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Kim A. Eagle

Bio: Kim A. Eagle is an academic researcher from University of Michigan. The author has contributed to research in topics: Aortic dissection & Myocardial infarction. The author has an hindex of 129, co-authored 823 publications receiving 75160 citations. Previous affiliations of Kim A. Eagle include University of Wisconsin Hospital and Clinics & Spaulding Rehabilitation Hospital.


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Journal ArticleDOI
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.

11 citations

Journal ArticleDOI
TL;DR: TAAAD patients presenting with abnormal ECG results are sicker, have more in-hospital complications, and are more likely to die, and the frequency of nonspecific ST-T abnormalities and its association with delay in diagnosis and treatment presents an opportunity for practice improvement.

11 citations

Journal ArticleDOI
TL;DR: Symptom burden, perceived disease severity, age and physical function appear to be associated with perceived work performance in patients previously diagnosed with acute coronary syndrome.
Abstract: The objectives of this study were to describe the perceived work performance of patients previously diagnosed with acute coronary syndrome (ACS) and to determine the relationship between patient-speci

11 citations

Journal ArticleDOI
10 Feb 2010-JAMA
TL;DR: The acute hemodynamic effects of -blockers help explain the adverse events associated with perioperative -blockade, because postoperative stroke and death are associated with -blocker–mediated bradycardiaandhypotension.
Abstract: PERIOPERATIVE CARDIAC EVENTS ARE COMMON AND thought to result from coronary plaque rupture, myocardial oxygen supply-demand mismatch, or a combination of these processes. In theory, -blockers are ideal for preventing these events, because they decrease myocardial oxygen requirements (by lowering heart rate and reducing blood pressure) and are thought to stabilize atherosclerotic plaque. However, perioperative -blockade has become controversial because of conflicting results of recent studies. Based on the latest evidence, the American College of Cardiology Foundation/American Heart Association (ACCF/ AHA) restricted the once-broad class I indication for perioperative -blockers to only patients already receiving this therapy. Why has the evidence not provided clarity? The underpinnings of the debate over perioperative -blockers may relate to fundamental differences among clinical studies. First, every trial of perioperative -blockers used unique inclusion criteria and risk-stratification methods (TABLE). For instance, the MSCPI study enrolled patients either “with or at risk for” coronary artery disease; cardiac risk was based on factors such as hyperlipidemia, hypertension, or tobacco use. The DECREASE I study included high-risk patients with active cardiac ischemia (wall-motion abnormalities on stress echocardiography) who were undergoing vascular surgery. The DECREASE IV study enrolled a heterogeneous group of patients at intermediate risk of cardiac events (determined by the Revised Cardiac Risk Index) who were undergoing various surgical procedures. The POISE study included patients undergoing vascular surgery who had varied risk factors including peripheral vascular disease, congestive heart failure, or need for emergency surgery. Given these variable inclusion criteria, operative interventions, and risk-stratification methods, unique cohorts are produced that are not directly comparable and may explain conflicting findings. In fact, a patient considered at high risk of cardiac events by one study could potentially be classified as at moderate risk by the standards of another. Second, the effects of -blockers vary according to agent, dose, duration of therapy, and pharmacological properties. Initiation time and dose titration influence the effectiveness and safety of perioperative -blockade. Even so, significant differences exist across studies in the manner in which -blockers were prescribed (Table). The acute hemodynamic effects of -blockers help explain the adverse events associated with perioperative -blockade (especially among patients naive to -blockers), because postoperative stroke and death are associated with -blocker–mediated bradycardiaandhypotension. Conversely, carefuldose titrationcoupled with the plaque-stabilizing effects of -blockers explains the benefit of these agents when time to achieve these results and attention to hemodynamic parameters are applied. Third,perioperative -blockerstudiesvariablydefine,measure, and report clinical outcomes. For instance, electrocardiographicchanges, intraoperativeHoltermonitoring,andmeasurement of biomarker levels have been used interchangeably to report cardiac ischemia. Some studies measure only early cardiacoutcomes,whereasothers report compositeoutcomes at 6-month and 1-year intervals. The MSCPI trial showed decreased incidence of myocardial ischemia during hospitalization and decreased mortality in the -blocker cohort. The study excluded immediate postoperative deaths, which (if included in the intent-to-treat analysis) would statistically negateanymortalitybenefit.Similarly,theunblindedDECREASE Istudywasprematurelyterminatedwheninterimanalysis(based on 20 outcomes) showed an incredible 90% relative-risk reduction in the composite outcome of cardiac death and nonfatal myocardial infarction. Thus, it is not surprising that a recent meta-analysis suggested that the beneficial effects of -blockers were driven mainly by trials with high risk of bias. Trials of perioperative -blockers have left clinicians with more questions than answers. Who should receive perioperative -blockers? Which agent should be used? When should these drugs be started and at what dose? Several recommendationsaresummarizedasfollows:(1)Perioperative -blockers protect patients at highest risk of cardiac events who are undergoinghigh-risksurgery. InaccordancewiththeACCF/AHA update,patientswithdemonstrableoractiveischemiaandthose already taking -blockers should receive perioperative -blockade but only if offered in a careful manner; (2) The approach of initiating -blockers days to weeks prior to surgery and individually adjusting dose to achieve a heart rate of 50/ minto70/min isasafe, logical, andcriticalaspectof implementation.Exposingpatientswithoutcoronarydiseaseorwithcoronary risk factors to large, standard preoperative doses of -blockers blunts protective responses to surgery and causes harm.Suchpractice isno longer justified; (3)Theevidence re-

11 citations

Journal ArticleDOI
TL;DR: The Committee proposed an algorithm to define the need the further diagnostic testing before noncardiac surgery, incorporating patient and surgeryspecific factors and exercise tolerance, and confirmed the value of self-reported exercise tolerance.
Abstract: I n March 1996, a Committee convened by the American College of Cardiology/American Heart Association published Guidelines on Perioperative Cardiovascular Evaluation for Noncardiac Surgery (1). As outlined in the original guideline process, the Committee was queried every year since publication to determine if significant new information had been published which would warrant updating the Guidelines. In 2000, the Committee deemed there was sufficient new information, the culmination of which is published in this issue of Anesthesia & Analgesia (2). Using a MEDLINE search, the committee identified and reviewed over 400 relevant new articles. When the original Guidelines were developed, the number of randomized trials addressing perioperative cardiovascular evaluation and therapy was extremely limited. Most of the literature reported on the relationship between adverse events and known risk factors or interventions. To develop a meaningful document, we incorporated these data with information from the nonsurgical arena to make recommendations. The goal of the final document was to define those situations in which testing and perioperative interventions may benefit patients and situations in which those interventions are not indicated. Using a Delphi approach, the Committee proposed an algorithm to define the need the further diagnostic testing before noncardiac surgery, incorporating patient and surgeryspecific factors and exercise tolerance. Considering the nature of the original guidelines, what should be the basis of any update? Clearly, the proposed algorithm needs validation. In fact, several nonrandomized studies published during the intervening years demonstrated low morbidity and mortality using an approach either identical or similar to the one advocated in the Guidelines (3,4). Importantly, no randomized trials have been published during the intervening period. In reviewing the components of the decision to perform further diagnostic testing (clinical factors, surgical risk, and exercise tolerance), there have been numerous papers to refine or confirm the previous designations. For example, chronic renal insufficiency is now considered an intermediate risk marker, but recent myocardial infarction (more than 7 days but less than or equal to 1 mo before examination) with evidence of important ischemic risk by clinical symptoms or noninvasive study is a major predictor. Finally, a recent report confirmed the value of self-reported exercise tolerance and its association with an increased incidence of perioperative morbidity and mortality (5). This is an important finding in light of statements made in the Guidelines published by the American College of Physicians in 1997, in which the use of self-reported exercise tolerance is questioned because of the lack of evidence (6). The greatest advancements have been made in the area of perioperative interventions. Numerous randomized clinical trials have been published during the intervening years (7). These include trials of betaadrenergic blocking drugs, alpha-2 agonists and other medical therapies. Based on this stronger evidence, the Committee was able to rate the strength of evidence and provide formal recommendations using a classification schema:

11 citations


Cited by
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Journal ArticleDOI
TL;DR: In those older than age 50, systolic blood pressure of greater than 140 mm Hg is a more important cardiovascular disease (CVD) risk factor than diastolic BP, and hypertension will be controlled only if patients are motivated to stay on their treatment plan.
Abstract: The National High Blood Pressure Education Program presents the complete Seventh Report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure. Like its predecessors, the purpose is to provide an evidence-based approach to the prevention and management of hypertension. The key messages of this report are these: in those older than age 50, systolic blood pressure (BP) of greater than 140 mm Hg is a more important cardiovascular disease (CVD) risk factor than diastolic BP; beginning at 115/75 mm Hg, CVD risk doubles for each increment of 20/10 mm Hg; those who are normotensive at 55 years of age will have a 90% lifetime risk of developing hypertension; prehypertensive individuals (systolic BP 120-139 mm Hg or diastolic BP 80-89 mm Hg) require health-promoting lifestyle modifications to prevent the progressive rise in blood pressure and CVD; for uncomplicated hypertension, thiazide diuretic should be used in drug treatment for most, either alone or combined with drugs from other classes; this report delineates specific high-risk conditions that are compelling indications for the use of other antihypertensive drug classes (angiotensin-converting enzyme inhibitors, angiotensin-receptor blockers, beta-blockers, calcium channel blockers); two or more antihypertensive medications will be required to achieve goal BP (<140/90 mm Hg, or <130/80 mm Hg) for patients with diabetes and chronic kidney disease; for patients whose BP is more than 20 mm Hg above the systolic BP goal or more than 10 mm Hg above the diastolic BP goal, initiation of therapy using two agents, one of which usually will be a thiazide diuretic, should be considered; regardless of therapy or care, hypertension will be controlled only if patients are motivated to stay on their treatment plan. Positive experiences, trust in the clinician, and empathy improve patient motivation and satisfaction. This report serves as a guide, and the committee continues to recognize that the responsible physician's judgment remains paramount.

14,975 citations

Journal ArticleDOI
TL;DR: This document provides updated normal values for all four cardiac chambers, including three-dimensional echocardiography and myocardial deformation, when possible, on the basis of considerably larger numbers of normal subjects, compiled from multiple databases.
Abstract: The rapid technological developments of the past decade and the changes in echocardiographic practice brought about by these developments have resulted in the need for updated recommendations to the previously published guidelines for cardiac chamber quantification, which was the goal of the joint writing group assembled by the American Society of Echocardiography and the European Association of Cardiovascular Imaging. This document provides updated normal values for all four cardiac chambers, including three-dimensional echocardiography and myocardial deformation, when possible, on the basis of considerably larger numbers of normal subjects, compiled from multiple databases. In addition, this document attempts to eliminate several minor discrepancies that existed between previously published guidelines.

11,568 citations

Journal ArticleDOI
TL;DR: It is important that the medical profession play a significant role in critically evaluating the use of diagnostic procedures and therapies as they are introduced in the detection, management, and management of diseases.
Abstract: PREAMBLE......e4 APPENDIX 1......e121 APPENDIX 2......e122 APPENDIX 3......e124 REFERENCES......e124 It is important that the medical profession play a significant role in critically evaluating the use of diagnostic procedures and therapies as they are introduced in the detection, management,

8,362 citations

Journal ArticleDOI
TL;DR: Although considerable improvement has occurred in the process of care for patients with ST-elevation myocardial infarction (STEMI), room for improvement exists as discussed by the authors, and the purpose of the present guideline is to focus on the numerous advances in the diagnosis and management of patients
Abstract: Although considerable improvement has occurred in the process of care for patients with ST-elevation myocardial infarction (STEMI), room for improvement exists.[1–3][1][][2][][3] The purpose of the present guideline is to focus on the numerous advances in the diagnosis and management of patients

8,352 citations