Showing papers by "William S. Weintraub published in 2006"

Depressive Symptoms After Acute Myocardial Infarction Evidence for Highest Rates in Younger Women

Abstract: Background Depression is common in patients hospitalized with acute myocardial infarction (AMI). In the community, younger women are uniquely prone to depression. Whether younger women are also more likely to have depression during hospitalization with AMI is unknown. Methods A total of 2498 AMI patients (1284 patients ≤60 years; 814 women and 1684 men) were enrolled from 19 US centers in the Prospective Registry Evaluating Outcomes After Myocardial Infarction: Events and Recovery (PREMIER) study between January 2003 and June 2004. Depression was assessed at the time of hospitalization and was defined as a Primary Care Evaluation of Mental Disorders Brief Patient Health Questionnaire (PHQ) score of 10 or higher. Results Younger (≤60 years) patients had higher mean PHQ scores than older patients (6.4 vs 5.0; P P P Conclusions The prevalence of depression is high in younger women with AMI. Because depression after AMI has been associated with adverse outcomes, younger women, a high-risk group compared with men, may particularly benefit from aggressive screening and treatment of post-AMI depression.

Time course of depression and outcome of myocardial infarction.

Abstract: Methods: In a prospective registry of acute MI (Prospective Registry Evaluating outcomes after Myocardial Infarction: Events and Recovery [PREMIER]), depressive symptoms were measured in 1873 patients with the Patient Health Questionnaire (PHQ) during hospitalization and 1 month after discharge and were classified as transient (only at baseline), new (only at 1 month), or persistent (at both times). Outcomes at 6 months included (1) all-cause rehospitalization or mortality and (2) health status (angina, physical limitation, and quality of life using the Seattle Angina Questionnaire). Results: Compared with nondepressed patients, all categories of depression were associated with higher rehospitalization or mortality rates, more frequent angina, more physical limitations, and worse quality of life. The adjusted hazard ratios for rehospitalization or mortality were 1.34, 1.71, and 1.42 for transient, new, and persistent depression, respectively (all P.05). Corresponding odds ratios were 1.62, 2.73, and 2.64 (all P.01) for angina and 1.69, 2.25, and 3.27 (all P.05) for physical limitation. Depressive symptoms showed a stronger association with health status compared with traditional measures of disease severity. Conclusion: Depressive symptoms after MI, irrespective of whether they persist, subside, or newly develop in the first month after hospitalization, are associated with worse outcomes after MI. Arch Intern Med. 2006;166:2035-2043

Gender Differences in Short-Term Cardiovascular Outcomes After Percutaneous Coronary Interventions

Abstract: Recent studies have been inconsistent in demonstrating a decrease in the gender gap in short-term post-percutaneous coronary intervention (PCI) outcomes. We sought to determine gender differences in outcomes in younger and older patients who underwent PCI during the current stent era. We studied 4,768 elective PCI procedures performed at Emory University Hospital from 2001 to 2004. The baseline characteristics, periprocedural complications, angiographic success, procedural success, and major in-hospital complications (death, myocardial infarction, and emergency coronary artery bypass graft surgery) after PCI were compared between men and women. Women were more likely to be nonwhite and older, with a greater prevalence of hypertension and diabetes mellitus (all p 55 years (OR 1.32, 95% CI 0.87 to 1.99, p = 0.047 for gender–age interaction). The adjusted odds of bleeding complications were also higher in women than in men (≤55 years OR 5.39, 95% CI 2.26 to 12.8, >55 years OR 2.55, 95% CI 1.68 to 3.87, p = 0.121 for gender–age interaction). No significant gender differences were present in a combined end point of death, myocardial infarction, and emergency coronary artery bypass graft surgery. In conclusion, among patients who have undergone PCI, women, particularly younger women, are more likely than men to experience coronary vascular injury and bleeding complications unaccounted for by coronary artery size and other patient characteristics. No differences were found in major in-hospital complications by gender.

Diagnosing and managing cutaneous pigmented lesions: Primary care physicians versus dermatologists

Abstract: BACKGROUND: Primary care physicians (PCPs) are often expected to screen for melanomas and refer patients with suspicious pigmented lesions to dermatologists.

On- Versus Off-Label Use of Drug-Eluting Coronary Stents in Clinical Practice (Report from the American College of Cardiology National Cardiovascular Data Registry [NCDR])

Abstract: Limited data are available on the off-label use of drug-eluting stents (DESs) in clinical practice. We used data from the American College of Cardiology National Cardiovascular Data Registry to describe the rates and outcomes of DES use in 4 common off-label situations: ST-elevation myocardial infarction, in-stent restenosis, coronary artery bypass grafts, and chronic total occlusions. The rates of in-hospital adverse events for each off-label situation were determined and compared with the expected rates calculated from a validated model. From approval of DESs to the end of 2004, a total of 408,033 procedures involved placement of a DES. The use of DESs increased from 19.7% at the start of the study to 78.2% by the end of fourth quarter of 2004. Off-label use of DESs occurred in 24.1% of procedures. The rates of in-hospital adverse events with DES use in ST-elevation myocardial infarction, in-stent restenosis, coronary artery bypass grafting, and chronic total occlusions were lower than expected from the validated model. In conclusion, off-label use of DESs is common and is associated with a low rate of short-term adverse events. Randomized clinical trials are needed to confirm the efficacy of DESs in these clinical and angiographic settings. These data also highlight the importance of multicenter registries in tracking new technologies.

Ad Hoc percutaneous coronary interventions in patients with stable coronary artery disease—A study of prevalence, safety, and variation in use from the American College of Cardiology National Cardiovascular Data Registry (ACC‐NCDR®)

Abstract: Objective: To utilize the American College of Cardiology National Cardiovascular Data Registry (ACC-NCDR®) to monitor the performance and safety of ad hoc PCIs. Background: The performance of ad hoc PCI remains controversial. Patients' preference, cost, and vascular access issues favor an ad hoc strategy. Adequate time for thoughtful decision-making, scheduling complexity, informed consent, and physician reimbursement favor PCI on a subsequent day. Methods: We analyzed results in 68,528 patients with stable angina entered in the ACC-NCDR from 2001–2003. Ad hoc PCI was evaluated in many clinical and nonclinical subgroups. A multivariable analysis was performed to determine whether ad hoc PCI had an independent relationship with complications or procedure success. Results: Overall, 60.6% of patients underwent ad hoc PCI. There was no difference in ad hoc PCI mortality, renal failure, or vascular complications from staged PCI. A lower percentage of patients at high vs. low risk and with vs. without renal failure underwent ad hoc PCIs (58.6% vs.63.0% and 50.7% vs. 60.9% respectively). There was wide variation in the performance of ad hoc PCIs according to payer (70.2–60.3%), hospital PCI volume (67–50.2%), hospital owner (89.7–59.6%), and geographic area (75.5–47.4%). Ad hoc PCI per se was not independently related to PCI success or complications. Conclusions: PCI success was related to patient/lesion related factors and not to the performance of ad hoc PCIs per se. Although ad hoc PCI can be performed in more patients than at present, this strategy will never be possible in all patients at all times. © 2006 Wiley-Liss, Inc.

All Pre-Diabetes Is Not the Same: Metabolic and Vascular Risks of Impaired Fasting Glucose at 100 Versus 110 mg/dl: The Screening for Impaired Glucose Tolerance Study 1 (SIGT 1)

Abstract: The dramatic increase in incidence of diabetes (1) has prompted efforts to identify individuals who have milder glucose intolerance, because early management with lifestyle change and/or medication can delay progression to diabetes with its attendant morbidity, mortality, and cost (2). It has long been recognized that impaired glucose tolerance (IGT) is a diabetes precursor, but recognition of IGT requires oral glucose tolerance tests (OGTTs), which many health care providers are reluctant to order (3). As a more convenient alternative, the American Diabetes Association has emphasized screening by measurement of fasting plasma glucose (FPG) and lowered the cutoff for abnormal FPG progressively from 140 to 125 to 110 mg/dl. However, compared with IGT, an impaired fasting glucose (IFG) cutoff of 110 mg/dl provided good specificity but reduced sensitivity for detecting risk of developing diabetes (4–6). To obtain increased sensitivity, the American Diabetes Association recently lowered the cutoff for IFG from 110 to 100 mg/dl (7), and application of this cutoff has increased the number of Americans thought to have “pre-diabetes” to 41 million (8). Although such individuals are considered candidates for management aimed at decreasing their risk of progressing to diabetes (9), the metabolic and cardiovascular risks of individuals with very modest abnormalities in FPG are not well understood. In this study, we compared measures of risk in individuals with fasting glucose 100–109 mg/dl (IFG100) with those with fasting glucose 110–125 mg/dl (IFG110). The …

Early invasive strategy improves outcomes in patients with acute coronary syndrome with previous coronary artery bypass graft surgery: a report from TACTICS-TIMI 18.

Abstract: BACKGROUND Patients with previous coronary artery bypass graft surgery (CABG) have been classified as a high-risk subset of patients who experience non-ST elevation acute coronary syndrome (ACS). Recent studies suggest that an early invasive strategy is beneficial in moderate- and high-risk patients with non-ST elevation ACS. We hypothesized that an early invasive strategy is associated with improved outcomes in patients with non-ST elevation ACS with prior CABG. METHODS AND RESULTS In the Treat Angina with Aggrastat and determine Cost of Therapy with an Invasive or Conservative Strategy-Thrombolysis in Myocardial Infarction 18 trial (TACTICS-TIMI 18), 2220 patients with non-ST segment elevation ACS were randomized to an early invasive or conservative (selectively invasive) strategy. All patients were treated with aspirin, heparin, and tirofiban. Four hundred eighty-four (22%) of these patients had undergone CABG before enrollment. We analyzed whether patients with previous CABG had different 6-month outcomes and whether an early invasive strategy was associated with an improvement in long-term outcomes. Prior CABG was associated with a higher risk of adverse outcomes by 6 months, including a higher rate of readmission for ACS (17.4% vs 11.0%, P < 0.001) and a higher incidence of the composite end point of death, myocardial infarction, or rehospitalization for ACS (22.3% vs 16.4%, P = 0.002). There was a trend toward a higher incidence of myocardial infarction (7.1% vs 5.3%, P = 0.051). An early invasive strategy was associated with a reduction in the composite of death or myocardial infarction (odds ratio [OR], 0.58; 95% confidence interval [CI], 0.31-1.0; P = 0.089) and a significant reduction in the incidence of myocardial infarction at 6 months (OR, 0.44; 95% CI, 0.21-0.93; P=0.032). CONCLUSIONS Patients with non-ST segment elevation ACS who have had previous CABG are a high-risk subset. An early invasive strategy reduces risk of myocardial infarction in this high-risk group.

Impact of diabetes on five-year outcomes after vein graft interventions performed prior to the drug-eluting stent era.

Abstract: Objective. The aim of this study was to evaluate the differences in 5-year outcomes among diabetic and nondiabetic patients undergoing saphenous vein graft (SVG) percutaneous coronary intervention (PCI) prior to the era of distal protection and drug-eluting stents. Background. PCI of native coronary arteries is known to be associated with higher rates of adverse outcomes in diabetic patients compared to nondiabetic patients. However, the impact of diabetes on long-term outcomes after SVG interventions is not as well established. We conducted an evaluation of 5-year outcomes after SVG PCI in the two decades prior to the availability of distal protection devices and drug-eluting stents. Methods. Data on 2,556 subjects (1,780 nondiabetic and 776 diabetic) undergoing SVG PCI at Emory Hospital from 1981 to 2001 were collected and entered into a computerized database and analyzed for adverse cardiovascular outcomes. Results. Compared to the nondiabetic group, the diabetic group had worse 1-year (87.7% vs. 94.9%; p < 0.0001) and 5-year survival rates (62.9% vs. 78.5%; p < 0.0001). In the subset of patients receiving stents, 5-year survival remained significantly worse in the diabetic group (78.2% vs. 87.1%; p = 0.009). After multivariate analysis, diabetes was an independent predictor of 5-year mortality (hazard ratio = 1.8; 95% CI = 1.5-2.5; p < 0.0001). Conclusion. Diabetic patients undergoing vein graft PCI prior to the distal protection and drug-eluting stent era had significantly worse long-term outcomes compared to nondiabetic patients. The effect on long-term outcomes using these newer devices in diabetic subjects undergoing SVG PCI must be established for a true assessment of their impact.

Cost-effectiveness of eplerenone in patients with left ventricular dysfunction after myocardial infarction--an analysis of the EPHESUS study from a Swiss perspective.

Abstract: Objective The EPHESUS study demonstrated that aldosterone blockade with eplerenone decreased mortality in patients with left ventricular systolic dysfunction (LVSD) and heart failure after acute myocardial infarction (AMI). The EPHESUS pharmacoeconomic analysis was performed to evaluate the cost-effectiveness of eplerenone in the Swiss setting.

Abstract 2675: Effect of a Psychoeducational Intervention on Depressive Symptoms and Anxiety in ICD Patients

Abstract: Objective : Clinically important levels of depression and anxiety have been reported for persons receiving implantable cardioverter defibrillators (ICD). This study tested the hypothesis that a psychoeducational intervention would reduce depressive symptoms and anxiety during the first year after ICD. Methods : An experimental design randomized 246 ICD patients to usual care (UC) or intervention provided by group (G) or telephone (T). The intervention, provided in acute care and 2–3 months after implant, included education, symptom management training, and cognitive behavioral techniques to improve coping skills and illness appraisal. Participants were 58 ± 11 years, 73% men, 20% African American, mean LVEF of 26 ± 12%. Variables were depressive symptoms (Beck Depression Inventory; BDI-II), anxiety (State-Trait Anxiety Inventory; STAI) and functional status (Duke Activity Index; DASI) measured at baseline (BL), 3, 6 &12 M. Social support (ESSI) was measured at BL. Group X Time effects for BDI-II and STAI were analyzed with mixed models repeated-measures analyses adjusted for BL scores, gender, medications, DASI, ESSI, and comorbidities. Additionally, logistic regression determined predicted probability of depressive symptoms based on BDI-II scores controlling for BL BDI-II, gender and depression/anxiety medications. Results : All groups decreased mean BDI-II and STAI over 12M. Both G and T had lower BDI-II and STAI scores than UC, and when controlling for covariates, a trend for group differences in STAI (p=.059) was noted at 3 months. At 12 M, the percent with depressive symptoms was 31.4% in UC vs 15.3% for the combined G & T intervention groups. Logistic regression with covariates revealed differences (p=.03) for predicted probablility (UC=.31, G=.17, T=.13) of having mild to severe depressive symptoms at 12M. Conclusion : A psychoeducational intervention which included information, symptom management training and cognitive behavioral techniques was effective in reducing anxiety early in recovery after ICD and reduced probability of depressive symptoms at one year. These findings support both the group and cost-effective telephone intervention approaches to yield better overall psychological outcomes in high risk ICD patients.

Do patients undergoing percutaneous coronary intervention benefit from clopidogrel pretreatment

Abstract: Do patients undergoing percutaneous coronary intervention benefit from clopidogrel pretreatment?