluated the impact of evidence-based, secondary preventive medications on the overall clinical outcome among this population. METHODS We observed 2,627 consecutive patients admitted to our institution for acute coronary syndrome. The glomerular filtration rate was estimated by the four-component Modification of Diet in Renal Disease equation and the patients were stratified into groups on the basis of the guidelines of the National Kidney Foundation. Mortality and the composite event rate of death, myocardial infarction and stroke were assessed at six months. We evaluated the impact of evidence-based medications as an independent predictor of outcomes, using a logistic regression analysis. RESULTS- Patients with a relatively greater decline in the glomerular filtration rate had poorer outcomes, both in hospital and at six-month follow-up. Among those with stages III-V of chronic kidney disease, the use of 3-hydroxy-3-methylglutaryl coenzyme A reductase inhibitors (statins) was associated with 44% lower odds of death (95% CI: 0.14-0.63), as well as 40% lower odds of the composite end-point (95% CI: 0.13-0.59) at six months. CONCLUSION Chronic kidney disease was independently associated with mortality and major adverse cardiovascular events in a hospital registry of consecutive patients with acute coronary syndrome. Our results add to the existing body of evidence that more appropriate use of evidence-based medications, particularly statins, may significantly improve clinical outcomes in these highndash;risk patients. We should aim to improve the quality of treatment options available to patients suffering from both conditions.
Journal Article•
TL;DR: Patients with acute coronary syndrome had a higher 6-month smoking cessation rate than previously published rates seen in ambulatory practice, and the more severely ill patients had higher cessation rates.
Abstract: BACKGROUND, In patients with acute coronary syndrome, smoking cessation rates, demographics, and management strategies havenot been well described. We hypothesized that hospitalized patients with acute coronary syndrome would have higher smoking cessation rates than other currently available therapies. In-hospital counseling and referral to cardiac rehabilitation may further improve cessation rates. METHODS, We reviewed 1098 consecutive admissions for acute coronary syndrome at the University of Michigan; 254 of thesepatients reported active smoking status on admission. Patients were divided into (i) those who continued smoking and (ii) those who quit smoking based on a 6-month telephonic interview. Clinical variables, management and therapies were com-pared for the two cohorts. RESULTS, The mean age of the 254 patients was 56 years and 65% were male. At six months, 49.2% of patients had quit smok-ing. Significant predictors of smoking cessation were coronary artery bypass grafting, pulmonary artery catheter placement, and need for mechanical ventilation. Patients who underwent cardiac rehabilitation post-discharge had a trendtoward higher cessation rates. Formal counseling during hospitalization did not seem to affect cessation rates. CONCLUSIONS, In this study, patients with acute coronary syndrome had a higher 6-month smoking cessation rate than previously published rates seen in ambulatory practice, and the more severely ill patients had higher cessation rates. Smoking cessation rates were not higher in those who received in-patient smoking counseling.