Showing papers by "Kim A. Eagle published in 2014"

Statin therapy and long-term adverse limb outcomes in patients with peripheral artery disease: insights from the REACH registry

Abstract: Aims Due to a high burden of systemic cardiovascular events, current guidelines recommend the use of statins in all patients with peripheral artery disease (PAD). We sought to study the impact of statin use on limb prognosis in patients with symptomatic PAD enrolled in the international REACH registry. Methods Statin use was assessed at study enrolment, as well as a time-varying covariate. Rates of the primary adverse limb outcome (worsening claudication/new episode of critical limb ischaemia, new percutaneous/surgical revascularization, or amputation) at 4 years and the composite of cardiovascular death/myocardial infarction/stroke were compared among statin users vs. non-users. Results A total of 5861 patients with symptomatic PAD were included. Statin use at baseline was 62.2%. Patients who were on statins had a significantly lower risk of the primary adverse limb outcome at 4 years when compared with those who were not taking statins [22.0 vs. 26.2%; hazard ratio (HR), 0.82; 95% confidence interval (CI), 0.72–0.92; P = 0.0013]. Results were similar when statin use was considered as a time-dependent variable ( P = 0.018) and on propensity analysis ( P < 0.0001). The composite of cardiovascular death/myocardial infarction/stroke was similarly reduced (HR, 0.83; 95% CI, 0.73–0.96; P = 0.01). Conclusion Among patients with PAD in the REACH registry, statin use was associated with an ∼18% lower rate of adverse limb outcomes, including worsening symptoms, peripheral revascularization, and ischaemic amputations. These findings suggest that statin therapy not only reduces the risk of adverse cardiovascular events, but also favourably affects limb prognosis in patients with PAD.

The Role of Imaging in Aortic Dissection and Related Syndromes

Abstract: Aortic aneurysm and acute aortic syndrome are not uncommon conditions. Management of acute aortic dissection and related syndromes requires a multidisciplinary approach with input from the patient, clinician, imager, surgeon, and anesthesiologist. This requires an integrated evaluation of pathophysiology, anatomy, and severity to enable appropriate therapy. This review includes discussion of essential anatomy of the aortic valve and the aorta that determines the candidacy for surgical repair. It also includes discussion of various imaging modalities, particularly echocardiography, cardiac computed tomography, and cardiac magnetic resonance angiography. The relative benefits and demerits of each of these techniques are reviewed. This paper is intended to help guide management decisions for patients with acute aortic dissection and related syndromes.

Predicting In-Hospital Mortality in Acute Type B Aortic Dissection Evidence From International Registry of Acute Aortic Dissection

Abstract: Background— The outcome of patients with acute type B aortic dissection (ABAD) is strongly related to their clinical presentation. The purpose of this study was to investigate predictors for mortality among patients presenting with ABAD and to create a predictive model to estimate individual risk of in-hospital mortality using the International Registry of Acute Aortic Dissection (IRAD). Methods and Results— All patients with ABAD enrolled in IRAD between 1996 and 2013 were included for analysis. Multivariable logistic regression analysis was used to investigate predictors of in-hospital mortality. Significant risk factors for in-hospital death were used to develop a prediction model. A total of 1034 patients with ABAD were included for analysis (673 men; mean age, 63.5±14.0 years), with an overall in-hospital mortality of 10.6%. In multivariable analysis, the following variables at admission were independently associated with increased in-hospital mortality: increasing age (odds ratio [OR], 1.03; 95% confidence interval [CI], 1.00–1.06; P =0.044), hypotension/shock (OR, 6.43; 95% CI, 2.88–18.98; P =0.001), periaortic hematoma (OR, 3.06; 95% CI, 1.38–6.78; P =0.006), descending diameter ≥5.5 cm (OR, 6.04; 95% CI, 2.87–12.73; P P P =0.001), and limb ischemia (OR, 3.02; 95% CI, 1.05–8.68; P =0.040). Based on these multivariable results, a reliable and simple bedside risk prediction tool was developed. Conclusions— We present a simple prediction model using variables that are independently associated with in-hospital mortality in patients with ABAD. Although it needs to be validated in an independent population, this model could be used to assist physicians in their choice of management and for informing patients and their families.

Acute type B aortic dissection: insights from the International Registry of Acute Aortic Dissection

Abstract: Acute type B aortic dissection comprises approximately one-third of all aortic dissection cases. Although this catastrophic cardiovascular condition was first described in the medical literature over two centuries ago, data on the optimal diagnostic and treatment modalities for type B dissection was slow to evolve throughout the latter half of the twentieth century, even as newer diagnostic techniques and management strategies became commonplace. To further elucidate contemporary practice patterns and outcomes of aortic dissection, the International Registry of Acute Aortic Dissection (IRAD) was established in 1996. Over the past two decades, IRAD publications have steadily increased our knowledge and understanding about aortic dissection. Specifically in recent years, analyses of IRAD data have gone beyond simply characterizing the patient with acute type B aortic dissection and have attempted to identify the means by which the outcome of such a patient could be improved. Thus, we present herein three areas in which IRAD data has recently advanced our understanding of acute type B aortic dissection: temporal classification especially for the subacute time period, risk stratification for identifying complicated cases, and thoracic endovascular aortic repair (TEVAR).

Activity Recommendations for Postaortic Dissection Patients

Abstract: Individuals who have survived an aortic dissection are often faced with the question of how life can be maximally and safely lived, with functional independence preserved. Routine exercise is important for both physical and emotional health. During exercise, blood pressure and heart rate increase in part related to the intensity, duration, and specific type of activity performed. The goal of this Cardiology Patient Page is to provide the postaortic dissection patient with an understanding of how blood pressure changes with different activities. We will provide information to patients and families that leads to a greater sense of comfort during physical activity, while possibly decreasing the risk of future aortic complications, thus improving overall quality of life. It is our goal that patients will continue to engage in consistent exercise, given its beneficial effects on mental, physical, and emotional health. When a handgrip (Figure) is squeezed maximally for 1 minute, the systolic blood pressure (SBP) increases by approximately 50 mm Hg. The diastolic pressure increases by about 30 mm Hg.1 When a handgrip is squeezed at 30% of maximal effort, the SBP increases by about 20 to 30 mm Hg, and the diastolic pressure increases by about 10 to 20 mm Hg. Although these studies are limited by small sample size, they do suggest that blood pressure may increase more than is appreciated …

Medical management in type B aortic dissection

Abstract: Medical management is generally the preferred treatment for uncomplicated type B acute aortic dissection cases. It is often centered on the use of antihypertensive agents, which alleviates hemodynamic stress on the damaged aortic wall. Methods of medical management and drug selection are still based mainly on personal experience, expert opinion and historical observational studies as randomized controlled studies are lacking. Guidelines from European (ESC), American (ACC/AHA) and Asian (Japan) societies in the last decade have made recommendations on use of medications, but also reaffirmed the lack of evidence for therapeutic approaches and targeted medical management. More recent evidence suggests that there may be type-selective benefits for antihypertensive medications. Here, we will discuss the present understanding of medical management of acute aortic dissection.

Renin-angiotensin system antagonists and clinical outcomes in stable coronary artery disease without heart failure

Abstract: Aims The aim of this study was to determine whether angiotensin-converting enzyme inhibitor (ACEI) or angiotensin-II receptor blocker (ARB) use is associated with lower rates of cardiovascular events in patients with stable coronary artery disease (CAD) but without heart failure (HF) receiving contemporary medical management. Methods and results Using data from the Reduction of Atherothrombosis for Continued Health (REACH) registry, we examined, using propensity score approaches, relationships between cardiovascular outcomes and ACEI/ARB use (64.1% users) in 20 909 outpatients with stable CAD and free of HF at baseline. As internal control, we assessed the relation between statin use and outcomes. At 4-year follow-up, the risk of cardiovascular death, MI, or stroke (primary outcome) was similar in ACEI/ARB users compared with non-users (hazard ratio, 1.03; 95% confidence interval [CI], 0.91–1.16; P = 0.66). Similarly, the risk of the primary outcome and cardiovascular hospitalization for atherothrombotic events (secondary outcome) was not reduced in ACEI/ARB users (hazard ratio, 1.08; 95% CI, 1.01–1.16; P = 0.04), nor were the rates of any of its components. Analyses using propensity score matching yielded similar results, as did sensitivity analyses accounting for missing covariates, changes in medications over time, or analysing separately ACEI and ARB use. In contrast, in the same cohort, statin use was associated with lower rates for all outcomes. Conclusions Use of ACEI/ARB was not associated with better outcomes in stable CAD outpatients without HF. The benefit of ACEI/ARB seen in randomized clinical trials was not replicated in this large contemporary cohort, which questions their value in this specific subset.

The Addition of the Charlson Comorbidity Index to the GRACE Risk Prediction Index Improves Prediction of Outcomes in Acute Coronary Syndrome

Abstract: Patients with cardiovascular disease have increased risk of poor outcomes when coexisting illnesses are present. Clinicians, administrators, and health services researchers utilize risk adjustment indices to stratify patients for various outcomes. The GRACE Risk Prediction Index (GRPI) was developed to risk stratify patients who experienced an acute coronary syndrome (ACS) event. GRPI does not account for the presence of comorbid conditions. The objective of this study was to compare the ability of the GRPI and the Charlson Comorbidity Index (CCI), used independently or combined, to predict mortality or secondary coronary events in patients admitted for ACS. Data were obtained from an academic health system's ACS registry. Outcomes included inpatient and 6-month postdischarge mortality and occurrence of secondary cardiovascular events or revascularization procedures. Logistic regression derived C statistics for CCI, GRPI, and CCI-GRPI predictive models for each outcome. Likelihood ratio tests det...

Metabolic syndrome, diabetes mellitus, or both and cardiovascular risk in outpatients with or at risk for atherothrombosis.

Abstract: BackgroundThe incidence of metabolic syndrome (MetS), diabetes mellitus (DM), and their coexistence is increasing but whether MetS increases cardiovascular risk beyond component risk factors is con...

Cardiac Implantable Electronic Device Reutilization: Battery Life of Explanted Devices at a Tertiary Care Center

Abstract: Introduction Prior studies have suggested that pacemaker reuse may be a reasonable alternative to provide device therapy in the low- and middle-income countries. We studied explant indications and remaining battery life of cardiac implantable electronic devices (CIEDs) at a tertiary medical center. Methods and Results We conducted a retrospective review of all CIEDs extracted at the University of Michigan between 2007 and 2011. Devices were considered reusable if battery longevity was ≥48 months or >75% battery life was remaining; there was no evidence of electrical malfunction, and they were not under advisory or recall. Eight hundred and one CIEDs were explanted: Medtronic (MDT [Medtronic Inc., Minneapolis, MN, USA]; 454), Boston Scientific (BS [Boston Scientific Corp., Natick, MA, USA])/Guidant (GDT; 255 [Guidant Corp., St. Paul, MN, USA]), St. Jude Medical (SJM; 73 [St. Paul, MN, USA]), and Biotronik (BTK; 15 [Biotronik GmBH, Berlin, Germany]). After eliminating devices explanted for elective replacement indicator (ERI, 541), 51.9% of pacemakers (41/79), 54.2% of implantable cardioverter-defibrillators (ICDs) (64/118), and 47.6% of cardiac resynchronization therapy and defibrillation (CRT-D) devices (30/63) had sufficient battery life and no evidence of electrical malfunction to be considered for reuse. A logistic regression analysis found that the indications for device removal independently predicted reusability: upgrade to an ICD (odds ratio [OR] 162.8, P < 0.001) or CRT-D (OR 63.8, P < 0.001), infection (OR 110.7, P < 0.001), heart transplantation or left ventricular assist device placement (OR 56.6, P < 0.001), and device removal at patient's request (OR 115.4, P < 0.001). Conclusion The majority of explanted CIEDs for reasons other than ERI have an adequate battery life and, if proven safe, may conceivably be reutilized for basic pacing in underserved nations where access to this life-saving therapy is limited.

Pulse pressure and type A acute aortic dissection in-hospital outcomes (from the International Registry of Acute Aortic Dissection).

Abstract: Little is known about the relation between type A acute aortic dissection (TAAAD) and pulse pressure (PP), defined as the difference between systolic and diastolic blood pressure. In this study, we explored the association between PP and presentation, complications, and outcomes of patients with TAAAD. PP at hospital presentation was used to divide 1,960 patients with noniatrogenic TAAAD into quartiles: narrowed (≤39 mm Hg, n = 430), normal (40 to 56 mm Hg, n = 554), mildly elevated (57 to 75 mm Hg, n = 490), and markedly elevated (≥76 mm Hg, n = 486). Variables relating to index presentation and in-hospital outcomes were analyzed. Patients with TAAAD in the narrowed PP quartiles were frequently older and Caucasian, whereas patients with markedly elevated PPs tended to be male and have a history of hypertension. Patients who demonstrated abdominal vessel involvement more commonly demonstrated elevated PPs, whereas patients with narrowed PPs were more likely to have periaortic hematoma and/or pericardial effusion. Narrowed PPs were also correlated with greater incidences of hypotension, cardiac tamponade, and mortality. Patients with TAAAD who were managed with endovascular and hybrid procedures and those with renal failure tended to have markedly elevated PPs. No difference in aortic regurgitation at presentation was noted among groups. In conclusion, patients with TAAAD in the third PP quartile had better in-hospital outcomes than patients in the lowest quartile. Patients with narrowed PPs experienced more cardiac complications, particularly cardiac tamponade, whereas those with markedly elevated PPs were more likely to have abdominal aortic involvement. Presenting PP offers a clue to different manifestations of acute aortic dissection that may facilitate initial triage and care.

The Yin and Yang of Perioperative Medicine

Abstract: The past four decades have seen remarkable progress in establishing best perioperative practices.1 One of the challenges in improving perioperative care, however, is rooted in the interplay of the myriad interdependent, often opposing, mechanisms that contribute to perioperative myocardial infarction — excess bleeding, dramatic fluid shifts, unrelenting tachycardia, myocardial stress with fixed coronary obstruction, profound hypotension or hypertension, coronary plaque rupture, and coronary spasm. Strategies that mitigate one mechanism may lead to another. Devereaux et al. now report on two such strategies in the Journal — the perioperative use of aspirin and the perioperative use of clonidine in patients undergoing . . .

β-blockade to prevent perioperative death in non-cardiac surgery: questions, controversy, and not enough answers

Abstract: The use of perioperative β-blockade in patients undergoing non-cardiac surgery are informed, in part, by the Dutch Echocardiographic Cardiac Risk Evaluation Applying Stress Echocardiography (DECREASE) family of studies.1 Allegations of research fraud have discredited the DECREASE studies and diluted the evidence supporting the cardiovascular benefit of perioperative β blockade.2–4 All studies investigated in the DECREASE family were found to be insecure because of flaws ranging from fictitious methods to fabrication of data to no evidence of written informed consent.3 ,4 Current European and American guidelines continue to offer Class I recommendations for continuation of pre-existing β-blockade,5 ,6 and initiation of β-blockade in those patients known to have ischaemic heart disease or myocardial ischaemia according to preoperative testing,5 and those undergoing high-risk (primarily vascular) surgery.5 Recognising the limitations of the flawed DECREASE data, Bouri et al 3 performed a meta-analysis of secure intention-to-treat randomised controlled trial (RCT) data of β-blockade on perioperative mortality, non-fatal myocardial infarction, stroke and hypotension in patients undergoing non-cardiac surgery. Studies from the DECREASE family of studies were excluded; the meta-analysis included 10 529 patients from nine secure trials. Initiation of a course of β-blockade before surgery was associated with a significant 27% increase in mortality (relative risk (RR) 1.27, 95% CI 1.01 to 1.60, p=0.04). β-blockade reduced non-fatal myocardial infarction (RR …

High-Density Lipoprotein Cholesterol Levels in Middle-School Children: Association with Cardiovascular Risk Factors and Lifestyle Behaviors

Abstract: To examine factors associated with low high-density lipoprotein cholesterol (HDL-C) levels among middle school children. HDL-C levels were the primary outcome of interest. A total of 1,104 middle-school children (mean age 11.6 years, 51.2 % female) were included in this analysis, of whom 177 (16 %) had an HDL-C level ≤40 mg/dL. More than half of those with low HDL-C were overweight or obese (62.2 %) and had greater systolic and diastolic blood pressure, triglyceride (TRG) levels, and low-density lipoprotein cholesterol levels compared with children with an HDL-C level >40 mg/dL. Among those with an HDL-C ≤ 40 mg/dL, 35 % also had body mass index ≥85 % and TRG levels ≥150 mg/dL. Exercise habits were significantly associated with HDL-C level, whereas sedentary behaviors, such as screen time, were not significantly associated with HDL-C level. Fruit and vegetable intake was also not significantly associated with HDL-C level. Children with low HDL-C levels are more likely to be overweight and to have other physiological indicators of increased cardiovascular risk. Further research is needed to determine if school-based interventions can result in long-term improvements in HDL-C.

The epidemiology and outcomes of percutaneous coronary intervention before high-risk noncardiac surgery in contemporary practice: insights from the Blue Cross Blue Shield of Michigan Cardiovascular Consortium (BMC2) Registry.

Abstract: Background Percutaneous coronary intervention (PCI) is sometimes performed with the intent to lower cardiovascular risk before high-risk noncardiac surgery (HRNCS). There are limited data on the frequency and outcome of PCIs performed in this setting. Methods and Results We assessed the frequency, characteristics, and in-hospital outcomes of patients undergoing PCI as part of the preoperative workup for HRNCS among all 61 145 elective PCIs performed between 2002 and 2009 at 14 hospitals in the Blue Cross Blue Shield of Michigan Cardiovascular Consortium. Propensity matching was performed to compare outcomes of patients undergoing PCI before HRNCS with all other elective PCI patients. The frequency of PCI before HRNCS was low (4.2%). Patients undergoing PCI before HRNCS were older (67.3 versus 64.9 years, P <0.0001) and had a greater burden of comorbidity. Patients undergoing PCI before HRNCS had an increase in unadjusted major adverse cardiovascular events, postprocedure transfusion, contrast-induced nephropathy, nephropathy requiring dialysis, and same-admission coronary artery bypass graft surgery, but there was no difference in mortality (0.27% versus 0.14%, P =0.11). However, in propensity score–matched samples, there was a significant difference only in nephropathy requiring dialysis. Conclusions The incidence of PCI performed in preparation for high-risk noncardiac surgery is low, and these procedures are currently being performed on a highly selected high-risk patient population.

Abstract 490: Vertebral Artery Tortuosity Index is a Novel Biomarker of Surgery and Aortic Dissection or Rupture in Children and Young Adults: Findings From the National Registry of Genetically Triggered Thoracic Aortic Aneurysms and Cardiovascular Conditions

Abstract: Background: Little is known about reliable predictors of thoracic aortic dissection or rupture (TAD) in children and young adults. We sought to determine whether elevated vertebral artery tortuosity is a biomarker of TAD or aortic surgery at an early age. Methods: We identified 208 patients ≤50 years old in the GenTAC Registry who had ≥2.5 cm of either vertebral artery visualized on a computed tomography angiogram (CTA). In a blinded fashion, using a volume-rendered projection, each patient’s vertebral artery tortuosity index (VTI) was calculated using the larger distance factor (% by which actual length exceeds straight-line length) of the two vertebral arteries. We then investigated associations between VTI and freedom from prophylactic or post-TAD surgery. Results: Subjects included 73 with Marfan syndrome (MS), 34 with bicuspid aortic valve, 18 with Loeys-Dietz syndrome (LDS), 16 with familial thoracic aneurysms and dissections, 12 with Ehlers-Danlos syndrome type IV (EDS), 6 with congenital heart disease, and 49 with other aneurysms and dissections. Median age was 38.5 years [interquartile range (IQR) 29.6-44.6]; 23 were ≤18 years. Indication for first surgery was prophylactic in 80 patients and TAD in 49. VTI was highest in LDS (median 50, IQR 21-72), followed by MS (median VTI 27, IQR 16-52), and lowest in EDS (median 7, IQR 4-13). VTI was not associated with age at CTA. When controlling for diagnosis and race/ethnicity, higher VTI was associated with younger age at prophylactic surgery [HR 1.28, 95%CI 1.09-1.50 for every increase in VTI of 20 (VTI20)] and at surgery for TAD (HR 1.38, 95%CI 1.13-1.69 for VTI20). There was no difference in freedom from prophylactic or post-TAD surgery among LDS and MS subgroups (adjusted p=0.95 and p=0.17 respectively). In patients ≤18 years, the association between increased VTI and age at prophylactic surgery was strongest: HR 1.73 (95%CI 1.11-2.69 for VTI20). One patient ≤18 had TAD with VTI 105. Conclusions: Increased vertebral artery tortuosity is associated with earlier thoracic aortic surgery and dissection in patients under 50 years, and may be most predictive in children. VTI can identify patients at high risk for TAD who may benefit from targeted therapies.

Surgery: β-Blockers—still a trusted ally or time for retirement?

Abstract: Uncertainty surrounds the benefit of β-blocker treatment in various clinical settings. The researchers in a new retrospective analysis of preoperative β-blocker use in CABG surgery now add to the debate, and suggest that these drugs might not improve perioperative outcomes.

Perioperative Management of Oral Anticoagulants: A Focus on Target-Specific Oral Anticoagulants

Abstract: Although warfarin has historically been the dominant oral anticoagulant, newer target-specific oral anticoagulants (TSOACs) have been introduced in the marketplace in the past few years. Dabigatran, rivaroxaban, and apixaban, collectively referred to as TSOACs, have undergone extensive testing in comparison with warfarin and other anticoagulants for a variety of conditions. Compared with warfarin, the shorter time to peak effect, shorter half-life, and fewer drug-drug interactions have helped make the TSOACs attractive alternatives to warfarin for the prevention and treatment of thromboembolic disease associated with orthopedic surgery and atrial fibrillation as well as for the treatment of venous thromboembolism. However, their unique properties pose a challenge for their management in the perioperative period. This article reviews the current guideline-based approach to perioperative management of anticoagulants, the clinical data, and the recommendations supporting use of the TSOACs in the perioperative period. The article also addresses common pitfalls in their perioperative management. By understanding a few key properties of the new oral anticoagulants and with careful perioperative planning, physicians can ensure that their patients will safely undergo most surgical procedures with minimal disruption of their chronic anticoagulation.

Reforming Cardiovascular Care in the United States towards High-Quality Care at Lower Cost with Examples from Model Programs in the State of Michigan.

Abstract: Despite its status as a world leader in treatment innovation and medical education, a quality chasm exists in American health care. Care fragmentation and poor coordination contribute to expensive care with highly variable quality in the United States. The rising costs of health care since 1990 have had a huge impact on individuals, families, businesses, the federal and state governments, and the national budget deficit. The passage of the Affordable Care Act represents a large shift in how health care is financed and delivered in the United States. The objective of this review is to describe some of the economic and social forces driving health care reform, provide an overview of the Patient Protection and Affordable Care Act (ACA), and review model cardiovascular quality improvement programs underway in the state of Michigan. As health care reorganization occurs at the federal level, local and regional efforts can serve as models to accelerate improvement toward achieving better population health and better care at lower cost. Model programs in Michigan have achieved this goal in cardiovascular care through the systematic application of evidence-based care, the utilization of regional quality improvement collaboratives, community-based childhood wellness promotion, and medical device-based competitive bidding strategies. These efforts are examples of the direction cardiovascular care delivery will need to move in this era of the Affordable Care Act.