Showing papers by "Kim A. Eagle published in 2013"
TL;DR: Results from IRAD show that TEVAR is associated with lower mortality over a 5-year period than medical therapy for TBAAD, and further randomized trials with long-term follow-up are needed.
Abstract: Objectives This study sought to evaluate long-term survival in type B aortic dissection patients treated with thoracic endovascular aortic repair (TEVAR) therapy. Background Historical data have supported medical therapy in type B acute aortic dissection (TBAAD) patients. Recent advances in TEVAR appear to improve in-hospital mortality. Methods We examined 1,129 consecutive patients with TBAAD enrolled in IRAD (International Registry of Acute Aortic Dissection) between 1995 and 2012 who received medical (n = 853, 75.6%) or TEVAR (n = 276, 24.4%) therapy. Results Clinical history was similar between groups. TEVAR patients were more likely to present with a pulse deficit (28.3% vs. 13.4%, p Conclusions Results from IRAD show that TEVAR is associated with lower mortality over a 5-year period than medical therapy for TBAAD. Further randomized trials with long-term follow-up are needed.
340 citations
TL;DR: Type A acute aortic dissection complicated by mesenteric malperfusion is a rare but ominous complication carrying a high risk of hospital mortality and surgical/hybrid management, although associated with 2-fold hospital mortality, appears to be associated with better long-term outcomes.
229 citations
TL;DR: This IRAD classification system can provide clinicians with a more robust method of characterizing survival after aortic dissection over time than previous methods and will be useful for treating patients, counseling patients and families, and studying new diagnostic and treatment methods.
214 citations
TL;DR: The presence of resistant hypertension identifies a subgroup of patients with hypertension and atherothrombosis who are at heightened risk for adverse long-term outcomes.
Abstract: Aims The effect of resistant hypertension on outcomes in patients with atherothrombotic disease is currently unknown. Accordingly, we sought to determine the prevalence and outcomes of resistant hypertension in stable hypertensive outpatients with subclinical or established atherothombotic disease enrolled in the international Reduction of Atherothrombosis for Continued Health (REACH) registry.
Methods and results Resistant hypertension was defined as a blood pressure ≥140/90 mmHg at baseline (≥130/80 mmHg if diabetes/renal insufficiency) with the use of ≥3 antihypertensive medications, including a diuretic. The primary outcome was a composite of cardiovascular death, myocardial infarction, or stroke at 4 years. A total of 53 530 hypertensive patients were included. The prevalence of resistant hypertension was 12.7%; 6.2% on 3 antihypertensive agents, 4.6% on 4 agents, and 1.9% on ≥5 agents (mean: 4.7 ± 0.8). In addition to a diuretic, these patients were being treated mostly with ACE-inhibitors/angiotensin receptor blockers (90.1%), beta-blockers (67.0%), and calcium channel blockers (50.8%). Patients with resistant hypertension had a higher risk of the primary endpoint on multivariable analysis [hazard ratio (HR) 1.11, 95% confidence interval (CI) 1.02–1.20; P = 0.017], including an increased non-fatal stroke risk (HR: 1.26; 95% CI: 1.10–1.45; P = 0.0008). Hospitalizations due to congestive heart failure were higher ( P < 0.0001). Patients on ≥5 agents had a higher adjusted risk for the primary endpoint when compared with those on ≤3 agents ( P = 0.03).
Conclusion The presence of resistant hypertension identifies a subgroup of patients with hypertension and atherothrombosis who are at heightened risk for adverse long-term outcomes.
183 citations
TL;DR: In patients with acute type B aortic dissection, aorti segments with a partially thrombosed false lumen have a significantly higher annual aorta growth rate when compared with those presenting with patent or complete thromBosis of thefalse lumen.
155 citations
TL;DR: This analysis of a large international registry demonstrates that nonadherence with evidence-based secondary prevention therapies in patients with established atherothrombosis is associated with a significant increase in long-term adverse events, including mortality.
124 citations
TL;DR: Stoke occurred in >1 of 20 patients with TAAAD and was associated with increased in-hospital morbidity but not long-term mortality, and whether aggressive early invasive interventions will reduce negative outcomes remains to be evaluated in future studies.
Abstract: Background—Stroke is a highly dreaded complication of type A acute aortic dissection (TAAAD). However, little data exist on its incidence and association with prognosis. Methods and Results—We evaluated 2202 patients with TAAAD (mean age 62±14 years, 1487 [67.5%] men) from the International Registry of Acute Aortic Dissection to determine the incidence and prognostic impact of stroke in TAAAD. Stroke was present at arrival in 132 (6.0%) patients with TAAAD. These patients were older (65±12 versus 62±15 years; P=0.002) and more likely to have hypertension (86% versus 71%; P=0.001) or atherosclerosis (29% versus 22%; P=0.04) than patients without stroke. Chest pain at arrival was less common in patients with stroke (70% versus 82%; P<0.001), and patients with stroke presented more often with syncope (44% versus 15%; P<0.001), shock (14% versus 7%; P=0.005), or pulse deficit (51% versus 29%; P≤0.001). Arch vessel involvement was more frequent among patients with stroke (68% versus 37%; P<0.001). They had les...
118 citations
TL;DR: In the present observational study, the patients selected to undergo surgery demonstrated improved late survival and frequent reversal of neurologic deficits.
86 citations
TL;DR: Despite overall improvements in cardiovascular‐disease therapies and outcomes, medication nonadherence remains an important barrier to effective secondary prevention of atherothrombotic disease.
Abstract: Background: Despite overall improvements in cardiovascular-disease therapies and outcomes, medication nonadherence remains an important barrier to effective secondary prevention of atherothrombotic disease. Hypothesis: Long-term medication adherence in outpatients with stable atherothrombotic disease is impacted by demographic and clinical factors. Methods: We examined data from the prospective international Reduction of Atherothrombosis for Continued Health (REACH) Registry. Analyses were derived from 25 737 patients with established atherothrombotic disease with complete adherence data at enrollment and at year 4. Adherence was defined as patients’ self-report of taking medications based on class I American College of Cardiology/American Heart Association guidelines for secondary prevention as defined, including antiplatelet agents, statins, and antihypertensive medications. Results: Among patients with atherothrombotic disease, 12 500 (48.6%) were deemed adherent to guidelinerecommended medications. Adherent patients were younger, white, and had less polyvascular disease. Hispanic and East Asian patients were less likely to be adherent as compared with white patients (odds ratio [OR]: 0.72, 95% confidence interval [CI]: 0.59-0.88; and OR: 0.67, 95% CI: 0.53-0.83, respectively). Patients who had a nonfatal MI or underwent coronary angioplasty/stenting during follow-up were more likely to be adherent compared with patients without these events (OR: 1.73, 95% CI: 1.25-2.38; and OR: 2.15, 95% CI: 1.72-2.67, respectively). On the other hand, nonfatal stroke during follow-up was inversely associated with adherence (OR: 0.77, 95% CI: 0.61-0.97). Conclusions: Using a large international registry of outpatients with atherothrombotic disease, we found that age, region, race/ethnicity, and incident cardiovascular events were predictive of long-term guideline adherence for secondary prevention, suggesting that certain patient groups may benefit from targeted interventions to improve adherence.
77 citations
TL;DR: Most IMHB patients can be treated medically, and aortic enlargement is less common during follow-up, which may suggest that IMHB may have a slightly more benign course compared with classic ABAD in the acute setting.
60 citations
TL;DR: Although aortic dissection has been most vigorously pursued, there has also been notable recent progress in biomarkers of aneurysms and inflammatory aorta disease.
TL;DR: Differences in type, etiology, and presentation of blacks and whites with acute aortic dissection, yet similar mortality for these cohorts are shown.
TL;DR: Gender-related differences in factors associated with obesity among middle-school children are observed, and nonobese students (both boys and girls) showed significantly healthier physiologic parameters compared with their obese counterparts.
Abstract: BACKGROUND: Previous studies have demonstrated gender-related differences in body composition, physical activity, and diet. This observational study assesses gender variance in independent predictors for obesity to determine targeted areas for intervention. METHODS: Data from 1714 sixth-grade students enrolled in Project Healthy Schools were compared by using health behaviors and physiologic markers (lipids, random glucose, blood pressure, and resting and recovery heart rates). Students were stratified by gender and obesity (BMI ≥95th percentile by age and gender). Physiologic markers and behaviors were compared by using χ 2 analysis. Univariate associations with P RESULTS: Nonobese students (both boys and girls) showed significantly healthier physiologic parameters compared with their obese counterparts. Two behaviors independently correlated with obesity in both boys and girls: regularly eating school lunches (odds ratio [OR] 1.29, 95% confidence interval [CI] 1.01–1.64; OR 1.27, 95% CI 1.00–1.62, respectively) and watching ≥2 hours of television per day (OR 1.19, 95% CI 1.07–1.32; OR 1.19, 95% CI 1.06–1.34, respectively). Vigorous physical activity and involvement in school sports teams appeared to be protective against obesity in boys (OR 0.90, 95% CI 0.82–0.98; OR 0.77, 95% CI 0.64–0.94, respectively), whereas milk consumption appeared protective in girls (OR 0.81, 95% CI 0.67–0.98). CONCLUSIONS: Among middle-school children, we observed gender-related differences in factors associated with obesity. Additional research is warranted to determine the beneficial impact of improving school lunches and decreasing screen time, while improving our understanding of gender-related differences in milk consumption and physical activities in relation to BMI.
TL;DR: In women, decreased prevalence of aortic operations and less treatment with ACEi may be due to their smaller absolute aortIC diameters, and longitudinal studies are needed to determine if women are at higher risk for adverse events.
Abstract: Previous data suggest women are at increased risk of death from aortic dissection. Therefore, we analyzed data from the GenTAC registry, the NIH-sponsored program that collects information about individuals with genetically-triggered thoracic aortic aneurysms and cardiovascular conditions. We performed cross-sectional analyses in adults with Marfan syndrome (MFS), familial thoracic aortic aneurysm or dissection (FTAAD), bicuspid aortic valve (BAV) with thoracic aortic aneurysm or dissection, and subjects under 50 years of age with thoracic aortic aneurysm or dissection (TAAD<50y). Women comprised 32% of 1449 subjects and were 21% of subjects with BAV, 34% with FTAAD, 22% with TAAD <50y, and 47% with MFS. Thoracic aortic dissections occurred with equal gender frequency yet women with BAV had more extensive dissections. Aortic size was smaller in women but was similar after controlling for BSA. Age at operation for aortic valve dysfunction, aneurysm or dissection did not differ by gender. Multivariate analysis (adjusting for age, BSA, hypertension, study site, diabetes, and subgroup diagnoses) showed that women had fewer total aortic surgeries (OR= 0.65, p < 0.01) and were less likely to receive angiotensin converting enzyme inhibitors (ACEi) (OR=0.68, p < 0.05). As in BAV, other genetically-triggered aortic diseases such as FTAAD and TAAD<50 are more common in males. In women, decreased prevalence of aortic operations and less treatment with ACEi may be due to their smaller absolute aortic diameters. Longitudinal studies are needed to determine if women are at higher risk for adverse events.
TL;DR: Compared to patients with "definite" ACS on presentation, those with "possible" ACS had higher baseline GRACE risk scores but less frequently received evidence-based medical therapies within 24 hours of admission or underwent cardiac procedures during hospitalization.
Abstract: The early diagnosis of acute coronary syndrome (ACS) remains challenging, and a considerable proportion of patients are diagnosed with "possible" ACS on admission. The Global Registry of Acute Coronary Events (GRACE/GRACE(2)) and Canadian Registry of Acute Coronary Events (CANRACE) enrolled 16,618 Canadian patients with suspected ACS in 1999 to 2008. We compared the demographic and clinical characteristics, use of cardiac procedures, prognostic accuracy of the GRACE risk score, and in-hospital outcomes between patients given an admission diagnosis of "definite" versus "possible" ACS by the treating physician. Overall, 11,152 and 5,466 patients were given an initial diagnosis of "definite" ACS and "possible" ACS, respectively. Patients with a "possible" ACS had higher GRACE risk score (median 130 vs 125) and less frequently received aspirin, clopidogrel, heparin, or β blockers within the first 24 hours of presentation and assessment of left ventricular function, stress testing, cardiac catheterization, and percutaneous coronary intervention (all p <0.05). Patients with "possible" ACS had greater rates of in-hospital myocardial infarction (9.0% vs 2.0%, p <0.05) and heart failure (12% vs 8.9%, p <0.05). The GRACE risk score demonstrated excellent discrimination for in-hospital mortality in both groups and for the entire study population. In conclusion, compared to patients with "definite" ACS on presentation, those with "possible" ACS had higher baseline GRACE risk scores but less frequently received evidence-based medical therapies within 24 hours of admission or underwent cardiac procedures during hospitalization. The GRACE risk score provided accurate risk assessment, regardless of the initial diagnostic impression.
TL;DR: In high-risk patients undergoing major vascular surgery, ABBS therapy has superior 30-day and 12-month risk reduction benefits for MI, stroke, and mortality as compared with A, BB, or S independently.
TL;DR: The results showed significant improvements in risk factors associated with early atherosclerosis among sixth-grade students, including total cholesterol, low-density lipoprotein cholesterol, triglycerides, and systolic and diastolic blood pressures.
TL;DR: A nonsignificant trend toward lower mortality after endovascular management was observed, both for younger patients and for elderly patients.
TL;DR: All AAD patients should be administered with strict antihypertensive management combined with imaging surveillance and careful periodic clinical follow-up, as it reduces propagation of the dissection and aortic rupture.
Abstract: Recent improvements in diagnosis, peri-operative management, surgical techniques and postoperative care have resulted in decreased mortality and morbidity in acute aortic dissections (AAD). The classic treatment algorithm indicates that type A patients require direct surgical intervention and type B patients should be treated medically, in absence of complications. Initial medical treatment is adopted in all AAD patients, as it reduces propagation of the dissection and aortic rupture. In type A aortic dissection (TAAD) several techniques have contributed to major changes in the surgical approach, such as cerebral protection using moderate circulatory arrest, selective cerebral perfusion, and aortic valve sparing with root replacement. In TAAD with involvement of the descending aorta, thoracic endovascular aortic repair (TEVAR) can be performed as a part of a complex hybrid procedure, in which surgical ascending/arch repair is combined with the placement of a stent graft in the descending aorta. Future developments in stent graft technologies might broaden the usefulness of TEVAR for the total endovascular repair of TAAD. In complicated type B aortic dissection (TBAD), the use of TEVAR has become the therapy of first choice. By covering the proximal entry tear, the stent graft reduces the pressurization of the false lumen, treating malperfusion and inducing favorable aortic remodeling. In uncomplicated TBAD, TEVAR has been used to prevent long term complications, such as aortic aneurysm, but this concept is not yet routinely recommended. Regardless of their initial treatment, all AAD patients should be administered with strict antihypertensive management combined with imaging surveillance and careful periodic clinical follow-up.
TL;DR: Among middle school children, RHR appears to be associated with physiologic parameters and health behaviors, and may be useful for identifying children at increased risk for developing CV risk factors.
Abstract: Recovery heart rate (RHR) has been used in adults to evaluate cardiovascular (CV) fitness, but less is known about RHR in children. Data from 1,276 participants in Project Healthy Schools, a school-based intervention in southeast Michigan, were collected. In addition, to demographic characteristics, physiologic factors examined included body mass index (BMI), lipid and glucose levels, blood pressure, and HR. Information on diet, physical activity, and sedentary behavior was collected through self-report. RHR was determined by measurement of HR after a 3-minute step test. Using quartiles of RHR as a marker of fitness, associations with demographic, physiologic, and behavioral factors were explored using χ2 and Student t tests. Compared with children in the lowest quartile of RHR (i.e., most fit), those in the upper quartile of RHR (i.e., least fit) had greater mean LDL cholesterol (93.0 vs. 86.7 mg/dL; P = 0.02) and lower mean HDL cholesterol (50.9 vs. 55.9 mg/dL; P < 0.001). Children in the upper 95 % of BMI had greater mean RHR compared with those in the normal BMI range (116.6 vs. 100.3 kg/m2). Children in the upper quartile of RHR reported fewer days of vigorous to moderate exercise per week compared with children in the lowest quartile of RHR [4.8 vs. 4.1 (P < 0.001) for moderate exercise and 3.6 vs. 3.0 (P = 0.001) for vigorous exercise]. Among middle school children, RHR appears to be associated with physiologic parameters and health behaviors. RHR may be useful for identifying children at increased risk for developing CV risk factors.
TL;DR: A retrospective study on the Italian National Hospital Database findsrupture in patients treated with a history of prior heart attack or stroke is a major cause of death in women over 50 years of age.
TL;DR: Patients with acute type A aortic dissection who survive to discharge have a favorable prognosis, and preoperative false lumen thrombosis does not influence long‐term mortality, reintervention rates, or aORTic growth.
Abstract: BackgroundPartial thrombosis of the false lumen has been related to aortic growth, reoperations, and death in the chronic phase of type B and repaired type A aortic dissections. The impact of preop...
TL;DR: PCS delays presentation, diagnosis, and treatment of type A acute aortic dissection and is an important adverse risk factor for early and intermediate-term mortality.
Abstract: Background—Prior cardiac surgery (PCS) can complicate the presentation and management of patients with type A acute aortic dissection (TAAAD). This report from the International Registry of Acute Aortic Dissection examines this hypothesis. Methods and Results—A total of 352 of 2196 patients with TAAAD (16%) enrolled in the International Registry of Acute Aortic Dissection had cardiac surgery before dissection, including coronary artery bypass grafting (34%), aortic or mitral valve surgery (36%), aortic surgery (42%), and other cardiac surgery (16%). Those with PCS were older, had a higher frequency of diabetes mellitus, hypertension, and atherosclerosis, and presented later from symptom onset to hospital presentation and diagnosis (all P 70 years (HR, 2.65; 95% CI, 1.40–5.05), medica...
TL;DR: Although future directions should involve the evolution of operative and endovascular techniques and the development of sophisticated risk prediction tools, risk factor modification by addressing the burden of uncontrolled hypertension cannot be overlooked.
TL;DR: A high clinical index of suspicion followed by an imaging study, namely transesophageal echocardiography, computed tomography, and magnetic resonance imaging is a conditio sine qua non for prompt diagnosis of acute aortic syndromes.
Abstract: Acute aortic syndromes are fatal medical conditions including classic acute aortic dissection, intramural hematoma, and penetrating atherosclerotic ulcer. Given the nonspecific symptoms and signs, a high clinical index of suspicion followed by an imaging study, namely transesophageal echocardiography, computed tomography, and magnetic resonance imaging (sensitivity 98-100% and specificity 95-100%), is a conditio sine qua non for prompt diagnosis of acute aortic syndromes. This article provides an overview of established and emerging approaches for the assessment of acute aortic syndromes, with focus on imaging and biomarkers. In this regard, D-dimer levels (cut-off: 500 ng/ml) may be useful to rule out aortic dissection, if used within the first 24 h after symptom onset.
01 Jul 2013
TL;DR: There is a trend for increased in-hospital mortality in painless TBAAD patients, which may be the result of a delay in diagnosis and management, and physicians should be aware of this relative rare presentation of TBAAD.
Abstract: Introduction: The classical presentation of a patient with Type B acute aortic dissection (TBAAD) is characterized by severe chest, back, or abdominal pain, ripping or tearing in nature. However, some patients present with painless acute aortic dissection, which can lead to a delay in diagnosis and treatment. We utilized the International Registry on Acute Aortic Dissections (IRAD) database to study these patients. Methods: We analyzed 43 painless TBAAD patients enrolled in the database between January 1996 and July 2012. The differences in presentation, diagnostics, management, and outcome were compared with patients presenting with painful TBAAD. Results: Among the 1162 TBAAD patients enrolled in IRAD, 43 patients presented with painless TBAAD (3.7%). The mean age of patients with painless TBAAD was significantly higher than normal TBAAD patients (69.2 versus 63.3 years, P = 0.020). The presence of atherosclerosis (46.4% versus 30.1%, P = 0.022), diabetes (17.9% versus 7.5%; P = 0.018), and other aortic diseases (8.6% versus 2.3%, P= 0.051), such as prior aortic aneurysm (31% versus 18.8% P = 0.049) was more common in these patients. Median delay time between presentation and diagnosis was longer in painless patients (median 34.0 versus 19.0 hours; P = 0.006). Dissection of iatrogenic origin (19.5% versus 1.3%; P < 0.001) was significantly more frequent in the painless group. The in-hospital mortality was 18.6% in the painless group, compared with an in-hospital mortality of 9.9% in the control group (P = 0.063). Conclusion: Painless TBAAD is a relatively rare presentation (3.7%) of aortic dissection, and is often associated with a history of atherosclerosis, diabetes, prior aortic disease including aortic aneurysm, and an iatrogenic origin. We observed a trend for increased in-hospital mortality in painless TBAAD patients, which may be the result of a delay in diagnosis and management. Therefore, physicians should be aware of this relative rare presentation of TBAAD.
TL;DR: The findings suggest that patients on chronic OAC are less likely to receive guideline-indicated management, but have similar adjusted rates of in-hospital and 6-month mortality.
Abstract: Aims:To describe the characteristics, treatment, and mortality in patients with ST-elevation myocardial infarction (STEMI) by use of chronic oral anticoagulant (OAC) therapy.Methods:Using data from the Global Registry of Acute Coronary Syndromes (GRACE), patient characteristics, treatment, and reperfusion strategies of STEMI patients on chronic OAC are described, and relevant variables compared with patients not on chronic OAC. Six-month post-discharge mortality rates were evaluated by Cox proportional hazard models.Results:Of 19,094 patients with STEMI, 574 (3.0%) were on chronic OAC at admission. Compared with OAC non-users, OAC users were older (mean age 73 vs. 65 years), more likely to be female (37 vs. 29%), were more likely to have a history of atrial fibrillation, prosthetic heart valve, venous thromboembolism, or stroke/transient ischaemic attack, had a higher mean GRACE risk score (166 vs. 145), were less likely to be Killip class I (68 vs. 82%), and were less likely to undergo catheterization/pe...
TL;DR: Despite challenging logistical and regulatory obstacles, post-mortem pacemaker reuse may be a feasible, safe and cost-effective strategy to provide life-saving therapy to patients in LMICs.
Abstract: Cardiac pacemakers have revolutionized the management of symptomatic bradyarrhythmia (slow heart rate) and are in part responsible for the dramatic reduction in morbidity and mortality from cardiov...
TL;DR: Elderly acute aortic dissection pts ≥70 years of age have higher in-hospital mortality and less Type A (TA) surgical management (mgmt) and these differences may also hold true within the elderly cohort.