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Showing papers by "Kim A. Eagle published in 2011"


Journal ArticleDOI
TL;DR: In 2010, the American Heart Association and American College of Cardiology released guidelines for the diagnosis and management of patients with thoracic aortic disease, which identified high-risk clinical features to assist in the early detection of acute aortal dissection.
Abstract: Background—In 2010, the American Heart Association and American College of Cardiology released guidelines for the diagnosis and management of patients with thoracic aortic disease, which identified high-risk clinical features to assist in the early detection of acute aortic dissection. The sensitivity of these risk markers has not been validated. Methods and Results—We examined patients enrolled in the International Registry of Acute Aortic Dissection from 1996 to 2009. The number of patients with confirmed acute aortic dissection who presented with 1 or more of 12 proposed clinical risk markers was determined. An aortic dissection detection (ADD) risk score of 0 to 3 was calculated on the basis of the number of risk categories (high-risk predisposing conditions, high-risk pain features, high-risk examination features) in which patients met criteria. The ADD risk score was tested for sensitivity. Of 2538 patients with acute aortic dissection, 2430 (95.7%) were identified by 1 or more of 12 proposed clinic...

217 citations


Journal ArticleDOI
TL;DR: Improved physician awareness of atypical presentations and prompt transport of acute aortic dissection patients could reduce crucial time variables.
Abstract: Background—In acute aortic dissection, delays exist between presentation and diagnosis and, once diagnosed, definitive treatment. This study aimed to define the variables associated with these delays. Methods and Results—Acute aortic dissection patients enrolled in the International Registry of Acute Aortic Dissection (IRAD) between 1996 and January 2007 were evaluated for factors contributing to delays in presentation to diagnosis and in diagnosis to surgery. Multiple linear regression was performed to determine relative delay time ratios (DTRs) for individual correlates. The median time from arrival at the emergency department to diagnosis was 4.3 hours (quartile 1–3, 1.5–24 hours; n=894 patients) and from diagnosis to surgery was 4.3 hours (quartile 1–3, 2.4–24 hours; n=751). Delays in acute aortic dissection diagnosis occurred in female patients; those with atypical symptoms that were not abrupt or did not include chest, back, or any pain; patients with an absence of pulse deficit or hypotension; or t...

208 citations


Journal ArticleDOI
TL;DR: It is shown that common genetic variants at 15q21.1 that probably act via FBN1 are associated with STAAD, suggesting a common pathogenesis of aortic disease in Marfan syndrome and STAAD.
Abstract: Although thoracic aortic aneurysms and dissections (TAAD) can be inherited as a single-gene disorder, the genetic predisposition in the majority of affected people is poorly understood. In a multistage genome-wide association study (GWAS), we compared 765 individuals who had sporadic TAAD (STAAD) with 874 controls and identified common SNPs at a 15q21.1 locus that were associated with STAAD, with odds ratios of 1.6-1.8 that achieved genome-wide significance. We followed up 107 SNPs associated with STAAD with P < 1 × 10(-5) in the region, in two separate STAAD cohorts. The associated SNPs fall into a large region of linkage disequilibrium encompassing FBN1, which encodes fibrillin-1. FBN1 mutations cause Marfan syndrome, whose major cardiovascular complication is TAAD. This study shows that common genetic variants at 15q21.1 that probably act via FBN1 are associated with STAAD, suggesting a common pathogenesis of aortic disease in Marfan syndrome and STAAD.

183 citations


Journal ArticleDOI
TL;DR: This review focuses on the pathophysiology and various etiologies that lead to thoracic aortic aneurysm along with the diagnostic modalities and management of asymptomatic patients with thoraco-aortic disease.

122 citations


Journal ArticleDOI
TL;DR: The REACH Registry Investigators are pleased to announce that the number of patients diagnosed with central giant cell granuloma in the USA has halved in the past five years, compared with the same period of time in the previous year.

119 citations


Journal ArticleDOI
10 Sep 2011-Herz
TL;DR: 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.
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.

100 citations


Journal ArticleDOI
01 Feb 2011-Heart
TL;DR: The extent of troponin elevation is an independent predictor of morbidity and mortality and was predictive of early mortality and longer term mortality.
Abstract: Background The objective of this study was to determine if the extent of quantitative troponin elevation predicted mortality as well as in-hospital complications of cardiac arrest, new heart failure and cardiogenic shock. Design 16 318 patients with non-ST-segment elevation acute coronary syndromes (NSTE ACS) from the Global Registry of Acute Coronary Events (GRACE) were included. The maximum 24 h troponin value as a multiple of the local laboratory upper limit of normal was used. The population was divided into five groups based on the degree of troponin elevation, and outcomes were compared. An adjusted analysis was performed using quantitative troponin as a continuous variable with adjustment for known prognostic variables. Results For each approximate 10-fold increase in the troponin ratio, there was an associated increase in cardiac arrest, sustained ventricular tachycardia (VT) or ventricular fibrillation (VF) (1.0, 2.4, 3.4, 5.9 and 13.4%; p Conclusion The extent of troponin elevation is an independent predictor of morbidity and mortality.

87 citations


Journal Article
TL;DR: In this article, the cause of childhood obesity is identified as one of the most pressing health problems in the United States and understanding its causes is critical to the creation of strategies to improve children's health.
Abstract: Background Childhood obesity is our nation's most pressing health problem. Understanding its causes is critical to the creation of strategies to improve our children's health. Study Questions What ...

81 citations



Journal ArticleDOI
TL;DR: In this article, a computerized search from January 1, 1970, to September 1, 2010, identified 18 studies with outcomes of pacemaker reuse and the primary outcome was pacemaker infection or device erosion as defined by each individual study protocol.
Abstract: Background— A large disparity in medical health care is clearly evident between developed and underserved nations in the field of cardiac electrophysiology, specifically pacemaker implantation. This study aimed to assess the safety of pacemaker reuse. Methods and Results— A computerized search from January 1, 1970, to September 1, 2010, identified 18 studies with outcomes of pacemaker reuse. The primary outcome was pacemaker infection or device erosion as defined by each individual study protocol. Secondary end points were device malfunction defined as a defect in the structural or electric integrity of the pulse generator. Pooled individual patient data (n=2270) from 18 trials were included in the analysis. The proportion of patients in whom an infection developed after pacemaker reuse was 1.97% (1.15% to 3.00%). There was no significant difference in infection rate between pacemaker reuse and new device implantation (odds ratio, 1.31 [0.50 to 3.40], P =0.580). The proportion of patients in whom device malfunction developed after pacemaker reuse was 0.68% (0.27% to 1.28%). Compared with new device implantation, there was an increased risk for malfunction in the reuse group (odds ratio, 5.80 [1.93 to 17.47], P =0.002). This difference was mainly driven by abnormalities in set screws, which possibly occurred during device extraction, as well as nonspecific device “technical errors.” Conclusions— This study suggests that pacemaker reuse has an overall low rate of infection and device malfunction and may be a safe and efficacious means of treating patients in underserved nations with symptomatic bradyarrhythmias and no other method of obtaining a device. However, the results also denote a higher rate of device malfunction as compared with new device implantation. Patients with highly symptomatic conduction disease may benefit from pacemaker reuse; however, they should be closely monitored for device malfunction, especially during implantation.

63 citations



Journal ArticleDOI
TL;DR: Recurrent pain and refractory hypertension appeared as clinical signs associated with increased in-hospital mortality, particularly when managed medically, and suggest that aortic intervention, such as via an endovascular approach, may be indicated in this intermediate-risk group.


Journal ArticleDOI
TL;DR: Although its presence does not appear to predict an increased risk of mortality, ascending thoracic aortic enlargement is associated with more frequent open surgical intervention that often involves replacement of the proximal aorta.
Abstract: It is not well known if the size of the ascending thoracic aorta at presentation predicts features of presentation, management, and outcomes in patients with acute type B aortic dissection. The International Registry of Acute Aortic Dissection (IRAD) database was queried for all patients with acute type B dissection who had documentation of ascending thoracic aortic size at time of presentation. Patients were categorized according to ascending thoracic aortic diameters ≤4.0, 4.1 to 4.5, and ≥4.6 cm. Four hundred eighteen patients met inclusion criteria; 291 patients (69.6%) were men with a mean age of 63.2 ± 13.5 years. Ascending thoracic aortic diameter ≤4.0 cm was noted in 250 patients (59.8%), 4.1 to 4.5 cm in 105 patients (25.1%), and ≥4.6 cm in 63 patients (15.1%). Patients with an ascending thoracic aortic diameter ≥4.6 cm were more likely to be men (p = 0.01) and have Marfan syndrome (p <0.001) and known bicuspid aortic valve disease (p = 0.003). In patients with an ascending thoracic aorta ≥4.1 cm, there was an increased incidence of surgical intervention (p = 0.013). In those with an ascending thoracic aorta ≥4.6 cm, the root, ascending aorta, arch, and aortic valve were more often involved in surgical repair. Patients with an ascending thoracic aorta ≤4.0 were more likely to have endovascular therapy than those with larger ascending thoracic aortas (p = 0.009). There was no difference in overall mortality or cause of death. In conclusion, ascending thoracic aortic enlargement in patients with acute type B aortic dissection is common. Although its presence does not appear to predict an increased risk of mortality, it is associated with more frequent open surgical intervention that often involves replacement of the proximal aorta. Those with smaller proximal aortas are more likely to receive endovascular therapy.

Journal ArticleDOI
TL;DR: Circulating transforming growth factor (TGF)-beta has received recent attention because it may potentially serve as a biomarker for therapeutic monitoring of aortic remodeling processes in patients with Marfan syndrome.

Journal ArticleDOI
TL;DR: Evidence is lent that collection of devices for reuse is feasible and that establishing a framework for regional pacemaker reutilization program is warranted and that the feasibility of this model should be investigated in other parts of the country to alleviate the burden of untreated symptomatic bradycardia.
Abstract: Significant healthcare disparities exist between the developed world and low and middle income countries (LMIC), specifically in the field of cardiac electrophysiology. As a result, pacemaker reutilization has been proposed as a viable option for those in LMIC and no other means of obtaining a device. Little data exist regarding the feasibility of establishing a reuse program in addition to understanding the views of society on device reutilization. This study investigated the views of funeral directors, patients with cardiac devices, and members of the general population regarding reutilization of previously implanted pacemakers. Ninety funeral directors in Michigan were surveyed regarding current practice as well as preferences for post-mortem device disposal. One hundred and fourteen patients with devices and 1,009 members of the general population were surveyed regarding post-mortem device handling. Funeral directors had an average of 21 years of experience with an annual volume of 120 deceased persons per year, with a cremation rate of 35%. When asked about disposal methods of explanted devices, the majority of devices (84%) were discarded as medical waste or stored with no intended purpose, with a total of 171 devices currently in possession at the funeral homes. Eighty-nine percent of funeral directors expressed a desire to donate devices for reuse in LMIC and 10% acknowledged previous device donation. Eighty-seven percent of device patients and 71% of the general population also expressed a desire to donate devices. The results of our survey show that a large percentage of funeral directors, patients with implantable devices, and members of the general population support a pacemaker reutilization initiative. This study lends further evidence that collection of devices for reuse is feasible and that establishing a framework for regional pacemaker reutilization program is warranted. If successful, the feasibility of this model should be investigated in other parts of the country in order to alleviate the burden of untreated symptomatic bradycardia in our world.

Journal ArticleDOI
TL;DR: TTC seems to exhibit a temporal variation of onset, with preferred peaks during morning and summer, and stress and catecholamines might play a pivotal role.
Abstract: The occurrence of major cardiovascular events is not randomly distributed over time, but exhibits chronobiological patterns, i.e., circadian, weekly, or seasonal. No systematic studies on the temporal preference of onset of Tako-tsubo cardiomyopathy (TTC) are known. We performed a computer-assisted search of the literature (from 2000 to January 2010), with the following search terms: transient left ventricular apical ballooning syndrome, takotsubo-like left ventricular dysfunction, ampulla cardiomyopathy, tako-tsubo or takotsubo cardiomyopathy, tako-tsubo, apical ballooning. Criteria for publication inclusion were (a) reporting of original data, (b) inclusion of at least 30 or more cases, (c) adherence to the requested diagnostic criteria for TTC. We focused on studies including in their purposes the “time of onset” of events. Out of the 19 studies found, 7 (4 from Europe, 1 each from Asia, Australia and USA) specifically addressed this aspect. A circadian (morning) and a seasonal (summer) higher frequency of events was found. TTC seems to exhibit a temporal variation of onset, with preferred peaks during morning and summer. Stress and catecholamines, also according to their temporal organization, might play a pivotal role. The demonstration of time frames characterized by highest frequency of occurrence might help to try to ensure maximal protection during particularly vulnerable periods.

Journal ArticleDOI
15 Dec 2011-Heart
TL;DR: With increasing global disparities in medical care, post mortem explantation and reuse of pacemakers presents a potential means for mitigating the rising burden of cardiovascular disease in LMIC.
Abstract: Symptomatic bradycardia contributes significantly to mortality and decreased functional status in many low and middle income countries (LMIC). In contrast to the developed world, where bradycardia often results from sinus node dysfunction, patients requiring pacemakers in LMIC more commonly present with complete heart block.1–3 Yet many patients in LMIC have little to no access to electrophysiological therapies, as the cost of one device often exceeds the annual income of the average citizen.4 Several countries—including Sweden, India and Canada—have previously explanted and resterilised pacemakers from deceased donors for reutilisation.5–7 With increasing global disparities in medical care, post mortem explantation and reuse of pacemakers presents a potential means for mitigating the rising burden of cardiovascular disease in LMIC. Recent survey data indicate that almost 45% of deceased pacemaker patients in the USA have their devices extracted for reasons including family request and risk of device explosion during cremation. Notably, over 80% of these extracted devices are discarded or stored as waste. The vast majority of funeral directors, device patients and the general population support donation of explanted pacemakers to LMIC.8 ‘Project My Heart–Your Heart’ is a proof of concept pacemaker donation initiative that allows funeral directors to send explanted devices to an academic centre for evaluation and resterilisation before donation to underserved patients in LMIC.9 A recent case study of 12 resterilised pacemakers donated through this …

Journal ArticleDOI
TL;DR: This review provides a practical guide for primary care physicians, internists, and cardiologists on current management strategies for atrial fibrillation, based on recent guidelines and current clinical data.


Journal ArticleDOI
TL;DR: The purpose of this study was to determine the frequency emergency department nurses report guideline-related activities when triaging patients for complaints suggestive of myocardial infarction and recommend tailored educational interventions be developed to improve nurses awareness of the importance of complying with the ACC/AHA standard of care practice goals.
Abstract: Background and objective Mortality from acute coronary syndromes has decreased. This achievement is based on the rapid recognition of possible acute coronary syndrome, obtaining an electrocardiogram for diagnosis, and the prompt initiation of therapy, including aspirin, oxygen, thrombolytics, and cardiac catheterization. The importance of rapid diagnosis and therapy is emphasized by American College of Cardiology/American Heart Association (ACC/AHA) practice guidelines. However, these goals are not always met, and their failure leads to increased mortality. The purpose of this study was to determine the frequency emergency department nurses report guideline-related activities when triaging patients for complaints suggestive of myocardial infarction. Subjects and methods As part of a larger study examining nurses' cardiac triage decisions, 158 emergency department nurses who belonged to the Emergency Nurses Association responded to a mailed questionnaire, which asked how frequently certain nursing practice activities were performed that would facilitate the attainment of ACC/AHA myocardial infarction guidelines and goals. Responses were measured on a 5-point Likert-type scale from "none of the time" to "all of the time." Results Not a single one of the 9 goals was met "all of the time" by all of the nurse participants. "All of the time" ranged from 52% for giving analgesics to 87% asking about chest pain. Only 81% of participants had a goal of obtaining electrocardiogram within 10 minutes of arrival, and only 27% of participants met all 9 goals "all of the time." The likelihood of nurses meeting goals was not associated with their age, experience, educational level, or certification status. Conclusions We recommend tailored educational interventions be developed to improve nurses awareness of the importance of complying with the ACC/AHA standard of care practice goals and the necessity of achieving these goals all of the time as a path to improving patient outcome.

Journal ArticleDOI
TL;DR: To determine the feasibility of using geographic information system technology to identify geographic areas of high and low adherence to cardiovascular drug therapy for treatment of acute coronary syndrome in patients discharged from a university‐affiliated hospital.
Abstract: Study Objective. To determine the feasibility of using geographic information system (GIS) technology to identify geographic areas of high and low adherence to cardiovascular drug therapy for treatment of acute coronary syndrome (ACS) in patients discharged from a university-affiliated hospital. Design. Retrospective analysis. Data Source. A registry of patients admitted to and discharged from a large university-affiliated medical center for the treatment of ACS . Patients. A total of 1081 adults distributed over 300 census tracts who were discharged between April 1999 and December 2004 with a diagnosis of an ACS event of unstable angina or acute myocardial infarction. Measurements and Main Results. Data were collected on patient demographics, home addresses, and adherence to four classes of drugs—statins, angiotensin-converting enzyme inhibitors, -blockers, and aspirin—at 6–12 months after discharge for the ACS index event. A GIS program was used to map patient addresses and adherence data to geographic coordinates. Hot Spot Analysis was used to determine the existence of any spatial clustering patterns in adherence rates. The analysis was performed at the census tract level by using the percentage of nonadherent patients within a census tract to represent adherence for the people living within that tract, standardized by the number of residents in a census tract aged 40 years or older. Hot Spot Analysis identified unique geographic areas of high, neutral, and low adherence in the southeast area. Highly adherent census tracts were primarily located in and around the city where the university hospital and clinics are located. Areas of low adherence were located to the west, southwest, and southeast of the city. All other census tracts were considered neutral in adherence rates. Conclusion. Mapping geographic areas of drug adherence is feasible with use of GIS technology, with spatial mapping able to detect areas of varying levels of adherence. Future research should examine local-level factors associated with low adherence, which can be used to derive tailored, locally relevant interventions to improve long-term drug adherence.


Journal ArticleDOI
TL;DR: Tako-tsubo cardiomyopathy is a novel cardiac syndrome characterized by transient left ventricular dysfunction, named by Japanese authors owing to the shape of the heart at ventriculogram, resembling the round-bottomed, narrownecked jar used for trapping the octopus (tako).
Abstract: Tako-tsubo cardiomyopathy (TTC) is a novel cardiac syndrome characterized by transient left ventricular dysfunction, named by Japanese authors owing to the shape of the heart at ventriculogram, resembling the round-bottomed, narrownecked jar (tsubo) used for trapping the octopus (tako). TTC is of great interest to cardiologists and emergency medicine physicians, since this condition mimics the clinical scenario of acute myocardial infarction (AMI) [1]. The diagnostic criteria include [1]:

Journal Article
TL;DR: Pacemaker reutilization is a safe, efficacious, and ethical alternative to address the medical needs for those in 3 rd world countries who could not afford therapy otherwise and is not associated with higher rates of infection, physiological malfunction, or device malfunction.
Abstract: Background: The inequality of healthcare between rich and poor countries appears to be escalating. Several small studies have suggested that pacemaker reutilization is an effective means of delivering healthcare for those with limited resources. This meta-analysis sought to evaluate the safety and efficacy of pacemaker reuse. Methods: We searched medical databases from January 1 st 1975 to July 1 st 2009 for studies that compared pacemaker reuse with a control population of new device implantation. Random-effects models were used to calculate summary odds ratios (OR). The primary endpoint was overall complication rate. Results: A total of 4 trials enrolling 603 subjects were integrated into this analysis. Compared to new pacemaker implantation, reutilization of previously implanted devices were not associated with a significant increase in overall complications (OR 0.98 [0.64 - 1.49]; p= 0.914). Furthermore, there was no increased risk of infection (OR 0.81 [0.41 - 1.62]; p=0.552), physiological complications (OR 1.06 [0.54 - 2.07]; p= 0.868), or device malfunction (OR 1.29 [0.51 - 3.29]; p=0.590). Device-related deaths were observed in neither group. Conclusions: Pacemaker reutilization, when compared to new device implantation, is not associated with higher rates of infection, physiological malfunction, or device malfunction. Pacemaker reuse is a safe, efficacious, and ethical alternative to address the medical needs for those in 3 rd world countries who could not afford therapy otherwise.

Journal ArticleDOI
TL;DR: Device reutilization appears to be a safe, feasible, and ethically responsible means of delivering electrophysiological healthcare to those in great need in underserved nations.
Abstract: In recent decades, the industrialized world has seen a dramatic decline in the morbidity and mortality associated with cardiovascular disease. Unfortunately, this benefit from preventative therapies and medical technologies has not been witnessed in lowand middle-income countries (LMIC) that account for >80% of all cardiovascular deaths worldwide.1 What was once thought to be a disease of only affluent industrialized nations has now superseded malaria and tuberculosis as the epidemic of the 21st century. There exists no greater inequality between industrialized nations and LMIC than in the field of cardiac electrophysiology—specifically device implantation. In 2005 alone, more than 1,050 new pacemakers and implantable defibrillators (ICDs) were implanted per million people in the United States as compared to 111 new cardiac device implants per million people in Brazil.2 As a result of these gross inequalities, various organizations have recently delivered cardiac devices to those in need in underserved nations: (1) Heartbeat International is a charitable organization that specializes in allocating pacemakers near their “sell-by” date generously donated by device manufacturers. To date, more than 9,000 devices have been implanted through pacemaker banks established by local Rotary International chapters in 24 countries over four continents.3 (2) World Medical Relief, a nonprofit organization specializing in delivery of medical equipment for distribution to hospitals and clinics in underserved nations, recently delivered 12 resterilized pacemakers to patients in the Philippines who could not afford device therapy.4 Novel therapies must be considered in order to prevent the estimated one million deaths that occur annually due to a lack of access to bradyarrhythmia therapy.5 Device reutilization appears to be a safe, feasible, and ethically responsible means of delivering electrophysiological healthcare to those in great need in underserved nations.


Journal ArticleDOI
TL;DR: In this article, the authors determined in post hoc analysis of a large regional medical center presenting clinical characteristics, treatment differences, and in-hospital and 6-month outcomes of first troponin-negative MI (FTNMI), 659 of 1,855 consecutive patients with non-ST-segment elevation MI were classified as having FTNMI.
Abstract: Little is known about non–ST-segment elevation myocardial infarction (MI) in patients with an initial negative troponin finding. The aim of this study was to determine in post hoc analysis of a large regional medical center presenting clinical characteristics, treatment differences, and in-hospital and 6-month outcomes of first troponin-negative MI (FTNMI). In this study, 659 of 1,855 consecutive patients with non–ST-segment elevation MI (35.5%) were classified as having FTNMI. In-hospital cardiac catheterization rates were similar between the 2 groups (70.1% vs 71.5%, p = 0.53) In hospital, patients with FTNMI were less likely to receive statins (48.9% vs 59.9%, p

Journal ArticleDOI
TL;DR: There has been no significant change in the use of BB in patients with STEMI or NSTEACS after controlling for their clinical characteristics since the publication of COMMIT/CCS-2, and long-term BB use, higher systolic blood pressure, and higher heart rate were independent predictors of early BB use.