Showing papers by "Kim A. Eagle published in 2007"

Decline in rates of death and heart failure in acute coronary syndromes, 1999-2006

Abstract: Context Randomized trials provide robust evidence for the impact of pharmacological and interventional treatments in patients with ST-segment elevation and non–STsegment elevation acute coronary syndromes (NSTE ACS), but whether this translates to changes in clinical practice is unknown. Objective To determine whether changes in hospital management of patients with ST-segment elevation myocardial infarction (STEMI) and NSTE ACS are associated with improvements in clinical outcome. Design, Setting, and Patients In the Global Registry of Acute Coronary Events (GRACE), a multinational cohort study, 44 372 patients with an ACS were enrolled and followed up in 113 hospitals in 14 countries between July 1, 1999, and December 31, 2006. Main Outcome Measures Temporal trends in the use of evidence-based pharmacological and interventional therapies; patient outcomes (death, congestive heart failure, pulmonary edema, cardiogenic shock, stroke, myocardial infarction). Results Use of pharmacological medications increased over the study period (blockers, statins, angiotensin-converting enzyme inhibitors, thienopyridines with or without percutaneous coronary intervention [PCI], glycoprotein IIb/IIIa inhibitors, lowmolecular-weight heparin; allP.001). Pharmacological reperfusion declined in patients with STEMI by �22 percentage points (95% confidence interval [CI], �27 to �17), whereas primary PCI increased by 37 percentage points (95% CI, 33-41). In patients with non-STEMI, rates of PCI increased markedly by 18 percentage points (95% CI, 15-20). Rates of congestive heart failure and pulmonary edema declined in both populations: STEMI, �9 percentage points (95% CI, �12 to �6) and NSTE ACS, �6.9 percentage points (95% CI, �8.4 to �4.7). In patients with STEMI, hospital deaths decreased by 18 percentage points (95% CI, �5.3 to �1.9) and cardiogenic shock by �24 percentage points (95% CI, �4.3 to �0.5). Risk-adjusted hospital deaths declined �0.7 percentage points (95% CI, �1.7 to 0.3) in NSTE ACS patients. Six-month follow-up rates declined among STEMI patients: stroke by �0.8 percentage points (95% CI, �1.7 to 0.1) and myocardial infarction by �2.8 percentage points (95% CI, �6.4 to 0.9). In NSTE ACS, 6-month death declined �1.6 percentage points (95% CI, �3.0 to �0.1) and stroke by 0.7 percentage points (95% CI, �1.4 to 0.1). Conclusions In this multinational observational study, improvements in the management of patients with ACS were associated with significant reductions in the rates of new heart failure and mortality and in rates of stroke and mycoardial infarction at 6 months.

Aortic Diameter ≥5.5 cm Is Not a Good Predictor of Type A Aortic Dissection Observations From the International Registry of Acute Aortic Dissection (IRAD)

Abstract: Background— Studies of aortic aneurysm patients have shown that the risk of rupture increases with aortic size. However, few studies of acute aortic dissection patients and aortic size exist. We used data from our registry of acute aortic dissection patients to better understand the relationship between aortic diameter and type A dissection. Methods and Results— We examined 591 type A dissection patients enrolled in the International Registry of Acute Aortic Dissection between 1996 and 2005 (mean age, 60.8 years). Maximum aortic diameters averaged 5.3 cm; 349 (59%) patients had aortic diameters <5.5 cm and 229 (40%) patients had aortic diameters <5.0 cm. Independent predictors of dissection at smaller diameters (<5.5 cm) included a history of hypertension (odds ratio, 2.17; 95% confidence interval, 1.03 to 4.57; P=0.04), radiating pain (odds ratio, 2.08; 95% confidence interval, 1.08 to 4.0; P=0.03), and increasing age (odds ratio, 1.03; 95% confidence interval, 1.00 to 1.05; P=0.03). Marfan syndrome pati...

Partial thrombosis of the false lumen in patients with acute type B aortic dissection.

Abstract: Background Patency or thrombosis of the false lumen in type B acute aortic dissection has been found to predict outcomes. The prognostic implications of partial thrombosis of the false lumen have not yet been elucidated. Methods We examined 201 patients with type B acute aortic dissection who were enrolled in the International Registry of Acute Aortic Dissection between 1996 and 2003 and who survived to hospital discharge. Kaplan–Meier mortality curves were stratified according to the status of the false lumen (patent, partial thrombosis, or complete thrombosis) as determined during the index hospitalization. Cox proportional-hazards analysis was performed to identify independent predictors of death. Results During the index hospitalization, 114 patients (56.7%) had a patent false lumen, 68 patients (33.8%) had partial thrombosis of the false lumen, and 19 (9.5%) had complete thrombosis of the false lumen. The mean (±SD) 3-year mortality rate for patients with a patent false lumen was 13.7±7.1%, for those...

Management and 6-month outcomes in elderly and very elderly patients with high-risk non-ST-elevation acute coronary syndromes: The Global Registry of Acute Coronary Events

Abstract: Aims To test the hypothesis that increasing age in patients presenting with high-risk non-ST-segment elevation acute coronary syndromes (NSTE-ACS) does not adversely influence the benefit of an early invasive strategy on major adverse events at 6 months. Methods and results We report clinical outcomes in young ( 80 years) patients with high-risk NSTE-ACS enrolled in GRACE between 1999 and 2006. Six month data were available in 18 466 patients (27% elderly, 16% very elderly). Elderly and very elderly patients were less likely to receive evidence-based treatments at discharge and had a longer hospital stay (6 vs. 5 days). Angiography was performed more frequently in younger patients (67 vs. 33% in very elderly, 55% in elderly; P < 0.0001). Multiple logistic regression analysis confirmed the benefit of revascularization on the primary study endpoint (6-month stroke, death, myocardial infarction) in young [odds ratio (OR) 0.69, 95% confidence interval (CI) 0.56–0.86], elderly (0.60, 0.47–0.76), and very elderly (0.72, 0.54–0.95) patients. Revascularization was associated with reductions in 6-month mortality (OR 0.52, 95% CI 0.37–0.72 in young; 0.38, 0.26–0.54 in elderly; 0.68, 0.49–0.95 in very elderly). Stroke risk in hospital or at 6 months was not increased by revascularization. Conclusion Following presentation with high-risk NSTE-ACS, an evidence-based approach to management was noted less frequently with advancing patient age. Angiography, in particular, was less likely to be undertaken. Revascularization, however, when performed, was associated with significant benefits at 6 months, independent of age, and did not increase risk of stroke.

A systematic review of gender differences in mortality after coronary artery bypass graft surgery and percutaneous coronary interventions.

Abstract: Summary Gender differences exist in outcomes, particularly early mortality, for percutaneous interventions (PCI) and coronary artery bypass graft surgery (CABG) Better understanding of this issue may target areas for improvement for all patients undergoing revascularization Therefore, we summarized the evidence on gender differences in PCI and CABG outcomes, particularly early mortality, and mediators of this difference Using the key terms “women” or “gender,” “revascularization,” “coronary artery bypass,” “angioplasty,” “stent,” and “coronary intervention,” we searched MEDLINE from 1985 to 2005 for all randomized controlled trials (RCTs) and registries reporting outcomes by gender Bibliographies and the Web sites of cardiology conferences were also reviewed The literature was examined to identify gender differences in outcomes and mediators of these differences We identified 23 studies reporting outcomes by gender for CABG and 48 studies reporting outcomes by gender for PCI The majority of studies noted greater in-hospital mortality in women than in men, with mortality differences resolving with longer followup Early mortality differences were reduced but not consistently eliminated after adjustment for comorbidities, procedural characteristics, and body habitus Power to detect gender differences after multivariate adjustment was limited by declining mortality rates and small sample size Gender was an independent risk factor for complications after both CABG and PCI Women experience greater complications and early mortality after revascularization Future exploration is needed of gender differences in quality of care and benefit from combinations of stenting and antiplatelet, and anticoagulant medications in order to optimize treatment

Impact of prior peripheral arterial disease and stroke on outcomes of acute coronary syndromes and effect of evidence-based therapies (from the Global Registry of Acute Coronary Events)

Abstract: We assessed the effect of previous peripheral arterial disease (PAD) and stroke on clinical outcomes in patients with acute coronary syndrome (ACS) and sought to ascertain the effectiveness of evidence-based therapies in these patients. We used data from the multinational Global Registry of Acute Coronary Events. Patients were enrolled at 102 hospitals in 13 countries between April 1999 and September 2005. Patients presenting with ACS were stratified according to the presence of previous PAD, stroke, PAD and stroke, or neither. In-hospital analysis included 48,418 patients and 6-month analysis included 32,735 patients. The primary end point was all-cause mortality and major adverse cardiac events during 6-month follow-up. Adverse in-hospital and 6-month events were lowest in patients with neither PAD nor stroke and highest in patients with PAD and stroke after adjustment for baseline demographics and co-morbidities. In-hospital mortality for the 4 groups (neither, PAD, stroke, PAD and stroke) was 4.5% versus 7.2% versus 8.9% versus 9.4% (p <0.001) and that for 6-month mortality was 3.9% versus 8.8% versus 9.3% versus 12%, and these differences persisted after accounting for differences in baseline characteristics. Use of evidence-based therapies was associated with significantly less morbidity and mortality in all ACS subgroups. In conclusion, outcomes after ACS are worse in patients with PAD or stroke, with the highest risk in patients with the 2 conditions and the use of evidence-based therapies are associated with improved outcomes in all ACS subgroups.

Opening of Specialty Cardiac Hospitals and Use of Coronary Revascularization in Medicare Beneficiaries

Abstract: ContextAlthough proponents argue that specialty cardiac hospitals provide high-quality cost-efficient care, strong financial incentives for physicians at these facilities could result in greater procedure utilization.ObjectiveTo determine whether the opening of cardiac hospitals was associated with increasing population-based rates of coronary revascularization.Design, Setting, and PatientsIn a study of Medicare beneficiaries from 1995 through 2003, we calculated annual population-based rates for total revascularization (coronary artery bypass graft [CABG] plus percutaneous coronary intervention [PCI]), CABG, and PCI. Hospital referral regions (HRRs) were used to categorize health care markets into those where (1) cardiac hospitals opened (n = 13), (2) new cardiac programs opened at general hospitals (n = 142), and (3) no new programs opened (n = 151).Main Outcome MeasuresRates of change in total revascularization, CABG, and PCI using multivariable linear regression models with generalized estimating equations.ResultsOverall, rates of change for total revascularization were higher in HRRs after cardiac hospitals opened when compared with HRRs where new cardiac programs opened at general hospitals and HRRs with no new programs (P<.001 for both comparisons). Four years after their opening, the relative increase in adjusted rates was more than 2-fold higher in HRRs where cardiac hospitals opened (19.2% [95% confidence interval {CI}, 6.1%-32.2%], P<.001) when compared with HRRs where new cardiac programs opened at general hospitals (6.5% [95% CI, 3.2%-9.9%], P<.001) and HRRs with no new programs (7.4% [95% CI, 3.2%-11.5%], P<.001). These findings were consistent when rates for CABG and PCI were considered separately. For PCI, this growth appeared largely driven by increased utilization among patients without acute myocardial infarction (42.1% [95% CI, 21.4%-62.9%], P<.001).ConclusionThe opening of a cardiac hospital within an HRR is associated with increasing population-based rates of coronary revascularization in Medicare beneficiaries.

Acute Type B Aortic Dissection: Does Aortic Arch Involvement Affect Management and Outcomes? Insights From the International Registry of Acute Aortic Dissection (IRAD)

Abstract: Background— Stanford Type B acute aortic dissection (TB-AAD) spares the ascending aorta and is optimally managed with medical therapy in the absence of complications. However, the treatment of TB-AAD with aortic arch involvement (AAI) remains an unresolved issue. Methods and Results— We examined 498 patients with TB-AAD enrolled in the International Registry of Acute Aortic Dissection (IRAD) between 1996 and 2003. Kaplan-Meier mortality curves were constructed and multivariate regression models were performed to identify independent predictors of AAI and to evaluate whether AAI was an independent predictor of follow-up mortality. We found that 371 (74.5%) patients with TB-AAD did not have AAI versus 127 (25.5%) with AAI. Independent predictors of AAI were a history of previous aortic surgery (OR 3.4; 95% CI, 1.6 to 7.6; P =0.002), absence of back pain (OR 1.6; 95% CI, 1.1 to 2.5; P =0.05), and any pulse deficit (1.9; 95% CI, 1.1 to 3.3, P =0.03). Mortality for patients without AAI was 9.4%±4.3% and 21.0%±6.9% at 1 and 3 years versus 9.2%±7.7% and 19.9%±11.1% with AAI, respectively (mean follow-up overall, 2.3 years, log rank P =0.82). AAI was not an independent predictor of long-term mortality. Conclusions— Patients with TB-AAD and aortic arch involvement do not differ with regards to mortality at 3 years. Whether or not AAI involvement impacts other measures of morbidity such as freedom from operation or endovascular intervention deserves further study.

Atherosclerosis Secondary Prevention Performance Measures After Coronary Bypass Graft Surgery Compared With Percutaneous Catheter Intervention and Nonintervention Patients in the Get With the Guidelines Database

Abstract: Background— The American Heart Association Get With the Guidelines-Coronary Artery Disease program facilitates patient and physician compliance with proven atherosclerosis risk reduction strategies with collaborative learning sessions, teaching materials, predischarge online check lists, and web-based performance measure feedback for continuous quality improvement. Patients having coronary artery bypass graft surgery (CABG) may be subject to different care processes, nursing unit pathways, and personnel than patients having percutaneous catheter intervention or neither intervention, which may affect compliance. Methods and Results— The Get With the Guidelines-Coronary Artery Disease database was queried to determine whether compliance with secondary prevention performance measures for CABG patients was different from that for nonsurgical patients. A total of 119 106 patients were treated with CABG (14 118), percutaneous catheter intervention (58 702), or neither intervention (46 286). Compliance with medication prescriptions, including aspirin, β-blockers, angiotensin-converting enzyme inhibitors, and lipid-lowering drugs, and smoking cessation counseling for eligible patients was analyzed. Medically appropriate exclusions and contraindications were included in the analysis. After adjusting for 14 clinical variables, CABG patients were less likely to receive most secondary prevention measures relative to percutaneous catheter intervention patients. In contrast, CABG patients were more likely to receive aspirin, β-blocker, and smoking cessation counseling than neither intervention patients. Composite adherence and defect-free rates were highest for percutaneous catheter intervention patients and lowest for neither intervention patients after adjustment. Conclusions— There are significant differences in compliance at hospital discharge with secondary prevention performance measures for CABG patients compared with nonsurgical patients. Process of care differences may explain these differences and should be examined further because significant opportunities for improved compliance are evident. CABG patients in particular represent a group for whom secondary prevention has proven benefits, and they may benefit from future quality improvement interventions.

Prognostic value of transient and sustained increase in in-hospital creatinine on outcomes of patients admitted with acute coronary syndrome.

Abstract: A history of renal insufficiency or increased creatinine level on admission is associated with poor outcomes in patients with acute coronary syndrome (ACS). This study sought to determine whether in-hospital worsening of renal function, either transient or sustained, is an independent risk factor for 6-month mortality in patients admitted with ACS. A total of 1,417 patients admitted with ACS from June 2000 to May 2003 were reviewed. Patients were classified into 3 groups. Group I included patients with an increase in creatinine during hospitalization of ≤0.5 mg/dl. Group II included patients with an increase in creatinine of >0.5 mg/dl that resolved by discharge. Group III included patients with an increase in creatinine of >0.5 mg/dl that did not resolve. The primary end point was 6-month mortality from any cause. Patients in groups II and III had higher 6-month mortality rates (27% and 23%, respectively; both p

Evidence-Based Medical Therapy of Patients with Acute Coronary Syndromes

Abstract: Acute coronary syndromes (ACS) present a major health challenge in modern medicine. With new clinical trials being conducted, our knowledge of latest therapies for ACS continually evolves. In this article, we review currently available medical therapies and provide evidence-based rationale for current pharmacologic therapies. Among the antiplatelet therapies, aspirin, clopidogrel, and glycoprotein IIb/IIIa inhibitors demonstrate significant efficacy in reducing morbidity and mortality. Among the anticoagulants, unfractionated heparin and low molecular weight heparin, particularly enoxaparin sodium, remain the hallmarks of therapy against which newer anticoagulants are often compared. Bivalirudin has recently showed significant efficacy in decreasing cardiovascular events and mortality, but with potentially less risk of bleeding than heparin. Results of trials evaluating warfarin remain inconsistent regarding potential benefits. Finally, fondaparinux sodium, recently tested, shows promise as a powerful yet safe anticoagulant. Fibrinolysis is an acceptable modality for reperfusion if facilities equipped for primary percutaneous revascularization are not available. Regarding anti-ischemic therapy, β-adrenoceptor antagonists and nitrates remain critical in the early management of ACS. Inhibitors of the renin-angiotensin-aldosterone system have also shown significant reductions in the morbidity and mortality of patients presenting with ACS, particularly in patients with left ventricular dysfunction and clinical heart failure, with ACE inhibitors being first-line agents and angiotensin receptor antagonists being a reasonable substitute if ACE inhibitors are not tolerated. Among the lipid-lowering therapies, statins (HMG-CoA reductase inhibitors) have been documented as being the most well tolerated and most efficacious therapies for ACS patients and data exist that they should be administered early in ACS management. Studies evaluating combination therapy (antiplatelet drugs, β-adrenoceptor antagonists, ACE inhibitors, and lipid-lowering agents) show a clear benefit in mortality in patients with known coronary artery disease. Efforts to improve these key evidence-based medical therapies are numerous and include such programs as the American College of Cardiology’s Guidelines Applied in Practice, international patient registries such as the Global Registry of Acute Coronary Events, and studies such as CRUSADE. Finally, patients with diabetes mellitus pose a challenge to clinicians both in terms of their glycemic control and in their apparent relative resistance to antiplatelet therapy. Studies involving ACS patients suggest that stringent glycemic control may result in benefits in both morbidity and mortality.

Aortic dissection and related syndromes

Abstract: Aortic dissection and related syndromes / , Aortic dissection and related syndromes / , کتابخانه دیجیتال جندی شاپور اهواز

Temporal Trends in Antiplatelet/Antithrombotic Use in Acute Coronary Syndromes and In-Hospital Major Bleeding Complications

Abstract: Antithrombotic and antiplatelet agents are essential for the management of patients with acute coronary syndromes (ACSs). These pharmacologic agents have the potential for increased risk of bleeding. It is not clear if the increased uptake of these therapies has resulted in a clinically evident increase in bleeding complications over time. In this study, we included 3,193 consecutive patients who were admitted to the University of Michigan with an ACS (unstable angina or myocardial infarction) between January 1999 and December 2004. These patients were analyzed for temporal trends in antithrombotic and antiplatelet agent use, thrombolytic therapy, cardiac catheterizations, percutaneous coronary interventions, and major bleeding complications (including gastrointestinal, vascular access, and intracranial hemorrhage). We found a decreasing temporal trend in the incidence of major in-hospital bleeding complications (p

The duration of anticoagulation bridging therapy in clinical practice may significantly exceed that observed in clinical trials

Abstract: Background Clinical trials involving frequent, standardized monitoring of the international normalized ratio (INR) demonstrated that a short course of low-molecular-weight-heparin (LMWH) can successfully bridge patients to oral anticoagulation. However, rigidly performed INR testing is often not feasible in the outpatient setting in actual clinical practice. The purpose of this study was to determine if the anticoagulation results of clinical trials of LMWH bridging therapy are also achieved in a single-center clinical practice setting.

The nature of the problem: an overview of acute coronary syndromes and myocardial infarction

Abstract: The leading cause of death worldwide is coronary heart disease (CHD). This often presents with atherosclerotic plaque rupture, leading to a partial or complete obstruction of coronary artery flow, and resulting ischemia or infarction of myocardial tissue. There are risk factors which can predict CHD risk, and the treatment of some risk factors can reduce the likelihood of developing an acute coronary syndrome (ACS). While the incidence of CHD may be decreasing in the developed world, significant increases are projected in the developing world. In addition to the immediate adverse events associated with ACS, these patients have long-term increases in morbidity and mortality, which make the worldwide epidemic of CHD a leading public health issue.

Screening for myocardial infarction and ischemic stroke: a population-based study.

Abstract: Studies that accurately identify myocardial infarction (MI) and stroke within populations would provide valuable epidemiological information as well as data on vascular disease prevention. We performed a pilot study to assess the feasibility of adding MI surveillance to an ongoing population-based stroke surveillance study, the Brain Attack Surveillance in Corpus Christi (BASIC) Project. We also tested two screening methods for MI ascertainment: discharge International Classification of Diseases, Ninth Revision (ICD-9) codes and cardiac biomarker screening. This pilot study suggests that the addition of MI surveillance to community-based stroke surveillance studies is feasible. Screening for abnormal cardiac biomarkers to identify potential MI cases may be more accurate and efficient than using ICD-9 codes.

Aortic Dissection: Clinical Presentation

Abstract: More ink than blood has been split on the subject of aortic dissections, beginning with the first well-documented case of aortic dissection—George II of England, who died while straining on the commode. Morgagni first described aortic dissection more than 200 years ago. The advent and adoption of modern cardiac surgical procedures have dramatically altered the outcome what was once a uniformly fatal disease. Dramatic advances in imaging the aorta and the heart have facilitated the early diagnosis of aortic dissections. Here we go through the clinical presentation of aortic dissection, by way of history, clinical examination, physical findings, and laboratory investigations.

Revascularization in the acute coronary syndromes

Abstract: Coronary heart disease is the leading cause of death worldwide, and occurs when the coronary arteries are unable to supply adequate oxygenated blood to the myocardium, which in turn can lead to ischemia and infarction of myocardial tissue. There are three options for revascularization in the setting of acute coronary syndromes. In select patients, coronary artery bypass surgery remains an option. Thrombolytics were initially the mainstay of therapy, which has now shifted to angioplasty, with or without stents, when readily available. Revascularization has been demonstrated to improve patient outcomes, and has evolved rapidly in the recent past.