183 results on '"Malcolm R. Bell"'
Search Results
2. Outcomes Associated With Cardiac Arrest in Patients in the Cardiac Intensive Care Unit With Cardiogenic Shock
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Abdelrahman M. Ahmed, Meir Tabi, Brandon M. Wiley, Saraschandra Vallabhajosyula, Gregory W. Barsness, Malcolm R. Bell, and Jacob C. Jentzer
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Aged, 80 and over ,Intensive Care Units ,Shock, Cardiogenic ,Humans ,Female ,Hospital Mortality ,Middle Aged ,Cardiology and Cardiovascular Medicine ,Aged ,Heart Arrest ,Retrospective Studies - Abstract
Cardiac arrest (CA) is common and has been associated with adverse outcomes in patients with cardiogenic shock (CS). We sought to determine the prevalence, patient characteristics, and outcomes of CA in cardiovascular intensive care unit patients with CS. We queried cardiovascular intensive care unit admissions from 2007 to 2018 with an admission diagnosis of CS and compared patients with and without CA. Temporal trends were assessed using linear regression. The primary and secondary outcomes of in-hospital and 1-year mortality were analyzed using logistic regression and Cox proportional-hazards analysis, respectively. We included 1,498 patients, and CA was present in 510 patients (34%), with 258 (50.6% of patients with CA) having ventricular fibrillation (VF). Mean age was 68 ± 14 years, and 37% were females. The prevalence of CA decreased over time (from 43% in 2007 to 24% in 2018, p0.001). Hospital mortality was 33.3% and decreased over time in patients without CA (from 30% in 2007 to 22% in 2018, p = 0.05), but not in patients with CA (p = 0.71). CA was associated with a higher risk of hospital mortality (51.0% vs 24.2%, adjusted odds ratio 2.15, 95% confidence interval [CI] 1.52 to 3.05, p0.001), with no difference between VF CA and non-VF CA (p = 0.64). CA was associated with higher 1-year mortality (adjusted hazard ratio 1.53, 95% CI 1.24 to 1.89, p0.001). In conclusion, CA is present in 1 of 3 of CS hospitalizations and confers a substantially higher risk of hospital and 1-year mortality with no improvement during our 12-year study period contrary to prevailing trends. more...
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- 2022
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3. IMPROvE-CED Trial: Intracoronary Autologous CD34+ Cell Therapy for Treatment of Coronary Endothelial Dysfunction in Patients With Angina and Nonobstructive Coronary Arteries
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Michel T. Corban, Takumi Toya, Diana Albers, Faten Sebaali, Bradley R. Lewis, John Bois, Rajiv Gulati, Abhiram Prasad, Patricia J.M. Best, Malcolm R. Bell, Charanjit S. Rihal, Megha Prasad, Ali Ahmad, Lilach O. Lerman, Mary L. Solseth, Jeffrey L. Winters, Allan B. Dietz, and Amir Lerman more...
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Physiology ,Cardiology and Cardiovascular Medicine - Abstract
Background: Coronary endothelial dysfunction (CED) causes angina/ischemia in patients with nonobstructive coronary artery disease (NOCAD). Patients with CED have decreased number and function of CD34+ cells involved in normal vascular repair with microcirculatory regenerative potential and paracrine anti-inflammatory effects. We evaluated safety and potential efficacy of intracoronary autologous CD34+ cell therapy for CED. Methods: Twenty NOCAD patients with invasively diagnosed CED and persistent angina despite maximally tolerated medical therapy underwent baseline exercise stress test, GCSF (granulocyte colony stimulating factor)-mediated CD34+ cell mobilization, leukapheresis, and selective 1×10 5 CD34+ cells/kg infusion into left anterior descending. Invasive CED evaluation and exercise stress test were repeated 6 months after cell infusion. Primary end points were safety and effect of intracoronary autologous CD34+ cell therapy on CED at 6 months of follow-up. Secondary end points were change in Canadian Cardiovascular Society angina class, as-needed sublingual nitroglycerin use/day, Seattle Angina Questionnaire scores, and exercise time at 6 months. Change in CED was compared with that of 51 historic control NOCAD patients treated with maximally tolerated medical therapy alone. Results: Mean age was 52±13 years; 75% were women. No death, myocardial infarction, or stroke occurred. Intracoronary CD34+ cell infusion improved microvascular CED (%acetylcholine-mediated coronary blood flow increased from 7.2 [−18.0 to 32.4] to 57.6 [16.3–98.3]%; P =0.014), decreased Canadian Cardiovascular Society angina class (3.7±0.5 to 1.7±0.9, Wilcoxon signed-rank test, P =0.00018), and sublingual nitroglycerin use/day (1 [0.4–3.5] to 0 [0–1], Wilcoxon signed-rank test, P =0.00047), and improved all Seattle Angina Questionnaire scores with no significant change in exercise time at 6 months of follow-up. Historic control patients had no significant change in CED. Conclusions: A single intracoronary autologous CD34+ cell infusion was safe and may potentially be an effective disease-modifying therapy for microvascular CED in humans. Registration: URL: https://www.clinicaltrials.gov ; Unique identifier: NCT03471611. more...
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- 2022
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4. Cardiogenic shock complicating non-ST-segment elevation myocardial infarction: An 18-year study
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Pranathi R Sundaragiri, Abhiram Prasad, Wisit Cheungpasitporn, Allan S. Jaffe, Gurpreet S. Sandhu, Rajkumar Doshi, Saraschandra Vallabhajosyula, Huzefa Bhopalwala, David R. Holmes, Malcolm R. Bell, and Nakeya Dewaswala more...
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Adult ,medicine.medical_specialty ,medicine.medical_treatment ,Shock, Cardiogenic ,Percutaneous Coronary Intervention ,Internal medicine ,Epidemiology ,medicine ,Humans ,ST segment ,Hospital Mortality ,Myocardial infarction ,Non-ST Elevated Myocardial Infarction ,Intra-Aortic Balloon Pumping ,business.industry ,Cardiogenic shock ,Percutaneous coronary intervention ,Odds ratio ,medicine.disease ,United States ,Confidence interval ,Conventional PCI ,Cardiology ,ST Elevation Myocardial Infarction ,Cardiology and Cardiovascular Medicine ,business - Abstract
OBJECTIVE To evaluate the epidemiology and outcomes of non-ST-segment-elevation myocardial infarction-cardiogenic shock (NSTEMI-CS) in the United States. METHODS Adult (>18 years) NSTEMI-CS admissions were identified using the National Inpatient Sample (2000-2017) and classified by tertiles of admission year (2000-2005, 2006-2011 and 2012-2017). Outcomes of interest included temporal trends of prevalence and in-hospital mortality, use of cardiac procedures, in-hospital mortality, hospitalization costs, and length of stay. RESULTS In over 7.3 million NSTEMI admissions, CS was noted in 189,155 (2.6%). NSTEMI-CS increased from 1.5% in 2000 to 3.6% in 2017 (adjusted odds ratio [aOR] 2.03 [95% confidence interval {CI} 1.97-2.09]; p more...
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- 2022
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5. Multimorbidity and Mortality Models to Predict Complications Following Percutaneous Coronary Interventions
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Mandeep Singh, Rajiv Gulati, Bradley R. Lewis, Zhaoliang Zhou, Mohamad Alkhouli, Paul Friedman, and Malcolm R. Bell
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Multimorbidity ,Hemorrhage ,Acute Kidney Injury ,Risk Assessment ,Stroke ,Percutaneous Coronary Intervention ,Treatment Outcome ,Risk Factors ,Humans ,Female ,Hospital Mortality ,Registries ,Acute Coronary Syndrome ,Cardiology and Cardiovascular Medicine ,Aged - Abstract
Background: Previous percutaneous coronary intervention risk models were focused on single outcome, such as mortality or bleeding, etc, limiting their applicability. Our objective was to develop contemporary percutaneous coronary intervention risk models that not only determine in-hospital mortality but also predict postprocedure bleeding, acute kidney injury, and stroke from a common set of variables. Methods: We built risk models using logistic regression from first percutaneous coronary intervention for any indication per patient (n=19 322, 70.6% with acute coronary syndrome) using the Mayo Clinic registry from January 1, 2000 to December 31, 2016. Approval for the current study was obtained from the Mayo Foundation Institutional Review Board. Patients with missing outcomes (n=4183) and those under 18 (n=10) were removed resulting in a sample of 15 129. We built both models that included procedural and angiographic variables (Models A) and precatheterization model (Models B). Results: Death, bleeding, acute kidney injury, and stroke occurred in 247 (1.6%), 650 (4.3%), 1184 (7.8%), and 67 (0.4%), respectively. The C statistics from the test dataset for models A were 0.92, 0.70, 0.77, and 0.71 and for models B were 0.90, 0.67, 0.76, and 0.71 for in-hospital death, bleeding, acute kidney injury, and stroke, respectively. Bootstrap analysis indicated that the models were not overfit to the available dataset. The probabilities estimated from the models matched the observed data well, as indicated by the calibration curves. The models were robust across many subgroups, including women, elderly, acute coronary syndrome, cardiogenic shock, and diabetes. Conclusions: The new risk scoring models based on precatheterization variables and models including procedural and angiographic variables accurately predict in-hospital mortality, bleeding, acute kidney injury, and stroke. The ease of its application will provide useful prognostic and therapeutic information to both patients and physicians. more...
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- 2022
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6. Effect of CYP2C19 Genotype on Ischemic Outcomes During Oral P2Y12 Inhibitor Therapy
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Charanjit S. Rihal, Amir Lerman, Kent R. Bailey, Malcolm R. Bell, Ahmed A. K. Hasan, Gil Marcus, Yves Rosenberg, Ryan J. Lennon, Sanskriti Shrivastava, Derek So, Michael E. Farkouh, M. Hassan Murad, Shaun G. Goodman, Naveen L. Pereira, and Nancy L. Geller more...
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medicine.medical_specialty ,Prasugrel ,business.industry ,medicine.medical_treatment ,Percutaneous coronary intervention ,CYP2C19 ,030204 cardiovascular system & hematology ,medicine.disease ,Clopidogrel ,Coronary artery disease ,03 medical and health sciences ,0302 clinical medicine ,P2Y12 ,Internal medicine ,Conventional PCI ,medicine ,cardiovascular diseases ,030212 general & internal medicine ,Cardiology and Cardiovascular Medicine ,business ,Ticagrelor ,medicine.drug - Abstract
Objectives The aim of this study was to examine the effect of CYP2C19 genotype on clinical outcomes in patients with coronary artery disease (CAD) who predominantly underwent percutaneous coronary intervention (PCI), comparing those treated with ticagrelor or prasugrel versus clopidogrel. Background The effect of CYP2C19 genotype on treatment outcomes with ticagrelor or prasugrel compared with clopidogrel is unclear. Methods Databases through February 19, 2020, were searched for studies reporting the effect of CYP2C19 genotype on ischemic outcomes during ticagrelor or prasugrel versus clopidogrel treatment. Study eligibility required outcomes reported for CYP2C19 genotype status and clopidogrel and alternative P2Y12 inhibitors in patients with CAD with at least 50% undergoing PCI. The primary analysis consisted of randomized controlled trials (RCTs). A secondary analysis was conducted by adding non-RCTs to the primary analysis. The primary outcome was a composite of cardiovascular death, myocardial infarction, stroke, stent thrombosis, and severe recurrent ischemia. Meta-analysis was conducted to compare the 2 drug regimens and test interaction with CYP2C19 genotype. Results Of 1,335 studies identified, 7 RCTs were included (15,949 patients, mean age 62 years; 77% had PCI, 98% had acute coronary syndromes). Statistical heterogeneity was minimal, and risk for bias was low. Ticagrelor and prasugrel compared with clopidogrel resulted in a significant reduction in ischemic events (relative risk: 0.70; 95% confidence interval: 0.59 to 0.83) in CYP2C19 loss-of-function carriers but not in noncarriers (relative risk: 1.0; 95% confidence interval: 0.80 to 1.25). The test of interaction on the basis of CYP2C19 genotype status was statistically significant (p = 0.013), suggesting that CYP2C19 genotype modified the effect. An additional 4 observational studies were found, and adding them to the analysis provided the same conclusions (p value of the test of interaction Conclusions The effect of ticagrelor or prasugrel compared with clopidogrel in reducing ischemic events in patients with CAD who predominantly undergo PCI is based primarily on the presence of CYP2C19 loss-of-function carrier status. These results support genetic testing prior to prescribing P2Y12 inhibitor therapy. more...
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- 2021
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7. Fibrinolysis vs. primary percutaneous coronary intervention for ST‐segment elevation myocardial infarction cardiogenic shock
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Rajiv Gulati, Dhiran Verghese, Amir Lerman, Abhiram Prasad, David R. Holmes, Gregory W. Barsness, Bernard J. Gersh, Shannon M. Dunlay, Malcolm R. Bell, Wisit Cheungpasitporn, Gurpreet S. Sandhu, Mandeep Singh, Dennis H. Murphree, Paul Miller, and Saraschandra Vallabhajosyula more...
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Adult ,medicine.medical_specialty ,Palliative care ,medicine.medical_treatment ,Shock, Cardiogenic ,030204 cardiovascular system & hematology ,Percutaneous coronary intervention ,03 medical and health sciences ,0302 clinical medicine ,Original Research Articles ,Internal medicine ,Fibrinolysis ,ST‐segment elevation myocardial infarction ,medicine ,Diseases of the circulatory (Cardiovascular) system ,Humans ,Original Research Article ,030212 general & internal medicine ,Myocardial infarction ,Cardiogenic shock ,business.industry ,Odds ratio ,medicine.disease ,Treatment Outcome ,Outcomes research ,RC666-701 ,Conventional PCI ,Cardiology ,ST Elevation Myocardial Infarction ,Cardiology and Cardiovascular Medicine ,business ,Thrombolytics - Abstract
Aims There are limited contemporary data on the use of initial fibrinolysis in ST‐segment elevation myocardial infarction cardiogenic shock (STEMI‐CS). This study sought to compare the outcomes of STEMI‐CS receiving initial fibrinolysis vs. primary percutaneous coronary intervention (PPCI). Methods Using the National (Nationwide) Inpatient Sample from 2009 to 2017, a comparative effectiveness study of adult (>18 years) STEMI‐CS admissions receiving pre‐hospital/in‐hospital fibrinolysis were compared with those receiving PPCI. Admissions with alternate indications for fibrinolysis and STEMI‐CS managed medically or with surgical revascularization (without fibrinolysis) were excluded. Outcomes of interest included in‐hospital mortality, development of non‐cardiac organ failure, complications, hospital length of stay, hospitalization costs, use of palliative care, and do‐not‐resuscitate status. Results During 2009–2017, 5297 and 110 452 admissions received initial fibrinolysis and PPCI, respectively. Compared with those receiving PPCI, the fibrinolysis group was more often non‐White, with lower co‐morbidity, and admitted on weekends and to small rural hospitals (all P more...
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- 2021
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8. Ten-year trends, predictors and outcomes of mechanical circulatory support in percutaneous coronary intervention for acute myocardial infarction with cardiogenic shock
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Mandeep Singh, Patricia J.M. Best, Malcolm R. Bell, Gurpreet S. Sandhu, David R. Holmes, Abhiram Prasad, Gregory W. Barsness, Amir Lerman, Saraschandra Vallabhajosyula, Mackram F. Eleid, Charanjit S. Rihal, Bernard J. Gersh, and Rajiv Gulati more...
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medicine.medical_specialty ,business.industry ,medicine.medical_treatment ,Cardiogenic shock ,Percutaneous coronary intervention ,Retrospective cohort study ,030204 cardiovascular system & hematology ,medicine.disease ,humanities ,03 medical and health sciences ,surgical procedures, operative ,0302 clinical medicine ,Internal medicine ,Ventricular assist device ,Conventional PCI ,Cohort ,medicine ,Cardiology ,Extracorporeal membrane oxygenation ,cardiovascular diseases ,030212 general & internal medicine ,Myocardial infarction ,Cardiology and Cardiovascular Medicine ,business - Abstract
AIMS There are limited data on the trends and outcomes of mechanical circulatory support (MCS)-assisted early percutaneous coronary intervention (PCI) in acute myocardial infarction with cardiogenic shock (AMI-CS). In this study, we sought to assess the use, temporal trends, and outcomes of percutaneous MCS-assisted early PCI in AMI-CS. METHODS AND RESULTS Using the National Inpatient Sample database from 2005-2014, a retrospective cohort of AMI-CS admissions receiving early PCI (hospital day zero) was identified. MCS use was defined as intra-aortic balloon pump (IABP), percutaneous left ventricular assist device (pLVAD) and extracorporeal membrane oxygenation (ECMO) support. Outcomes of interest included in-hospital mortality, resource utilisation, trends and predictors of MCS-assisted PCI. Of the 110,452 admissions, MCS assistance was used in 55%. IABP, pLVAD and ECMO were used in 94.8%, 4.2% and 1%, respectively. During 2009-2014, there was a decrease in MCS-assisted PCI due to a decrease in IABP, despite an increase in pLVAD and ECMO. Younger age, male sex, lower comorbidity, and cardiac arrest independently predicted MCS use. MCS-assisted PCI was predictive of higher in-hospital mortality (31% vs 26%, adjusted odds ratio 1.23 [1.19-1.27]; p more...
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- 2021
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9. Management and outcomes of uncomplicated ST-segment elevation myocardial infarction patients transferred after fibrinolytic therapy
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Mandeep Singh, Sri Harsha Patlolla, Dhiran Verghese, Pranathi R. Sundaragiri, Gregory W. Barsness, Anna V. Subramaniam, Lina Ya'qoub, Vinayak Kumar, Wisit Cheungpasitporn, Saraschandra Vallabhajosyula, David R. Holmes, Allan S. Jaffe, Malcolm R. Bell, and Bernard J. Gersh more...
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medicine.medical_specialty ,business.industry ,medicine.medical_treatment ,Cardiogenic shock ,Percutaneous coronary intervention ,Odds ratio ,030204 cardiovascular system & hematology ,Revascularization ,medicine.disease ,03 medical and health sciences ,0302 clinical medicine ,Internal medicine ,Fibrinolysis ,Cohort ,Cardiology ,Medicine ,ST segment ,030212 general & internal medicine ,Myocardial infarction ,Cardiology and Cardiovascular Medicine ,business - Abstract
Background This study sought to assess the contemporary outcomes of patients transferred after receiving fibrinolytic therapy (‘drip-and-ship’) for ST-segment elevation myocardial infarction (STEMI) in the United States. Methods During 2009–2016, adults (>18 years) with STEMI (>18 years) without cardiac arrest and cardiogenic shock that received fibrinolytic therapy and were subsequently transferred were identified using the National Inpatient Sample (NIS). These admissions were divided into those undergoing fibrinolysis alone, subsequent coronary angiography (CA) without revascularization and subsequent CA with revascularization. Outcomes of interest included in-hospital mortality, resource utilization, and discharge disposition. Results A total of 27,454 STEMI admissions receiving a ‘drip-and-ship strategy’, 96.3% and 85.8% received subsequent coronary angiography and revascularization Admissions receiving CA and revascularization were younger, male, and with lower comorbidity. The fibrinolysis alone cohort had higher rates of organ failure, hemorrhagic sequelae, and intracranial hemorrhage. Compared to the fibrinolysis cohort, CA with revascularization (adjusted odds ratio [aOR] 0.17 [95% confidence interval {CI} 0.11–0.27]; p Conclusion Fibrinolysis with subsequent revascularization is associated with excellent outcomes in STEMI. Admissions receiving fibrinolysis alone were systematically different, sicker and had poorer outcomes. more...
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- 2020
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10. Sex Disparities in the Use and Outcomes of Temporary Mechanical Circulatory Support for Acute Myocardial Infarction-Cardiogenic Shock
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Virginia M. Miller, P. Elliott Miller, Saraschandra Vallabhajosyula, John M. Stulak, Gregory W. Barsness, Wisit Cheungpasitporn, David R. Holmes, Shannon M. Dunlay, Charanjit S. Rihal, and Malcolm R. Bell more...
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medicine.medical_specialty ,lcsh:Diseases of the circulatory (Cardiovascular) system ,Palliative care ,business.industry ,medicine.medical_treatment ,Cardiogenic shock ,MEDLINE ,medicine.disease ,humanities ,Transplantation ,lcsh:RC666-701 ,Ventricular assist device ,Shock (circulatory) ,Emergency medicine ,Circulatory system ,Medicine ,Original Article ,Myocardial infarction ,medicine.symptom ,Cardiology and Cardiovascular Medicine ,business ,health care economics and organizations - Abstract
Background: There are limited sex-specific data on patients receiving temporary mechanical circulatory support (MCS) for acute myocardial infarction-cardiogenic shock (AMI-CS). Methods: All admissions with AMI-CS with MCS use were identified using the National Inpatient Sample from 2005 to 2016. Outcomes of interest included in-hospital mortality, discharge disposition, use of palliative care and do-not-resuscitate (DNR) status, and receipt of durable left ventricular assist device (LVAD) and cardiac transplantation. Results: In AMI-CS admissions during this 12-year period, MCS was used more frequently in men—50.4% vs 39.5%; P < 0.001. Of the 173,473 who received MCS (32% women), intra-aortic balloon pumps, percutaneous LVAD, extracorporeal membrane oxygenation, and ≥ 2 MCS devices were used in 92%, 4%, 1%, and 3%, respectively. Women were on average older (69 ± 12 vs 64 ± 13 years), of black race (10% vs 6%), and had more comorbidity (mean Charlson comorbidity index 5.0 ± 2.0 vs 4.5 ± 2.1). Women had higher in-hospital mortality than men (34% vs 29%, adjusted odds ratio [OR]: 1.19, 95% confidence interval [CI]: 1.16-1.23; P < 0.001) overall, in intra-aortic balloon pumps users (OR: 1.20 [95% CI: 1.16-1.23]; P < 0.001), and percutaneous LVAD users (OR: 1.75 [95% CI: 1.49-2.06]; P < 0.001), but not in extracorporeal membrane oxygenation or ≥ 2 MCS device users (P > 0.05). Women had higher use of palliative care, DNR status, and discharges to skilled nursing facilities. Conclusions: There are persistent sex disparities in the outcomes of AMI-CS admissions receiving MCS support. Women have higher in-hospital mortality, palliative care consultation, and use of DNR status. Résumé: Contexte: On dispose de peu de données quant à l’influence du sexe sur les résultats pour les patients qui reçoivent une assistance circulatoire mécanique (ACM) temporaire à la suite d’un infarctus aigu du myocarde accompagné d’un choc cardiogénique (IAM-CC). Méthodologie: Nous avons recensé dans l’échantillon national des patients hospitalisés (NIS, National Inpatient Sample) tous les patients admis à l’hôpital pour un IAM-CC qui ont reçu une ACM de 2005 à 2016. Les résultats d’intérêt comprenaient la mortalité hospitalière, l’état à la sortie, le recours aux soins palliatifs et à une ordonnance de non-réanimation (ONR), l’implantation d’un dispositif d’assistance ventriculaire gauche (DAVG) permanent et la transplantation cardiaque. Résultats: Chez les patients admis à l’hôpital pour un IAM-CC durant la période de 12 ans étudiée, l’ACM a été utilisée plus fréquemment chez les hommes que chez les femmes (50,4 % vs 39,5 %; p < 0,001). Sur les 173 473 patients qui ont reçu une ACM (dont 32 % étaient des femmes), les méthodes employées se répartissaient comme suit : ballon de contre-pulsion intra-aortique, 92 %; assistance ventriculaire gauche percutanée, 4 %; oxygénation extracorporelle par membrane, 1 %; et au moins 2 types d’ACM, 3 %. Les femmes étaient plus âgées en moyenne (69 ± 12 ans vs 64 ± 13 ans), étaient plus souvent de race noire (10 % vs 6 %) et présentaient un plus grand nombre d’affections concomitantes (indice de comorbidité de Charlson moyen de 5,0 ± 2,0 vs 4,5 ± 2,1). Le taux de mortalité hospitalière était plus élevé chez les femmes que chez les hommes (34 % vs 29 %, risque relatif approché [RRA] corrigé : 1,19; intervalle de confiance [IC] à 95 % : de 1,16 à 1,23; p < 0,001) dans l’ensemble, ainsi que chez les utilisateurs d’un ballon de contre-pulsion intra-aortique (RRA : 1,20 [IC à 95 % : de 1,16 à 1,23]; p < 0,001), et chez les utilisateurs d’un DAVG percutané (RRA : 1,75 [IC à 95 % : 1,49 à 2,06]; p < 0,001), mais pas chez les utilisateurs de l’oxygénation extracorporelle par membrane ni chez les utilisateurs d’au moins 2 types d’ACM (p > 0,05). Le recours aux soins palliatifs, l’établissement d’une ordonnance de non-réanimation et l’orientation vers un établissement de soins infirmiers spécialisés à la sortie de l’hôpital étaient plus fréquents chez les femmes. Conclusions: Il existe toujours des disparités entre les sexes à l’égard des résultats pour les patients admis à l’hôpital pour IAM-CC recevant une ACM. Le taux de mortalité hospitalière était plus élevé chez les femmes, et celles-ci avaient plus souvent recours à une consultation en soins palliatifs et à une ONR. more...
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- 2020
11. Pulmonary artery catheter use in acute myocardial infarction‐cardiogenic shock
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Allan S. Jaffe, Shilpkumar Arora, David R. Holmes, Aditi Shankar, Saraschandra Vallabhajosyula, Shannon M. Dunlay, Abhiram Prasad, Malcolm R. Bell, Saarwaani Vallabhajosyula, Gregory W. Barsness, Jacob C. Jentzer, Sri Harsha Patlolla, and Bernard J. Gersh more...
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lcsh:Diseases of the circulatory (Cardiovascular) system ,medicine.medical_specialty ,Pulmonary artery catheterization ,medicine.medical_treatment ,education ,Myocardial Infarction ,Shock, Cardiogenic ,Heart failure ,Critical care cardiology ,Acute myocardial infarction ,030204 cardiovascular system & hematology ,Pulmonary Artery ,03 medical and health sciences ,0302 clinical medicine ,Internal medicine ,Original Research Articles ,medicine ,Humans ,030212 general & internal medicine ,Myocardial infarction ,Original Research Article ,Right heart catheterization ,Cardiac intensive care unit ,Cardiogenic shock ,business.industry ,Pulmonary artery catheter ,Retrospective cohort study ,Odds ratio ,Middle Aged ,medicine.disease ,Confidence interval ,lcsh:RC666-701 ,Catheterization, Swan-Ganz ,Cohort ,Coronary care unit ,Cardiology ,Cardiology and Cardiovascular Medicine ,business - Abstract
Aims The aim of this study is to evaluate the contemporary use of a pulmonary artery catheter (PAC) in acute myocardial infarction‐cardiogenic shock (AMI‐CS). Methods and results A retrospective cohort of AMI‐CS admissions using the National Inpatient Sample (2000–2014) was identified. Admissions with concomitant cardiac surgery or non‐AMI aetiology for cardiogenic shock were excluded. The outcomes of interest were in‐hospital mortality, resource utilization, and temporal trends in cohorts with and without PAC use. In the non‐PAC cohort, the use and outcomes of right heart catheterization was evaluated. Multivariable regression and propensity matching was used to adjust for confounding. During 2000–2014, 364 001 admissions with AMI‐CS were included. PAC was used in 8.1% with a 75% decrease during over the study period (13.9% to 5.4%). Greater proportion of admissions to urban teaching hospitals received PACs (9.5%) compared with urban non‐teaching (7.1%) and rural hospitals (5.4%); P < 0.001. Younger age, male sex, white race, higher comorbidity, noncardiac organ failure, use of mechanical circulatory support, and noncardiac support were independent predictors of PAC use. The PAC cohort had higher in‐hospital mortality (adjusted odds ratio 1.07 [95% confidence interval 1.04–1.10]), longer length of stay (10.9 ± 10.9 vs. 8.2 ± 9.3 days), higher hospitalization costs ($128 247 ± 138 181 vs. $96 509 ± 116 060), and lesser discharges to home (36.3% vs. 46.4%) (all P < 0.001). In 6200 propensity‐matched pairs, in‐hospital mortality was comparable between the two cohorts (odds ratio 1.01 [95% confidence interval 0.94–1.08]). Right heart catheterization was used in 12.5% of non‐PAC admissions and was a marker of greater severity but did not indicate worse outcomes. Conclusions In AMI‐CS, there was a 75% decrease in PAC use between 2000 and 2014. Admissions receiving a PAC were a higher risk cohort with worse clinical outcomes. more...
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- 2020
12. Early vs. delayed in-hospital cardiac arrest complicating ST-elevation myocardial infarction receiving primary percutaneous coronary intervention
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Abhiram Prasad, David R. Holmes, Allan S. Jaffe, Malcolm R. Bell, Saarwaani Vallabhajosyula, Mandeep Singh, Saraschandra Vallabhajosyula, Jacob C. Jentzer, and Roger D. White
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medicine.medical_specialty ,medicine.medical_treatment ,030204 cardiovascular system & hematology ,Emergency Nursing ,03 medical and health sciences ,Percutaneous Coronary Intervention ,0302 clinical medicine ,medicine ,Humans ,Hospital Mortality ,Myocardial infarction ,Retrospective Studies ,business.industry ,Percutaneous coronary intervention ,030208 emergency & critical care medicine ,Retrospective cohort study ,Odds ratio ,medicine.disease ,Comorbidity ,Hospitals ,Confidence interval ,Heart Arrest ,Treatment Outcome ,Emergency medicine ,Cohort ,Emergency Medicine ,ST Elevation Myocardial Infarction ,Female ,Outcomes research ,Cardiology and Cardiovascular Medicine ,business - Abstract
Background There are limited data on the timing and outcomes of in-hospital cardiac arrest (IHCA) in patients with ST-elevation myocardial infarction (STEMI) receiving primary percutaneous coronary intervention (pPCI). This study sought to examine the in-hospital mortality, temporal trends and resource utilization in early vs. delayed IHCA in STEMI. Methods Retrospective cohort study from the National Inpatient Sample of all STEMI admissions during 2000–2014 receiving pPCI on hospital day zero. Admissions transferred from other hospitals, with do-not-resuscitate status, without information on IHCA timing, and receiving surgical revascularization were excluded. IHCA was classified as early (hospital day zero) and delayed (on/after hospital day 1). The primary outcome was in-hospital mortality and secondary outcomes included prevalence, temporal trends, and resource utilization. Results During this 15-year period, 19,185 admissions met the inclusion criteria, with 15,404 (80%) experiencing an early IHCA. The cohort with delayed IHCA was on average older, female, with higher comorbidity, and greater prevalence of non-shockable rhythms and acute organ failure. There was a temporal increase in early IHCA (adjusted odds ratio [aOR] 1.67 [95% confidence interval {CI} 1.35–2.08]) and a decrease in delayed IHCA (aOR 0.60 [95% CI 0.48-0.74]) in 2014 compared to 2000. Compared to the early IHCA cohort, the delayed IHCA cohort had higher in-hospital mortality (aOR 5.35 [95% CI 4.83–5.94]), higher hospitalization costs ($115,165 ± 109,848 vs. 139,038 ± 142,745) and less frequent discharges to home (74% vs. 52%). Conclusions Delayed IHCA (on or after hospital day 1) was associated with higher in-hospital mortality and resource utilization compared to early IHCA. more...
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- 2020
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13. Admission Society for Cardiovascular Angiography and Intervention shock stage stratifies post-discharge mortality risk in cardiac intensive care unit patients
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David R. Holmes, Sean van Diepen, Srihari S. Naidu, David A. Baran, Timothy D. Henry, Malcolm R. Bell, Jacob C. Jentzer, and Gregory W. Barsness
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Male ,Acute coronary syndrome ,medicine.medical_specialty ,Time Factors ,Organ Dysfunction Scores ,Shock, Cardiogenic ,Kaplan-Meier Estimate ,030204 cardiovascular system & hematology ,Coronary Angiography ,Patient Readmission ,Risk Assessment ,03 medical and health sciences ,0302 clinical medicine ,Cause of Death ,medicine ,Humans ,Hospital Mortality ,Survivors ,030212 general & internal medicine ,Acute Coronary Syndrome ,Societies, Medical ,APACHE ,Aged ,Proportional Hazards Models ,Retrospective Studies ,Cause of death ,Heart Failure ,business.industry ,Proportional hazards model ,Cardiogenic shock ,Coronary Care Units ,Retrospective cohort study ,Length of Stay ,medicine.disease ,Patient Discharge ,Heart Arrest ,Heart failure ,Shock (circulatory) ,Emergency medicine ,Coronary care unit ,Female ,medicine.symptom ,Cardiology and Cardiovascular Medicine ,business - Abstract
The five-stage Society for Cardiovascular Angiography and Intervention (SCAI) cardiogenic shock classification scheme can stratify hospital mortality risk in patients admitted to the cardiac intensive care unit (CICU). We sought to evaluate the SCAI shock classification for prediction of post-discharge mortality in CICU survivors.We retrospectively analyzed hospital survivors admitted to a single CICU between 2007 and 2015. SCAI CS stages A through E were classified using CICU admission data using a previously published algorithm. All-cause post-discharge mortality was compared across SCAI stages using Kaplan-Meier analysis and Cox proportional hazards models.Among 9096 unique hospital survivors, 43.2% had acute coronary syndrome (ACS), 44.6% had heart failure (HF), and 8.7% had cardiac arrest (CA) on admission. The proportion of patients in each SCAI shock stage was: A, 49.1%; B, 30.6%; C, 15.2; D/E 5.2%. Kaplan-Meier survival at 5 years in each SCAI shock stage was: A, 88.2%; B, 81.6%; C, 76.7%; D/E, 71.7% (P .001 by log-rank). Each higher SCAI shock stage was associated with increased adjusted post-discharge mortality compared to SCAI shock stage A (all P .001); results were consistent among patients with ACS or HF. Late hemodynamic deterioration after 24 hours, but not an admission diagnosis of CA, was associated with higher post-discharge mortality.The SCAI shock classification assessed at the time of CICU admission was predictive of post-discharge mortality risk among hospital survivors, although an admission diagnosis of CA was not. The SCAI shock classification can be used for post-discharge mortality risk stratification. more...
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- 2020
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14. Management and Outcomes of Acute Myocardial Infarction-Cardiogenic Shock in Uninsured Compared to Privately Insured Individuals
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Saraschandra Vallabhajosyula, Vinayak Kumar, Pranathi R. Sundaragiri, Wisit Cheungpasitporn, P. Elliott Miller, Sri Harsha Patlolla, Bernard J. Gersh, Amir Lerman, Allan S. Jaffe, Nilay D. Shah, David R. Holmes, Malcolm R. Bell, and Gregory W. Barsness more...
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Adult ,Heart Failure ,Male ,Medically Uninsured ,Insurance, Health ,Myocardial Infarction ,Shock, Cardiogenic ,Humans ,Hospital Mortality ,Cardiology and Cardiovascular Medicine ,Article ,United States ,Retrospective Studies - Abstract
Background: There are limited data on uninsured patients presenting with acute myocardial infarction-cardiogenic shock (AMI-CS). This study sought to compare the management and outcomes of AMI-CS between uninsured and privately insured individuals. Methods: Using the National Inpatient Sample (2000–2016), a retrospective cohort of adult (≥18 years) uninsured admissions (primary payer—self-pay or no charge) were compared with privately insured individuals. Interhospital transfers were excluded. Outcomes of interest included in-hospital mortality, temporal trends in admissions, use of cardiac procedures, do-not-resuscitate status, palliative care referrals, and resource utilization. Results: Of 402 182 AMI-CS admissions, 21 966 (5.4%) and 93 814 (23.3%) were uninsured and privately insured. Compared with private insured individuals, uninsured admissions were younger, male, from a lower socioeconomic status, had lower comorbidity, higher rates of acute organ failure, ST-segment elevation AMI-CS (77.3% versus 76.4%), and concomitant cardiac arrest (33.8% versus 31.9%; all P P P P P Conclusions: Uninsured individuals have higher in-hospital mortality and lower use of guideline-directed therapies in AMI-CS compared with privately insured individuals. more...
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- 2022
15. PREVALENCE OF HIGH BLEED RISK PATIENTS UNDERGOING PERCUTANEOUS CORONARY INTERVENTION AND IMPACT ON MORTALITY
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Brenden Ingraham, Aravdeep Jhand, Bradley R. Lewis, Rajiv Gulati, Malcolm R. Bell, Charanjit S. Rihal, and Mandeep Singh
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Cardiology and Cardiovascular Medicine - Published
- 2023
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16. Outcomes of excimer laser-contrast angioplasty for stent underexpansion
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Mandeep Singh, Malcolm R. Bell, Yader Sandoval, John Nan, Rajiv Gulati, and Timothy A. Joseph
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medicine.medical_specialty ,business.industry ,medicine.medical_treatment ,Stent ,Percutaneous coronary intervention ,030204 cardiovascular system & hematology ,medicine.disease ,Single Center ,Surgery ,03 medical and health sciences ,0302 clinical medicine ,Restenosis ,Angioplasty ,Conventional PCI ,medicine ,Hospital discharge ,030212 general & internal medicine ,Cardiology and Cardiovascular Medicine ,business ,Target lesion revascularization - Abstract
Aims Excimer Laser Coronary Angioplasty with adjunctive contrast (ELCA-con) is described as one potential option to facilitate intra-coronary stent expansion; however, the benefits and risks of this technology remain incompletely understood. We performed a retrospective single center study to evaluate procedural success, risks, and clinical outcomes of ELCA-con assisted percutaneous coronary intervention (PCI) for stent under-expansion. Methods and results Twenty-six consecutive patients underwent ELCA-con assisted PCI from 2014 to 2019 for stent under-expansion. All cases used a 0.9 mm fiber with pulse frequency 80 Hz and fluency 80mJ/mm 2 and adjunctive contrast injection during laser activation. Stent expansion improved in all cases, with 81% of patient achieving ≤ 40% residual stenosis and 58% of patients achieving ≤ 20% residual stenosis. Nonfatal complications were observed in 15% of patients. All patients survived to hospital discharge. Upon follow up (median 13 months), rate of restenosis requiring target lesion revascularization was 3.8%. Four deaths were observed, one from cardiac arrest 2 days later and the others from unrelated causes. Conclusions ELCA-con is a useful technique to manage stent under-expansion and facilitate stent expansion in many cases. The complication rate indicates that careful patient selection is warranted. more...
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- 2021
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17. Changes in comorbidities, diagnoses, therapies and outcomes in a contemporary cardiac intensive care unit population
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Allan S. Jaffe, Sunil Mankad, Joseph G. Murphy, Brandon M. Wiley, R. Scott Wright, David A. Morrow, Patricia J.M. Best, Courtney Bennett, Jason N. Katz, Lawrence J. Sinak, Sean van Diepen, Nandan S. Anavekar, Malcolm R. Bell, Jacob C. Jentzer, Gregory W. Barsness, and Joerg Herrmann more...
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Male ,medicine.medical_specialty ,Critical Care ,Critical Illness ,Population ,Diagnostic Techniques, Cardiovascular ,Comorbidity ,030204 cardiovascular system & hematology ,Logistic regression ,Severity of Illness Index ,03 medical and health sciences ,0302 clinical medicine ,Severity of illness ,Prevalence ,medicine ,Humans ,030212 general & internal medicine ,Mortality ,Critical Care Outcomes ,education ,Aged ,Retrospective Studies ,education.field_of_study ,business.industry ,Coronary Care Units ,Retrospective cohort study ,Patient Acceptance of Health Care ,medicine.disease ,United States ,Cardiovascular Diseases ,Cohort ,Emergency medicine ,Coronary care unit ,Female ,Cardiology and Cardiovascular Medicine ,business - Abstract
Background Prior studies have demonstrated that the cardiac intensive care unit (CICU) patient population has evolved over time. We sought to describe the temporal changes in comorbidities, illness severity, diagnoses, procedures and adjusted mortality within our CICU practice in recent years. Methods We retrospectively reviewed unique CICU admissions at the Mayo Clinic from January 2007 to April 2018. Comorbidities, severity of illness scores, discharge diagnosis codes and CICU procedures and therapies were recorded, and temporal trends were assessed using linear regression and Cochran-Armitage trend tests. Trends in adjusted hospital mortality over time were assessed using multivariable logistic regression. Results We included 12,418 patients with a mean age of 67.6 years (including 37.7% females). Temporal trends in the prevalence of several comorbidities and discharge diagnoses were observed, reflecting an increase in the prevalence of non-coronary cardiovascular diseases, critical care diagnoses, and organ failure (all P ≪ .05). The use of several CICU therapies and procedures increased over time, including mechanical ventilation, invasive lines and vasoactive drugs (all P ≪ .05). A temporal decrease in adjusted hospital mortality was observed among the subgroup of patients with (adjusted OR per year 0.97, 95% CI 0.94–0.99, P = .023) and without (adjusted OR per year 0.91, 95% CI 0.85–0.96, P = .002) a critical care discharge diagnosis. Conclusions We observed an increasing prevalence of critical care and organ failure diagnoses as well as increased utilization of critical care therapies in this CICU cohort, associated with a decrease in risk-adjusted hospital mortality over time. more...
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- 2019
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18. Leveraging Machine Learning Techniques to Forecast Patient Prognosis After Percutaneous Coronary Intervention
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Mandeep Singh, Malcolm R. Bell, Yaron Kinar, Yoav Bar-Sinai, Chad J. Zack, Conor Senecal, Ryan J. Lennon, R. Jay Widmer, Yaakov Metzger, Amir Lerman, and Rajiv Gulati
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Male ,Time Factors ,Minnesota ,medicine.medical_treatment ,Clinical Decision-Making ,Population ,Coronary Artery Disease ,030204 cardiovascular system & hematology ,Logistic regression ,Machine learning ,computer.software_genre ,Patient Readmission ,Risk Assessment ,Decision Support Techniques ,Machine Learning ,03 medical and health sciences ,Percutaneous Coronary Intervention ,0302 clinical medicine ,Predictive Value of Tests ,Risk Factors ,Humans ,Medicine ,Hospital Mortality ,Registries ,030212 general & internal medicine ,education ,Aged ,Heart Failure ,education.field_of_study ,business.industry ,Area under the curve ,Reproducibility of Results ,Percutaneous coronary intervention ,Middle Aged ,Confidence interval ,Regression ,Treatment Outcome ,Conventional PCI ,Cohort ,Female ,Artificial intelligence ,Cardiology and Cardiovascular Medicine ,business ,computer - Abstract
Objectives This study sought to determine whether machine learning can be used to better identify patients at risk for death or congestive heart failure (CHF) rehospitalization after percutaneous coronary intervention (PCI). Background Contemporary risk models for event prediction after PCI have limited predictive ability. Machine learning has the potential to identify complex nonlinear patterns within datasets, improving the predictive power of models. Methods We evaluated 11,709 distinct patients who underwent 14,349 PCIs between January 2004 and December 2013 in the Mayo Clinic PCI registry. Fifty-two demographic and clinical parameters known at the time of admission were used to predict in-hospital mortality and 358 additional variables available at discharge were examined to identify patients at risk for CHF readmission. For each event, we trained a random forest regression model (i.e., machine learning) to estimate the time-to-event. Eight-fold cross-validation was used to estimate model performance. We used the predicted time-to-event as a score, generated a receiver-operating characteristic curve, and calculated the area under the curve (AUC). Model performance was then compared with a logistic regression model using pairwise comparisons of AUCs and calculation of net reclassification indices. Results The predictive algorithm identified a high-risk cohort representing 2% of all patients who had an in-hospital mortality of 45.5% (95% confidence interval: 43.5% to 47.5%) compared with a risk of 2.1% for the general population (AUC: 0.925; 95% confidence interval: 0.92 to 0.93). Advancing age, CHF, and shock on presentation were the leading predictors for the outcome. A high-risk group representing 1% of all patients was identified with 30-day CHF rehospitalization of 8.1% (95% confidence interval: 6.3% to 10.2%). Random forest regression outperformed logistic regression for predicting 30-day CHF readmission (AUC: 0.90 vs. 0.85; p = 0.003; net reclassification improvement: 5.14%) and 180-day cardiovascular death (AUC: 0.88 vs. 0.81; p = 0.02; net reclassification improvement: 0.02%). Conclusions Random forest regression models (machine learning) were more predictive and discriminative than standard regression methods at identifying patients at risk for 180-day cardiovascular mortality and 30-day CHF rehospitalization, but not in-hospital mortality. Machine learning was effective at identifying subgroups at high risk for post-procedure mortality and readmission. more...
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- 2019
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19. Utility and Challenges of an Early Invasive Strategy in Patients Resuscitated From Out-of-Hospital Cardiac Arrest
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Abhiram Prasad, Jacob C. Jentzer, Joerg Herrmann, Gregory W. Barsness, and Malcolm R. Bell
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medicine.medical_specialty ,Resuscitation ,medicine.medical_treatment ,Clinical Decision-Making ,Population ,Shock, Cardiogenic ,Coronary Artery Disease ,030204 cardiovascular system & hematology ,Coronary Angiography ,Revascularization ,Decision Support Techniques ,law.invention ,Coronary artery disease ,03 medical and health sciences ,Percutaneous Coronary Intervention ,0302 clinical medicine ,Randomized controlled trial ,Predictive Value of Tests ,Risk Factors ,law ,Internal medicine ,medicine ,Humans ,030212 general & internal medicine ,Myocardial infarction ,Acute Coronary Syndrome ,education ,education.field_of_study ,business.industry ,Cardiogenic shock ,Percutaneous coronary intervention ,Recovery of Function ,medicine.disease ,Treatment Outcome ,Coronary occlusion ,Cardiology ,Cardiology and Cardiovascular Medicine ,business ,Algorithms ,Out-of-Hospital Cardiac Arrest - Abstract
Out-of-hospital cardiac arrest (OHCA) is frequently triggered by acute myocardial ischemia. Coronary angiography is an important component of post-resuscitation care for patients with OHCA without an evident noncardiac cause, to identify underlying coronary artery disease and allow revascularization. Most patients undergoing coronary angiography after OHCA have obstructive coronary artery disease, and nearly one-half of patients have acute coronary occlusion. Early coronary angiography and percutaneous coronary intervention after OHCA have been associated with improved survival in observational studies, but these studies demonstrate selection bias, and randomized trials are lacking. Selection of patients for coronary angiography after OHCA can be challenging, particularly in comatose patients whose outcomes are driven primarily by anoxic brain injury. As for other patients with acute coronary syndromes, patients with ST-segment elevation after OHCA have a high probability of acute coronary occlusion warranting emergent coronary angiography. Patients with cardiogenic shock after OHCA are a high-risk population also requiring emergent coronary angiography. Among patients in stable condition after OHCA without ST-segment elevation, other clinical predictors can be used to identify those needing early coronary angiography to identify obstructive coronary artery disease. Despite the challenges with early neurological prognostication in comatose patients with OHCA, those with multiple objective markers of poor prognosis appear less likely to benefit from revascularization, and early coronary angiography may be reasonably deferred in appropriately selected patients meeting these criteria. The authors propose an algorithm to guide patient selection for coronary angiography after OHCA that combines clinical predictors of acute coronary occlusion and early clinical predictors of severe brain injury. more...
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- 2019
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20. Racial and Ethnic Disparities in Management and Outcomes of Cardiac Arrest Complicating Acute Myocardial Infarction
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Malcolm R. Bell, Sri Harsha Patlolla, Gregory W. Barsness, Pranathi R. Sundaragiri, P. Elliott Miller, David R. Holmes, Anna V. Subramaniam, Wisit Cheungpasitporn, and Saraschandra Vallabhajosyula
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Male ,medicine.medical_specialty ,Myocardial Infarction ,Ethnic group ,acute myocardial infarction ,cardiac arrest ,030204 cardiovascular system & hematology ,Coronary Angiography ,Resuscitation Science ,outcomes research ,03 medical and health sciences ,0302 clinical medicine ,Ethnicity ,medicine ,Humans ,Diseases of the circulatory (Cardiovascular) system ,Hospital Mortality ,030212 general & internal medicine ,Myocardial infarction ,race ,Original Research ,Aged ,Retrospective Studies ,Health Equity ,business.industry ,Racial Groups ,Disease Management ,Middle Aged ,medicine.disease ,healthcare disparities ,minorities ,United States ,Heart Arrest ,RC666-701 ,Emergency medicine ,Female ,Outcomes research ,Cardiology and Cardiovascular Medicine ,business ,Follow-Up Studies - Abstract
Background The role of race and ethnicity in the outcomes of cardiac arrest (CA) complicating acute myocardial infarction (AMI) is incompletely understood. Methods and Results This was a retrospective cohort study of adult admissions with AMI‐CA from the National Inpatient Sample (2012–2017). Self‐reported race/ethnicity was classified as White, Black, and others (Hispanic, Asian or Pacific Islander, Native American, Other). Outcomes of interest included in‐hospital mortality, coronary angiography, percutaneous coronary intervention, palliative care consultation, do‐not‐resuscitate status use, hospitalization costs, hospital length of stay, and discharge disposition. Of the 3.5 million admissions with AMI, CA was noted in 182 750 (5.2%), with White, Black, and other races/ethnicities constituting 74.8%, 10.7%, and 14.5%, respectively. Black patients admitted with AMI‐CA were more likely to be female, with more comorbidities, higher rates of non–ST‐segment–elevation myocardial infarction, and higher neurological and renal failure. Admissions of patients of Black and other races/ethnicities underwent coronary angiography (61.9% versus 70.2% versus 73.1%) and percutaneous coronary intervention (44.6% versus 53.0% versus 58.1%) less frequently compared to patients of white race ( p P =0.007) whereas other races had higher in‐hospital mortality (OR, 1.11; 95% CI, 1.08–1.15; P P Conclusions Racial and ethnic minorities received less frequent guideline‐directed procedures and had higher in‐hospital mortality and worse outcomes in AMI‐CA. more...
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- 2021
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21. Temporal Trends, Clinical Characteristics, and Outcomes of Emergent Coronary Artery Bypass Grafting for Acute Myocardial Infarction in the United States
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Saraschandra Vallabhajosyula, Wisit Cheungpasitporn, John M. Stulak, Rajkumar Doshi, Ardaas Kanwar, Sri Harsha Patlolla, David R. Holmes, Mandeep Singh, and Malcolm R. Bell
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Male ,medicine.medical_specialty ,Emergency Medical Services ,Bypass grafting ,coronary artery bypass grafting ,Myocardial Infarction ,acute myocardial infarction ,030204 cardiovascular system & hematology ,Time-to-Treatment ,outcomes research ,03 medical and health sciences ,0302 clinical medicine ,acute cardiovascular care ,Internal medicine ,Epidemiology ,medicine ,Humans ,030212 general & internal medicine ,Myocardial infarction ,cardiovascular diseases ,Hospital Mortality ,Coronary Artery Bypass ,Hospital Costs ,Mortality ,Non-ST Elevated Myocardial Infarction ,Original Research ,Cardiovascular Surgery ,business.industry ,Length of Stay ,Middle Aged ,medicine.disease ,United States ,medicine.anatomical_structure ,Outcome and Process Assessment, Health Care ,Cardiology ,ST Elevation Myocardial Infarction ,Female ,epidemiology ,Outcomes research ,Cardiology and Cardiovascular Medicine ,business ,Procedures and Techniques Utilization ,Artery - Abstract
Background There are limited contemporary data on the use of emergent coronary artery bypass grafting (CABG) in acute myocardial infarction. Methods and Results Adult (aged >18 years) acute myocardial infarction admissions were identified using the National (Nationwide) Inpatient Sample (2000–2017) and classified by tertiles of admission year. Outcomes of interest included temporal trends of CABG use; age‐, sex‐, and race‐stratified trends in CABG use; in‐hospital mortality; hospitalization costs; and hospital length of stay. Of the 11 622 528 acute myocardial infarction admissions, emergent CABG was performed in 1 071 156 (9.2%). CABG utilization decreased overall (10.5% [2000] to 8.7% [2017]; adjusted odds ratio [OR], 0.98 [95% CI, 0.98–0.98]; P P P P Conclusions Utilization of CABG has decreased substantially in acute myocardial infarction admissions, especially in patients with ST‐segment–elevation myocardial infarction. Despite an increase in acuity and multiorgan failure, in‐hospital mortality consistently decreased in this population. more...
- Published
- 2021
22. Defining Shock and Preshock for Mortality Risk Stratification in Cardiac Intensive Care Unit Patients
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Venu Menon, Timothy D. Henry, Barry Burstein, David R. Holmes, Joseph G. Murphy, Charanjit S. Rihal, Jacob C. Jentzer, Srihari S. Naidu, Malcolm R. Bell, Sean van Diepen, Gregory W. Barsness, and David A. Baran more...
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Male ,medicine.medical_specialty ,Shock, Cardiogenic ,Blood Pressure ,Hospital mortality ,Urine ,Risk Assessment ,Severity of Illness Index ,Renal Circulation ,law.invention ,law ,medicine ,Humans ,Arterial Pressure ,Hospital Mortality ,Lactic Acid ,Aged ,Aged, 80 and over ,business.industry ,Coronary Care Units ,Middle Aged ,medicine.disease ,Intensive care unit ,Creatinine ,Heart failure ,Shock (circulatory) ,Emergency medicine ,Risk stratification ,Coronary care unit ,Female ,Hypotension ,medicine.symptom ,Cardiology and Cardiovascular Medicine ,business ,Perfusion - Abstract
Background: Previous studies have defined preshock as isolated hypotension or isolated hypoperfusion, whereas shock has been variably defined as hypoperfusion with or without hypotension. We aimed to evaluate the mortality risk associated with hypotension and hypoperfusion at the time of admission in a cardiac intensive care unit population. Methods: We analyzed Mayo Clinic cardiac intensive care unit patients admitted between 2007 and 2015. Hypotension was defined as systolic blood pressure 2 mmol/L, oliguria, or rising creatinine. Associations between hypotension and hypoperfusion with hospital mortality were estimated using multivariable logistic regression. Results: Among 10 004 patients with a median age of 69 years, 43.1% had acute coronary syndrome, and 46.1% had heart failure. Isolated hypotension was present in 16.7%, isolated hypoperfusion in 15.3%, and 8.7% had both hypotension and hypoperfusion. Stepwise increases in hospital mortality were observed with hypotension and hypoperfusion compared with neither hypotension nor hypoperfusion (3.3%; all P P =0.02) and not significant different from patients with both hypotension and hypoperfusion ( P =0.18). Conclusions: Hypotension and hypoperfusion are both associated with increased mortality in cardiac intensive care unit patients. Hospital mortality is higher with isolated hypoperfusion or concomitant hypotension and hypoperfusion (classic shock). We contend that preshock should refer to isolated hypotension without hypoperfusion, while patients with hypoperfusion can be considered to have shock, irrespective of blood pressure. more...
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- 2021
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23. Causes of Death After Type 2 Myocardial Infarction and Myocardial Injury
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Véronique L. Roger, Malcolm R. Bell, Rajiv Gulati, Charanjit S. Rihal, Yader Sandoval, Matthew P. Johnson, Claire E. Raphael, Amir Lerman, Allan S. Jaffe, and Mandeep Singh
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Male ,medicine.medical_specialty ,business.industry ,Troponin I ,Myocardial Infarction ,medicine.disease ,United States ,Survival Rate ,Cause of Death ,Internal medicine ,medicine ,Cardiology ,Humans ,Female ,Myocardial infarction ,Cardiology and Cardiovascular Medicine ,business ,Biomarkers ,Aged - Published
- 2021
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24. Abstract 16699: The Mayo Cardiac Intensive Care Unit Admission Risk Score Predicts One-Year Mortality
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Thomas J. Breen, Joseph G. Murphy, Courtney Bennett, Mitchell Padkins, Nandan S. Anavekar, Malcolm R. Bell, Gregory W. Barsness, and Jacob C. Jentzer
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medicine.medical_specialty ,education.field_of_study ,Framingham Risk Score ,business.industry ,Population ,Hospital mortality ,One year mortality ,Physiology (medical) ,Emergency medicine ,Coronary care unit ,Medicine ,Cardiology and Cardiovascular Medicine ,business ,education - Abstract
Introduction: The Mayo Clinic Cardiac Intensive Care Unit Admission Risk Score (M-CARS) has been shown to predict hospital mortality in the CICU population better than conventional critical care scoring models. We tested the hypothesis that M-CARS could similarly be used to predict one-year mortality. Methods: We retrospectively reviewed adult CICU patients admitted from 2007 to 2018. M-CARS was calculated using admission data. Groups were compared using Wilcoxon test for continuous variables and chi-squared test for categorical variables. Results: This study included 12428 unique patients with a mean age of 67 ± 15 years (37% females), of whom 11279 (90.8%) survived hospitalization and 2839 patients (22.8%) died within 1 year of admission. The 1-year survival decreased incrementally as a function of increasing M-CARS ( Figure 1A , pFigure 1B, p=0.99). M-CARS components associated with 1-year mortality among hospital survivors included blood urea nitrogen, red blood cell distribution width, Braden score, and respiratory failure (all p Conclusions: M-CARS accurately predicts 1-year mortality among CICU admissions, with a plateau effects at high M-CARS scores ≥3. Significant predictors of 1-year mortality among CICU survivors include frailty markers rather than admission severity. more...
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- 2020
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25. Sex Disparities in the Management and Outcomes of Cardiogenic Shock Complicating Acute Myocardial Infarction in the Young
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David R. Holmes, Bernard J. Gersh, Lina Ya'qoub, Allan S. Jaffe, Gregory W. Barsness, Mandeep Singh, Virginia M. Miller, Malcolm R. Bell, Wisit Cheungpasitporn, Rajiv Gulati, Saraschandra Vallabhajosyula, and Pranathi R. Sundaragiri more...
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medicine.medical_specialty ,business.industry ,Cardiogenic shock ,Retrospective cohort study ,Odds ratio ,medicine.disease ,Shock (circulatory) ,Internal medicine ,medicine ,Cardiology ,Myocardial infarction ,Young adult ,medicine.symptom ,Cardiology and Cardiovascular Medicine ,business - Abstract
Background: There are limited data on how sex influences the outcomes of acute myocardial infarction-cardiogenic shock (AMI-CS) in young adults. Methods: A retrospective cohort of AMI-CS admissions aged 18 to 55 years, during 2000 to 2017, was identified using the National Inpatient Sample. Use of coronary angiography, percutaneous coronary intervention, mechanical circulatory support and noncardiac interventions was identified. Outcomes of interest included in-hospital mortality, use of cardiac interventions, hospitalization costs, and length of stay. Results: A total 90 648 AMI-CS admissions ≤55 years of age were included, of which 26% were women. Higher rates of CS were noted in men (2.2% in 2000 to 4.8% in 2017) compared with women (2.6% in 2000 to 4.0% in 2017; P P P P P Conclusions: In young AMI-CS admissions, women are treated less aggressively and experience higher in-hospital mortality than men. more...
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- 2020
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26. Influence of age and shock severity on short-term survival in patients with cardiogenic shock
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Jacob C. Jentzer, Benedikt Schrage, Nandan S. Anavekar, Malcolm R. Bell, Stefan Blankenberg, Dirk Westermann, David R. Holmes, Paulus Kirchhof, Gregory W. Barsness, and Salim Dabboura
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Male ,medicine.medical_specialty ,Acute coronary syndrome ,Shock, Cardiogenic ,Renal function ,030204 cardiovascular system & hematology ,Critical Care and Intensive Care Medicine ,Risk Assessment ,03 medical and health sciences ,0302 clinical medicine ,Internal medicine ,medicine ,Humans ,In patient ,030212 general & internal medicine ,Hospital Mortality ,Stage (cooking) ,Acute Coronary Syndrome ,Aged ,Retrospective Studies ,Aged, 80 and over ,business.industry ,Cardiogenic shock ,General Medicine ,Middle Aged ,medicine.disease ,Shock (circulatory) ,Circulatory system ,Short term survival ,Female ,medicine.symptom ,Cardiology and Cardiovascular Medicine ,business - Abstract
Aims Cardiogenic shock (CS) is associated with poor outcomes in older patients, but it remains unclear if this is due to higher shock severity. We sought to determine the associations between age and shock severity on mortality among patients with CS. Methods and results Patients with a diagnosis of CS from Mayo Clinic (2007–15) and University Clinic Hamburg (2009–17) were subdivided by age. Shock severity was graded using the Society for Cardiovascular Angiography and Intervention (SCAI) shock stages. Predictors of 30-day survival were determined using Cox proportional-hazards analysis. We included 1749 patients (934 from Mayo Clinic and 815 from University Clinic Hamburg), with a mean age of 67.6 ± 14.6 years, including 33.6% females. Acute coronary syndrome was the cause of CS in 54.0%. The distribution of SCAI shock stages was 24.1%; C, 28.0%; D, 33.2%; and E, 14.8%. Older patients had similar overall shock severity, more co-morbidities, worse kidney function, and decreased use of mechanical circulatory support compared to younger patients. Overall 30-day survival was 53.3% and progressively decreased as age or SCAI shock stage increased, with a clear gradient towards lower 30-day survival as a function of increasing age and SCAI shock stage. Progressively older age groups had incrementally lower adjusted 30-day survival than patients aged Conclusion Older patients with CS have lower short-term survival, despite similar shock severity, with a high risk of death in older patients with more severe shock. Further research is needed to determine the optimal treatment strategies for older CS patients. more...
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- 2020
27. Red blood cell transfusion threshold and mortality in cardiac intensive care unit patients
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Jason N. Katz, Malcolm R. Bell, Jacob C. Jentzer, Dennis H. Murphree, Brandon M. Wiley, Patrick R. Lawler, Gregory W. Barsness, and Daryl J. Kor
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Male ,medicine.medical_specialty ,Acute coronary syndrome ,Blood transfusion ,Anemia ,medicine.medical_treatment ,Critical Illness ,030204 cardiovascular system & hematology ,03 medical and health sciences ,0302 clinical medicine ,medicine ,Humans ,030212 general & internal medicine ,Myocardial infarction ,Hospital Mortality ,Aged ,Retrospective Studies ,business.industry ,Cardiogenic shock ,medicine.disease ,United States ,Survival Rate ,Intensive Care Units ,Cardiovascular Diseases ,Heart failure ,Cohort ,Emergency medicine ,Coronary care unit ,Female ,Cardiology and Cardiovascular Medicine ,business ,Erythrocyte Transfusion ,circulatory and respiratory physiology - Abstract
The benefit of red blood cell (RBC) transfusion in anemic critically-ill patients with cardiovascular disease is uncertain, as is the optimal threshold at which RBC transfusion should be considered. We sought to examine the association between RBC transfusion and mortality stratified by nadir Hgb level and admission diagnosis among cardiac intensive care unit (CICU) patients.Retrospective single-center cohort of 11,754 CICU patients admitted between 2007 and 2018. The association between RBC transfusion and hospital mortality at each nadir Hgb (8 g/dL, 8-9.9 g/dL, ≥10 g/dL) was assessed using multivariable logistic regression adjusted for the propensity to receive RBC transfusion.The study population had a mean age of 68±15 years, including 38% females; 1,134 (11.4%) received RBC transfusion. Admission diagnoses included: acute coronary syndrome , 42%; heart failure, 50%; cardiac arrest , 12%; and cardiogenic shock , 12%. Patients who received RBC transfusion had higher crude hospital mortality (19% vs. 8%, P.001). RBC transfusion was associated with lower adjusted hospital mortality in patients with nadir Hgb8 g/dL after propensity adjustment, including subgroups with acute coronary syndrome, cardiac arrest, or cardiogenic shock (all P.01). RBC transfusion was not associated with lower adjusted hospital mortality in any subgroup of patients with nadir Hgb ≥8 g/dL.These observational data suggest the use of a Hgb threshold8 g/dL for RBC transfusion in most CICU patients, although we could not exclude a potential benefit of RBC transfusion at a nadir Hgb of 8 to 9.9 g/dL; we did not observe any benefit from RBC transfusion at a nadir Hgb ≥10 g/dL. more...
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- 2020
28. Abstract 322: The Mayo Cardiac Intensive Care Unit Admission Risk Score Predicts Resource Utilization During Hospitalization
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Joseph G. Murphy, Gregory W. Barsness, Thomas J. Breen, Nandan S. Anavekar, Courtney Bennett, Jacob C. Jentzer, and Malcolm R. Bell
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medicine.medical_specialty ,Framingham Risk Score ,business.industry ,Quality assessment ,Emergency medicine ,Coronary care unit ,Medicine ,Cardiology and Cardiovascular Medicine ,business ,Triage ,Resource utilization ,Patient care - Abstract
Background: With the rising cost of critical care and limited availability of critical care resources, improvements are need in the current cardiac intensive care unit (CICU) triage process. We sought to determine whether the Mayo Clinic Intensive Care Unit Admission Risk Score (M-CARS) could be used to predict which CICU patients will require critical care resources. Methods: Adult patients admitted to our CICU from 2007 to 2018 were retrospectively reviewed. The M-CARS was calculated using data from the time of admission. Groups were compared using Wilcoxon test for continuous variables and chi-squared test for categorical variables. Results: We included 12,428 patients with a mean age of 67 ± 15 years (37% females). The mean M-CARS was 2.1 ± 2.1, including 5,890 (47.4%) patients with M-CARS 6. Critical care therapies were frequently used, including mechanical ventilation in 28.0%, vasoactive medications in 25.5%, dialysis in 4.8% and invasive lines in 44.3%. The low-risk cohort with M-CARS Conclusions: In addition to predicting hospital mortality, the M-CARS predicts resource utilization during CICU admission and could be used in the triage of critically ill cardiac patients. Patients with M-CARS more...
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- 2020
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29. Burden of Arrhythmias in Acute Myocardial Infarction Complicated by Cardiogenic Shock
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Dhiran Verghese, Abhishek Deshmukh, Bernard J. Gersh, Pranathi R. Sundaragiri, Lina Ya'qoub, Anna V. Subramaniam, Wisit Cheungpasitporn, Vinayak Kumar, Sri Harsha Patlolla, Saraschandra Vallabhajosyula, Malcolm R. Bell, Siva K. Mulpuru, and Peter A. Noseworthy more...
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Male ,medicine.medical_specialty ,Myocardial Infarction ,Shock, Cardiogenic ,030204 cardiovascular system & hematology ,Ventricular tachycardia ,Article ,03 medical and health sciences ,0302 clinical medicine ,Risk Factors ,Internal medicine ,medicine ,Humans ,030212 general & internal medicine ,Myocardial infarction ,cardiovascular diseases ,Hospital Mortality ,Aged ,Retrospective Studies ,business.industry ,Cardiogenic shock ,Atrial fibrillation ,Arrhythmias, Cardiac ,medicine.disease ,Ventricular fibrillation ,Cardiology ,cardiovascular system ,Myocardial infarction complications ,Female ,Supraventricular tachycardia ,Cardiology and Cardiovascular Medicine ,business ,Atrial flutter - Abstract
There are limited data on arrhythmias in acute myocardial infarction with cardiogenic shock (AMI-CS). Using a 17-year AMI-CS population from the National Inpatient Sample, we identified common arrhythmias - atrial fibrillation (AF), atrial flutter, supraventricular tachycardia, ventricular tachycardia, ventricular fibrillation, and atrioventricular blocks (AVB). Admissions with concomitant cardiac surgery were excluded. Outcomes of interest included temporal trends, predictors, in-hospital mortality, and resource utilization in cohorts with and without arrhythmias. Of the 420,319 admissions with AMI-CS during 2000 to 2016, arrhythmias were noted in 213,718 (51%). AF (45%), ventricular tachycardia (35%) and ventricular fibrillation (30%) were the most common arrhythmias. Compared with those without, the cohort w`ith arrhythmias was more often male, of white race, with ST-segment elevation AMI-CS presentation, and had higher rates of cardiac arrest and acute organ failure (all p0.001). Temporal trends of prevalence revealed a stable trend of atrial and ventricular arrhythmias and declining trend in AVB. The cohort with arrhythmias had higher unadjusted (42% vs 41%; odds ratio [OR] 1.03 [95% confidence interval 1.02 to 1.05]; p0.001), but not adjusted (OR 1.01 [95% CI 0.99 to 1.03]; p = 0.22) in-hospital mortality compared with those without. The cohort with arrhythmias had longer hospital stay (9 ± 10 vs 7 ± 9 days; p0.001) and higher hospitalization costs ($124,000 ± 146,000 vs $91,000 ± 115,000; p0.001). In the cohort with arrhythmias, older age, female sex, non-white race, higher co-morbidity, presence of acute organ failure, and cardiac arrest, predicted higher in-hospital mortality. In conclusion, cardiac arrhythmias in AMI-CS are a marker of higher illness severity and are associated with greater resource utilization. more...
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- 2020
30. Regional Variation in the Management and Outcomes of Acute Myocardial Infarction with Cardiogenic Shock in the United States
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Allan S. Jaffe, Abhiram Prasad, David R. Holmes, Bernard J. Gersh, Shannon M. Dunlay, Gregory W. Barsness, Sri Harsha Patlolla, Saraschandra Vallabhajosyula, Charanjit S. Rihal, and Malcolm R. Bell
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Coronary angiography ,Adult ,Male ,medicine.medical_specialty ,Cardiac Catheterization ,Time Factors ,Databases, Factual ,medicine.medical_treatment ,Myocardial Infarction ,Shock, Cardiogenic ,Coronary Angiography ,Article ,Young Adult ,Percutaneous Coronary Intervention ,Renal Dialysis ,Internal medicine ,medicine ,Humans ,Myocardial infarction ,Healthcare Disparities ,Practice Patterns, Physicians' ,Aged ,Retrospective Studies ,Aged, 80 and over ,business.industry ,Cardiogenic shock ,Incidence ,Percutaneous coronary intervention ,Recovery of Function ,Middle Aged ,medicine.disease ,Respiration, Artificial ,United States ,Treatment Outcome ,Shock (circulatory) ,Cardiology ,Female ,Heart-Assist Devices ,medicine.symptom ,Cardiology and Cardiovascular Medicine ,business - Abstract
Background: There are few studies evaluating regional disparities in the care of acute myocardial infarction-cardiogenic shock (AMI-CS). Methods and Results: Using the National Inpatient Sample from 2000 to 2016, we identified adults with a primary diagnosis of AMI and concomitant CS admitted to the United States census regions of Northeast, Midwest, South, and West. Interhospital transfers were excluded. End points of interest included in-hospital mortality, use of coronary angiography, percutaneous coronary intervention, mechanical circulatory support, hospitalization costs, length of stay, and discharge disposition. Multivariable regression was used to adjust for potential confounding. Of the 402 825 AMI-CS admissions, 16.8%, 22.5%, 39.3%, and 21.4% were admitted to the Northeast, Midwest, South, and West, respectively. Higher rates of ST-elevation AMI-CS were noted in the Midwest and West. Admissions to the Northeast were on average characterized by a higher frequency of whites, Medicare beneficiaries, and lower rates of cardiac arrest. Admissions to the Northeast were less likely to receive coronary angiography, percutaneous coronary intervention, and mechanical circulatory support, despite the highest rates of extracorporeal membrane oxygenation use. Compared with the Northeast, in-hospital mortality was lower in the Midwest (adjusted odds ratio [aOR], 0.96 [95% CI, 0.93–0.98]; P P =0.001) but higher in the South (aOR, 1.04 [95% CI, 1.01–1.06]; P =0.002). The Midwest (aOR, 1.68 [95% CI, 1.62–1.74]; P P P Conclusions: There remain significant regional disparities in the management and outcomes of AMI-CS. more...
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- 2020
31. Incidence, Trends and Outcomes of Type 2 Myocardial Infarction in a Community Cohort
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Allan S. Jaffe, Bernard J. Gersh, Rajiv Gulati, Charanjit S. Rihal, Ryan J. Lennon, Malcolm R. Bell, Amir Lerman, Bradley Lewis, Claire E. Raphael, Véronique L. Roger, Yader Sandoval, and Mandeep Singh more...
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medicine.medical_specialty ,Oxygen supply ,Myocardial ischemia ,business.industry ,Incidence (epidemiology) ,MEDLINE ,medicine.disease ,Article ,Physiology (medical) ,Internal medicine ,Incidence trends ,Cohort ,Epidemiology ,medicine ,Cardiology ,Myocardial infarction ,Cardiology and Cardiovascular Medicine ,business - Abstract
Background: Type 2 myocardial infarction (T2MI) occurs because of an acute imbalance in myocardial oxygen supply and demand in the absence of atherothrombosis. Despite being frequently encountered in clinical practice, the population-based incidence and trends remain unknown, and the long-term outcomes are incompletely characterized. Methods: We prospectively recruited residents of Olmsted County, Minnesota, who experienced an event associated with a cardiac troponin T >99th percentile of a normal reference population (≥0.01 ng/mL) between January 1, 2003, and December 31, 2012. Events were retrospectively classified into type 1 myocardial infarction (T1MI, atherothombotic event), T2MI, or myocardial injury (troponin rise not meeting criteria for myocardial infarction [MI]) using the universal definition. Outcomes were long-term all-cause and cardiovascular mortality and recurrent MI. T2MI was further subclassified by the inciting event for supply/demand mismatch. Results: A total of 5460 patients had at least one cardiac troponin T ≥0.01 ng/mL; 1365 of these patients were classified as index T1MI (age, 68.5±14.8 years; 63% male) and 1054 were classified as T2MI (age, 73.7±15.8 years; 46% male). The annual incidence of T1MI decreased markedly from 202 to 84 per 100 000 persons between 2003 and 2012 ( P P =0.02). In comparison with patients with T1MI, patients with T2MI had higher long-term all-cause mortality after adjustment for age and sex, driven by early and noncardiovascular death. Rates of cardiovascular death were similar after either type of MI (hazard ratio, 0.8 [95% CI, 0.7–1.0], P =0.11). Subclassification of T2MI by cause demonstrated a more favorable prognosis when the principal provoking mechanism was arrhythmia, in comparison with postoperative status, hypotension, anemia, and hypoxia. After index T2MI, the most common MI during follow-up was a recurrent T2MI, whereas the occurrence of a new T1MI was relatively rare (estimated rates at 5 years, 9.7% and 1.7%). Conclusions: There has been an evolution in the type of MI occurring in the community over a decade, with the incidence of T2MI now being similar to T1MI. Mortality after T2MI is higher and driven by early and noncardiovascular death. The provoking mechanism of supply/demand mismatch affects long-term survival. These findings underscore the healthcare burden of T2MI and provide benchmarks for clinical trial design. more...
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- 2020
32. Temporal Trends and Outcomes of Percutaneous Coronary Interventions in Nonagenarians
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David R. Holmes, Kashish Goel, Tanush Gupta, Dhaval Kolte, Rajiv Gulati, Deepak L. Bhatt, Sahil Khera, Charanjit S. Rihal, and Malcolm R. Bell
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medicine.medical_specialty ,Percutaneous ,business.industry ,medicine.medical_treatment ,Psychological intervention ,Percutaneous coronary intervention ,030204 cardiovascular system & hematology ,medicine.disease ,humanities ,03 medical and health sciences ,surgical procedures, operative ,0302 clinical medicine ,Conventional PCI ,Emergency medicine ,Life expectancy ,Medicine ,In patient ,cardiovascular diseases ,030212 general & internal medicine ,Cardiology and Cardiovascular Medicine ,business ,Stroke ,Major bleeding - Abstract
Objectives This study sought to assess temporal trends and outcomes of percutaneous coronary intervention (PCI) in nonagenarians. Background With increasing life expectancy, nonagenarians requiring PCI are increasing even though outcomes data are limited. Methods The National Inpatient Sample was used to identify all hospitalizations for PCI in patients aged ≥90 years from January 1, 2003, to December 31, 2014. The primary outcome was in-hospital mortality. Results Nonagenarians (n = 69,271) constituted 0.9% of all PCI hospitalizations, increasing from 0.6% in 2003 to 2004 to 1.4% in 2013 to 2014 (ptrend Conclusions The rate of in-hospital mortality, major bleeding, vascular complications, and stroke after PCI in nonagenarians changed significantly from 2003 to 2014. This study provides a benchmark for discussion of PCI-related risks among physicians, patients, and families. more...
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- 2018
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33. Characteristics and long term outcomes of patients with acute coronary syndromes due to culprit left main coronary artery disease treated with percutaneous coronary intervention
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Dilip P. Pillai, S. Michael Gharacholou, Gary E. Lane, Charanjit S. Rihal, Malcolm R. Bell, Gurpreet S. Sandhu, Freddy Del-Carpio Munoz, Nkechinyere N. Ijioma, Patricia A. Pellikka, Jorge A. Brenes-Salazar, Mandeep Singh, Peter M. Pollak, Ryan J. Lennon, Rajiv Gulati, and Arashk Motiei more...
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Male ,medicine.medical_specialty ,Acute coronary syndrome ,Time Factors ,medicine.medical_treatment ,030204 cardiovascular system & hematology ,Coronary Angiography ,Culprit ,Electrocardiography ,03 medical and health sciences ,Percutaneous Coronary Intervention ,0302 clinical medicine ,Risk Factors ,Internal medicine ,Humans ,Medicine ,Hospital Mortality ,Prospective Studies ,Registries ,cardiovascular diseases ,030212 general & internal medicine ,Myocardial infarction ,Acute Coronary Syndrome ,Aged ,medicine.diagnostic_test ,business.industry ,Unstable angina ,Incidence ,Cardiogenic shock ,Coronary Stenosis ,Percutaneous coronary intervention ,medicine.disease ,Coronary Vessels ,United States ,Treatment Outcome ,surgical procedures, operative ,Echocardiography ,Conventional PCI ,Cardiology ,Female ,Cardiology and Cardiovascular Medicine ,business ,Follow-Up Studies - Abstract
Patients with acute coronary syndrome (ACS) due to unprotected culprit left main coronary artery disease (LMCAD) treated with percutaneous coronary intervention (PCI) are rare, high-risk, and not represented in trials. Data regarding long term outcome after PCI are limited.Between January 2000 and December 2014, there were 8,794 patients hospitalized with unstable angina/non-ST elevation myocardial infarction (UA/NSTEMI) or ST-elevation myocardial infarction (STEMI) treated with PCI at our institution; of these, 83 (0.94%) patients were identified as having culprit LMCAD ACS.Of the 83 patients with unprotected LMCAD ACS, 40 patients presented with STEMI and 43 patients presented with UA/NSTEMI. As compared to LM UA/NSTEMI, LM STEMI patients were younger and had less hypertension, with a trend towards greater frequency of cardiogenic shock. Distal LM involvement was common in both groups and did not differ by ACS type. In-hospital mortality was 33% in LM STEMI and 9% in LM UA/NSTEMI (P = .009). Over median follow up of 6.3 years, long term survival rates in both groups were similar (46% for STEMI vs 51% for UA/NSTEMI; P = .50 by log-rank).Unprotected culprit LMCAD ACS necessitating PCI is uncommon, occurring in1% of cases, but is associated with reduced survival, with long term follow-up noting continued and similar risk of death regardless of index ACS type. more...
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- 2018
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34. A Dangerous Dilemma
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Hartzell V. Schaff, Sorin V. Pislaru, Patricia J.M. Best, Malcolm R. Bell, John Nan, and Nicholas Y. Tan
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medicine.medical_specialty ,PFO, patent foramen ovale ,TTE, transthoracic echocardiogram ,Case Report ,VTE, venous thromboembolism ,congenital heart defect ,stomatognathic system ,Clinical Case ,Internal medicine ,medicine ,Diseases of the circulatory (Cardiovascular) system ,echocardiography ,cardiovascular diseases ,Thrombus ,Pregnancy ,business.industry ,PE - Pulmonary embolism ,digestive, oral, and skin physiology ,food and beverages ,Systemic embolism ,medicine.disease ,PFO - Patent foramen ovale ,thrombus ,RC666-701 ,DVT, deep venous thrombosis ,PE, pulmonary embolism ,Patent foramen ovale ,Cardiology ,pregnancy ,Cardiology and Cardiovascular Medicine ,business ,Venous thromboembolism - Abstract
Pregnancy is associated with venous thromboembolism. Occasionally, thrombus can become entrapped across a patent foramen ovale, with risk of systemic embolism. This report presents a case of a pregnant woman who had thrombus in transit diagnosed by echocardiography, which was successfully removed by surgical thrombectomy. (Level of Difficulty: Intermediate.), Graphical abstract, Pregnancy is associated with venous thromboembolism. Occasionally, thrombus can become entrapped across a patent foramen ovale, with risk of… more...
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- 2019
35. Multiarterial grafts improve the rate of early major adverse cardiac and cerebrovascular events in patients undergoing coronary revascularization: analysis of 12 615 patients with multivessel disease†
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Joseph A. Dearani, Lyle D. Joyce, Chaim Locker, Robert L. Frye, John M. Stulak, Ryan J. Lennon, Kevin L. Greason, Amir Lerman, Zhuo Li, Richard C. Daly, Hartzell V. Schaff, Sameh M. Said, Malcolm R. Bell, and Alberto Pochettino more...
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Male ,Bare-metal stent ,Cardiac Catheterization ,Databases, Factual ,medicine.medical_treatment ,Coronary Artery Disease ,030204 cardiovascular system & hematology ,Coronary Angiography ,Severity of Illness Index ,Cohort Studies ,Postoperative Complications ,0302 clinical medicine ,Medicine ,Hospital Mortality ,030212 general & internal medicine ,Myocardial infarction ,Angioplasty, Balloon, Coronary ,Coronary Artery Bypass ,Stroke ,Drug-Eluting Stents ,General Medicine ,Middle Aged ,Survival Rate ,Treatment Outcome ,surgical procedures, operative ,Cardiology ,Female ,Cardiology and Cardiovascular Medicine ,Pulmonary and Respiratory Medicine ,medicine.medical_specialty ,Internal thoracic artery ,Risk Assessment ,03 medical and health sciences ,medicine.artery ,Internal medicine ,Angioplasty ,Humans ,Saphenous Vein ,cardiovascular diseases ,Mammary Arteries ,Propensity Score ,Aged ,Retrospective Studies ,Analysis of Variance ,business.industry ,Percutaneous coronary intervention ,Stent ,medicine.disease ,Surgery ,Logistic Models ,Multivariate Analysis ,Conventional PCI ,business ,Follow-Up Studies - Abstract
OBJECTIVES Our goal was to compare the rates of in-hospital and 30-day major adverse cardiac and cerebrovascular events (MACCE) including death, stroke, myocardial infarction and repeat revascularization in patients with multivessel disease undergoing multiarterial (MultArt) coronary artery bypass grafting (CABG) with the left internal mammary artery/saphenous vein (LIMA/SV) CABG or percutaneous coronary intervention (PCI). METHODS From 1 January 1993 to 31 December 2009, 12 615 consecutive patients underwent isolated primary CABG (n = 6667) with LIMA/SV (n = 5712) or MultArt (n = 955) or were treated by PCI (n = 5948) with balloon angioplasty (n = 1020), bare metal stent (n = 3242), and drug-eluting stent (n = 1686). We excluded patients with acute myocardial infarction. We matched the CABG group with the 3 PCI subgroups, and the PCI group with the 2 CABG subgroups. Multivariable analyses were used to evaluate the impact of CABG versus PCI and their subgroups on early MACCE. RESULTS Unadjusted early MACCE were lower for MultArt (1.5%) than for LIMA/SV (4.5%, P more...
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- 2017
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36. Reoperation for Coronary Artery Bypass Grafting Surgery: Outcomes and Considerations for Expanding Interventional Procedures
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Malcolm R. Bell, Kevin L. Greason, Hartzell V. Schaff, David L. Joyce, Joseph A. Dearani, Robert J. Widmer, Lyle D. Joyce, John M. Stulak, Simon Maltais, and Richard C. Daly
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Adult ,Male ,Reoperation ,Pulmonary and Respiratory Medicine ,medicine.medical_specialty ,Kaplan-Meier Estimate ,030204 cardiovascular system & hematology ,Risk Assessment ,law.invention ,03 medical and health sciences ,Postoperative Complications ,0302 clinical medicine ,Risk Factors ,law ,Diabetes mellitus ,Internal medicine ,medicine ,Cardiopulmonary bypass ,Humans ,Myocardial infarction ,Coronary Artery Bypass ,Stroke ,Aged ,Retrospective Studies ,Aged, 80 and over ,Cardiopulmonary Bypass ,Vascular disease ,business.industry ,Hazard ratio ,Retrospective cohort study ,Middle Aged ,medicine.disease ,Surgery ,medicine.anatomical_structure ,030228 respiratory system ,Multivariate Analysis ,Cardiology ,Female ,Cardiology and Cardiovascular Medicine ,business ,Artery - Abstract
Owing to an inevitable degeneration of grafts over time, patients may require consideration for repeat coronary artery bypass graft (CABG) surgery. As our understanding of preoperative risks associated with redo CABG surgery is limited and availability of data is limited to historical cohorts, we sought to evaluate our contemporary 20-year experience with this challenging patient population.Between January 1993 and June 2014, 748 patients underwent redo CABG surgery at our institution. Median age at reoperation was 69 years (range, 36 to 88), and 644 (86%) were male. Median follow-up was 15.1 years and was 100% complete. Preoperatively, 191 patients (26%) had diabetes mellitus, 562 (75%) had hypertension, 206 (28%) had peripheral vascular disease with 121 (16%) having a history of cerebrovascular disease, and 459 (61%) had prior myocardial infarction. Number of prior CABG operations was 1 in 682 patients (91%), 2 in 62 patients (8%), and 3 in 4 patients (1%).All patients underwent isolated redo CABG surgery; all 748 (100%) procedures were performed using cardiopulmonary bypass, with median time on pump of 95 minutes (maximum, 378) and cross-clamp time of 48 minutes (maximum, 176). There were 47 early deaths (6%); early nonfatal morbidity included renal failure in 51 patients (7%), stroke in 15 (2%), and pneumonia in 22 (3%). Overall 1-, 5-, and 10-year survival was 89%, 77%, and 51%, respectively. Age (hazard ratio [HR] 1.74, p 0.001), diabetes (HR 1.51, p0.001), peripheral vascular disease (HR 1.51, p0.001), and end-stage renal disease with dialysis (HR 11.85, p0.001) were associated with increased long-term mortality, whereas higher left ventricular ejection fraction (per 10% increase) was protective (HR 0.78, p0.001).Redo CABG can be performed safely with low early and late morbidity and mortality. Important predictors of long-term mortality such as age, diabetes, renal disease, and peripheral vascular disease were identified and should guide the treatment strategy chosen for this challenging group of patients. more...
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- 2017
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37. Head and Neck Radiation Dose and Radiation Safety for Interventional Physicians
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Kenneth A. Fetterly, Michael P. Grams, Malcolm R. Bell, Beth A. Schueler, Glenn M. Sturchio, and Rajiv Gulati
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Models, Anatomic ,Thorax ,medicine.medical_specialty ,030204 cardiovascular system & hematology ,Radiation ,Radiation Dosage ,Radiography, Interventional ,Risk Assessment ,Imaging phantom ,030218 nuclear medicine & medical imaging ,03 medical and health sciences ,Radiation Protection ,0302 clinical medicine ,Protective Clothing ,Risk Factors ,Occupational Exposure ,Lens, Crystalline ,Radiologists ,medicine ,Humans ,Scattering, Radiation ,Radiochromic film ,Radiation Injuries ,Head and neck ,Occupational Health ,Dosimeter ,Radiation Dosimeters ,business.industry ,Radiation dose ,Brain ,Protective Factors ,Radiation Exposure ,Occupational Injuries ,Head Protective Devices ,Radiology ,Radiation protection ,Eye Protective Devices ,Cardiology and Cardiovascular Medicine ,Nuclear medicine ,business ,Neck - Abstract
Objectives The first aim of this study was to assess the magnitude of radiation dose to tissues of the head and neck of physicians performing x-ray-guided interventional procedures. The second aim was to assess protection of tissues of the head offered by select wearable radiation safety devices. Background Radiation dose to tissues of the head and neck is of significant interest to practicing interventional physicians. However, methods to estimate radiation dose are not generally available, and furthermore, some of the available research relating to protection of these tissues is misleading. Methods Using a single representative geometry, scatter radiation dose to a humanoid phantom was measured using radiochromic film and normalized by the radiation dose to the left collar of the radioprotective thorax apron. Radiation protection offered by leaded glasses and by a radioabsorbent surgical cap was measured. Results In the test geometry, average radiation doses to the unprotected brain, carotid arteries, and ocular lenses were 8.4%, 17%, and 50% of the dose measured at the left collar, respectively. Two representative types of leaded glasses reduced dose to the ocular lens on the side of the physician from which the scatter originates by 27% to 62% but offered no protection to the contralateral eye. The radioabsorbent surgical cap reduced brain dose by only 3.3%. Conclusions A method by which interventional physicians can estimate dose to head and neck tissues on the basis of their personal dosimeter readings is described. Radiation protection of the ocular lenses by leaded glasses may be incomplete, and protection of the brain by a radioabsorbent surgical cap was minimal. more...
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- 2017
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38. Extracorporeal Membrane Oxygenation Use in Acute Myocardial Infarction in the United States, 2000-2014
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Charanjit S. Rihal, Gregory W. Barsness, Malcolm R. Bell, Abhiram Prasad, Gurpreet S. Sandhu, Mandeep Singh, Allan S. Jaffe, John M. Stulak, Bernard J. Gersh, David R. Holmes, Shannon M. Dunlay, Gregory J. Schears, Saraschandra Vallabhajosyula, and Mackram F. Eleid more...
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Male ,medicine.medical_specialty ,Time Factors ,Databases, Factual ,medicine.medical_treatment ,Myocardial Infarction ,Article ,Ventricular Function, Left ,Extracorporeal Membrane Oxygenation ,Percutaneous Coronary Intervention ,Risk Factors ,Internal medicine ,medicine ,Extracorporeal membrane oxygenation ,Humans ,Myocardial infarction ,cardiovascular diseases ,Hospital Mortality ,Practice Patterns, Physicians' ,National data ,Aged ,Retrospective Studies ,Patient discharge ,Aged, 80 and over ,Intra-Aortic Balloon Pumping ,business.industry ,Recovery of Function ,Middle Aged ,medicine.disease ,United States ,surgical procedures, operative ,Treatment Outcome ,Cardiology ,Female ,Heart-Assist Devices ,Cardiology and Cardiovascular Medicine ,business - Abstract
Background: Extracorporeal membrane oxygenation (ECMO) is increasingly used in acute myocardial infarction (AMI); however, there are limited large-scale national data. Methods: Using the National Inpatient Sample database from 2000 to 2014, a retrospective cohort of AMI utilizing ECMO was identified. Use of percutaneous coronary intervention, intra-aortic balloon pump, and percutaneous left ventricular assist device (LVAD) was also identified in this population. Outcomes of interest included temporal trends in utilization of ECMO alone and with concomitant procedures (percutaneous coronary intervention, intra-aortic balloon pump, and percutaneous LVAD), in-hospital mortality, and resource utilization. Results: In ≈9 million AMI admissions, ECMO was used in 2962 ( Conclusions: In AMI admissions, a steady increase was noted in the utilization of ECMO alone and with concomitant procedures (percutaneous coronary intervention, intra-aortic balloon pump, and percutaneous LVAD). In-hospital mortality remained high in AMI admissions treated with ECMO. more...
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- 2019
39. Incidental Anomalous Left Coronary Artery in a Transplanted Heart
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Saraschandra Vallabhajosyula, Sri Harsha Patlolla, and Malcolm R. Bell
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Coronary angiography ,lcsh:Diseases of the circulatory (Cardiovascular) system ,medicine.medical_specialty ,business.industry ,Transplanted heart ,Case Report ,030204 cardiovascular system & hematology ,CONGENITAL CARDIAC ANOMALY ,030218 nuclear medicine & medical imaging ,Transplantation ,03 medical and health sciences ,0302 clinical medicine ,Donor heart ,Left coronary artery ,medicine.anatomical_structure ,lcsh:RC666-701 ,Internal medicine ,medicine.artery ,Cardiology ,Medicine ,Cardiology and Cardiovascular Medicine ,business ,Coronary sinus ,Artery - Abstract
Anomalous coronary artery is an uncommon congenital cardiac anomaly that is often detected incidentally on coronary angiography. It has rarely been reported in the donor heart of patients who have undergone cardiac transplantation. Here, we report a case of a 72-year-old patient who received a second heart transplant and has been identified to have an anomalous left main coronary artery originating from the right coronary sinus on postoperative coronary angiography. more...
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- 2019
40. Transradial Artery Access Complications
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Malcolm R. Bell, Yader Sandoval, and Rajiv Gulati
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Coronary angiography ,medicine.medical_specialty ,Reduced risk ,medicine.medical_treatment ,Arterial Occlusive Diseases ,Hemorrhage ,Punctures ,Risk Factors ,Internal medicine ,medicine.artery ,Catheterization, Peripheral ,medicine ,Humans ,Radial artery ,Muscle Cramp ,Randomized Controlled Trials as Topic ,business.industry ,Percutaneous coronary intervention ,Vascular System Injuries ,Prognosis ,medicine.anatomical_structure ,Vasoconstriction ,Radial Artery ,Cardiology ,medicine.symptom ,Cardiology and Cardiovascular Medicine ,business ,Muscle cramp ,Artery - Abstract
Transradial access (TRA) is favored over transfemoral access for performing coronary angiography and percutaneous coronary intervention due to the reduced risk for vascular and bleeding complications and the documented survival benefit in ST-segment–elevation myocardial infarction patients who undergo primary percutaneous coronary intervention. TRA complications can be categorized as intra- or postprocedural and further categorized as related to bleeding or nonbleeding issues. Major intra- and postprocedural complications such as radial artery perforation and compartment syndrome are rare following TRA. Their occurrence, however, can be associated with morbid consequences, including requirement for surgical intervention if not identified and treated promptly. Nonbleeding complications such as radial artery spasm and radial artery occlusion are typically less morbid but occur much more frequently. Strategies to prevent TRA complications are essential and include the use of contemporary access techniques that limit arterial injury. This document summarizes contemporary techniques to prevent, identify, and manage TRA complications. more...
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- 2019
41. Intravascular ultrasound, optical coherence tomography, and fractional flow reserve use in acute myocardial infarction
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Amir Lerman, Gregory W. Barsness, Stephanie El Hajj, Saraschandra Vallabhajosyula, Abhiram Prasad, David R. Holmes, Charanjit S. Rihal, and Malcolm R. Bell
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Male ,Cardiac Catheterization ,Time Factors ,Databases, Factual ,medicine.medical_treatment ,Myocardial Infarction ,Fractional flow reserve ,030204 cardiovascular system & hematology ,Coronary Angiography ,0302 clinical medicine ,Intravascular ultrasound ,Medicine ,030212 general & internal medicine ,Myocardial infarction ,Hospital Mortality ,Hospital Costs ,medicine.diagnostic_test ,Cardiogenic shock ,General Medicine ,Middle Aged ,Patient Discharge ,Fractional Flow Reserve, Myocardial ,surgical procedures, operative ,Treatment Outcome ,Cohort ,Cardiology ,Female ,Cardiology and Cardiovascular Medicine ,Tomography, Optical Coherence ,medicine.medical_specialty ,03 medical and health sciences ,Percutaneous Coronary Intervention ,Predictive Value of Tests ,Internal medicine ,Humans ,Radiology, Nuclear Medicine and imaging ,cardiovascular diseases ,Healthcare Disparities ,Ultrasonography, Interventional ,Aged ,Retrospective Studies ,Inpatients ,business.industry ,Percutaneous coronary intervention ,Retrospective cohort study ,Length of Stay ,medicine.disease ,United States ,Conventional PCI ,business - Abstract
BACKGROUND There are limited data on the use of intravascular ultrasound (IVUS), optical coherence tomography (OCT), and fractional flow reserve (FFR) during acute myocardial infarction (AMI). OBJECTIVES To assess the temporal trends of IVUS, OCT, and FFR use in AMI. METHODS A retrospective cohort study from the National Inpatient Sample (2004-2014) was designed to include AMI admissions that received coronary angiography. Administrative codes were used to identify percutaneous coronary intervention (PCI), IVUS, OCT, and FFR. Outcomes included temporal trends, inhospital mortality and resource utilization stratified by IVUS, OCT, or FFR use. RESULTS In 4,419,973 AMI admissions, IVUS, OCT, and FFR were used in 2.6%, 0.1%, and 0.6%, respectively. There was a 22-fold, 118-fold, and 33-fold adjusted increase in IVUS, OCT, and FFR use, respectively, in 2014 compared to the first year of use. Non-ST-elevation AMI presentation, male sex, private insurance coverage, admission to a large urban hospital, and absence of cardiac arrest and cardiogenic shock were associated with higher IVUS, OCT, or FFR use. PCI was performed in 83.2% of the IVUS, OCT, or FFR cohort compared to 64.2% of the control group (p more...
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- 2019
42. Derivation and Validation of a Novel Cardiac Intensive Care Unit Admission Risk Score for Mortality
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Dennis H. Murphree, Joseph G. Murphy, Brandon M. Wiley, Nandan S. Anavekar, Mark T. Keegan, Malcolm R. Bell, Jacob C. Jentzer, David A. Morrow, Courtney Bennett, and Gregory W. Barsness
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Male ,medicine.medical_specialty ,Time Factors ,Databases, Factual ,Heart Diseases ,Health Status ,030204 cardiovascular system & hematology ,Risk Assessment ,Decision Support Techniques ,03 medical and health sciences ,0302 clinical medicine ,Patient Admission ,Predictive Value of Tests ,Risk Factors ,medicine ,Humans ,030212 general & internal medicine ,Derivation ,Hospital Mortality ,risk scores ,Original Research ,Aged ,Retrospective Studies ,Aged, 80 and over ,Framingham Risk Score ,cardiac intensive care unit ,Quality and Outcomes ,business.industry ,coronary care unit ,Reproducibility of Results ,Middle Aged ,Prognosis ,mortality ,Intensive Care Units ,Emergency medicine ,Coronary care unit ,Female ,Mortality/Survival ,Cardiology and Cardiovascular Medicine ,business ,Health Services and Outcomes Research - Abstract
Background There are no risk scores designed specifically for mortality risk prediction in unselected cardiac intensive care unit ( CICU ) patients. We sought to develop a novel CICU ‐specific risk score for prediction of hospital mortality using variables available at the time of CICU admission. Methods and Results A database of CICU patients admitted from January 1, 2007 to April 30, 2018 was divided into derivation and validation cohorts. The top 7 predictors of hospital mortality were identified using stepwise backward regression, then used to develop the Mayo CICU Admission Risk Score (M‐ CARS ), with integer scores ranging from 0 to 10. Discrimination was assessed using area under the receiver‐operator curve analysis. Calibration was assessed using the Hosmer–Lemeshow statistic. The derivation cohort included 10 004 patients and the validation cohort included 2634 patients (mean age 67.6 years, 37.7% females). Hospital mortality was 9.2%. Predictor variables included in the M‐ CARS were cardiac arrest, shock, respiratory failure, Braden skin score, blood urea nitrogen, anion gap and red blood cell distribution width at the time of CICU admission. The M‐ CARS showed a graded relationship with hospital mortality (odds ratio 1.84 for each 1‐point increase in M‐ CARS , 95% CI 1.78–1.89). In the validation cohort, the M‐ CARS had an area under the receiver‐operator curve of 0.86 for hospital mortality, with good calibration ( P =0.21). The 47.1% of patients with M‐ CARS CARS >6 had hospital mortality of 51.6%. Conclusions Using 7 variables available at the time of CICU admission, the M‐ CARS can predict hospital mortality in unselected CICU patients with excellent discrimination. more...
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- 2019
43. Safety and Risk of Major Complications With Diagnostic Cardiac Catheterization
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Ryan J. Lennon, Atta Behfar, Daniel J. Crusan, Abdallah El Sabbagh, Amir Lerman, Malcolm R. Bell, Amrit Kanwar, Jae Yoon Park, Mohammed Al-Hijji, Mandeep Singh, David R. Holmes, and Rajiv Gulati
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Adult ,Male ,medicine.medical_specialty ,Cardiac Catheterization ,Percutaneous ,Time Factors ,medicine.medical_treatment ,Coronary Angiography ,Pericardial effusion ,Aortography ,Risk Assessment ,Percutaneous Coronary Intervention ,Predictive Value of Tests ,Risk Factors ,Internal medicine ,medicine ,Humans ,Myocardial infarction ,Hospital Mortality ,Coronary Artery Bypass ,Stroke ,Cardiac catheterization ,Aged ,medicine.diagnostic_test ,business.industry ,Incidence (epidemiology) ,Middle Aged ,medicine.disease ,Cardiovascular Diseases ,Angiography ,Cardiology ,Female ,Tamponade ,Patient Safety ,Cardiology and Cardiovascular Medicine ,business - Abstract
Background: We aim to study the incidence of major complications related to procedure defined as in-hospital death, myocardial infarction, stroke, pericardial effusion or tamponade, percutaneous coronary intervention due to iatrogenic coronary dissection, or unplanned bypass surgery within 72 hours after diagnostic left heart catheterization (LHC; primary end point). Furthermore, all causes of in-hospital death after LHC were adjudicated and reported (secondary end point). Methods and Results: Diagnostic LHC procedures (aortic angiography; coronary, including graft, angiography; and left ventricular angiography) from January 1, 2002, through December 31, 2013, were identified using the clinical scheduling system at Mayo Clinic, Rochester, and complications were identified through electronic records. International Classification of Diseases, Ninth Revision billing codes were used. Registration was queried to identify all-cause mortality. All events were reviewed and adjudicated. There were 43 786 diagnostic LHC procedures; 97.3% were coronary angiograms. The mean age of patients was 64.5 years (13.6), and the majority were male (61.5%). Primary end point was seen in 36 (0.082%) procedures or 8.2 of 10 000 LHCs. Combined right sided procedures with LHC did not increase the risk of major complications. Cardiogenic and septic shock, cardiac arrhythmia, and postsurgical complication were the most common causes of in-hospital death after LHC. Conclusions: The overall rates of major complications related to diagnostic cardiac catheterization procedures are extremely rare. The majority of the deaths occurring post-diagnostic LHC procedures were secondary to acute illness rather than directly related to diagnostic procedure. more...
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- 2019
44. COMPARING RADIAL AND FEMORAL APPROACHES IN PATIENTS WITH SEVERE AORTIC STENOSIS UNDERGOING PERCUTANEOUS CORONARY INTERVENTION PRIOR TO TRANSCATHETER AORTIC VALVE REPLACEMENT
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Mandeep Singh, Abdallah El Sabbagh, Rayan Suliman, Mackram F. Eleid, Shahyar M. Gharacholou, Yader Sandoval, Malcolm R. Bell, David R. Holmes, Mohammed Al-Khouli, Salman Farhat, Mohammed Al-Hijji, Mayra Guerrero, Charanjit S. Rihal, Peter M. Pollak, Rajiv Gulati, and Keniel F. Pierre more...
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medicine.medical_specialty ,Transcatheter aortic ,business.industry ,medicine.medical_treatment ,Percutaneous coronary intervention ,medicine.disease ,Stenosis ,Valve replacement ,Internal medicine ,medicine ,Cardiology ,In patient ,Cardiology and Cardiovascular Medicine ,business - Published
- 2021
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45. USE OF THE ZWOLLE SCORE FOR POST-STEMI TRIAGE: A SINGLE CENTER EXPERIENCE
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Robert Ward, Gregory W. Barsness, Jacob C. Jentzer, John Nan, and Malcolm R. Bell
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business.industry ,Medicine ,Medical emergency ,Cardiology and Cardiovascular Medicine ,business ,Single Center ,medicine.disease ,Triage - Published
- 2021
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46. INTRACORONARY AUTOLOGOUS CD34+ CELL THERAPY FOR TREATMENT OF CORONARY ENDOTHELIAL DYSFUNCTION IN PATIENTS WITH ANGINA AND NON-OBSTRUCTIVE CORONARY ARTERIES: IMPROVE-CED TRIAL
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John P. Bois, Amir Lerman, Mary L. Solseth, Rajiv Gulati, Abhiram Prasad, Michel T. Corban, Faten Sebaali, Megha Prasad, Takumi Toya, Diana Albers, Jeffrey L. Winters, Allan B. Dietz, Charanjit S. Rihal, Patricia J.M. Best, Lilach O. Lerman, and Malcolm R. Bell more...
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medicine.medical_specialty ,business.industry ,Cd34 cells ,medicine.disease ,Angina ,Coronary arteries ,medicine.anatomical_structure ,Internal medicine ,Cardiology ,Medicine ,In patient ,Endothelial dysfunction ,Cardiology and Cardiovascular Medicine ,business - Published
- 2021
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47. Relation between fractional flow reserve value of coronary lesions with deferred revascularization and cardiovascular outcomes in non-diabetic and diabetic patients
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Tao Sun, Malcolm R. Bell, Joerg Herrmann, Yasushi Matsuzawa, Rajiv Gulati, Taek Geun Kwon, Ryan J. Lennon, Zhi Liu, Shi-Wei Yang, Jing Li, Daniel J. Crusan, Lilach O. Lerman, Ming Zhang, and Amir Lerman more...
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Male ,medicine.medical_specialty ,medicine.medical_treatment ,Coronary Artery Disease ,Fractional flow reserve ,030204 cardiovascular system & hematology ,Revascularization ,Cohort Studies ,Coronary artery disease ,03 medical and health sciences ,0302 clinical medicine ,Diabetes mellitus ,Internal medicine ,Diabetes Mellitus ,Myocardial Revascularization ,medicine ,Humans ,Registries ,030212 general & internal medicine ,Myocardial infarction ,Aged ,business.industry ,Hazard ratio ,Percutaneous coronary intervention ,Middle Aged ,medicine.disease ,Surgery ,Fractional Flow Reserve, Myocardial ,Treatment Outcome ,Conventional PCI ,Cardiology ,Female ,Cardiology and Cardiovascular Medicine ,business ,Follow-Up Studies - Abstract
Background FFR of deferred PCI lesions can predict future cardiovascular events. However, the prognostic utility of FFR remains unclear in diabetic patients in view of the potential impact of the diffuse nature of vascular disease process. We aimed to study the relation between fractional flow reserve (FFR) values and long-term outcomes of diabetic and non-diabetic patients with deferred percutaneous coronary intervention (PCI). Methods Patients with FFR assessment and deferred PCI (n=630) were enrolled and stratified according to diabetes mellitus (DM) status and FFR values. Patients were followed over a median of 39months. Cox proportional hazard regression models were used to analyze the association between clinical endpoints and clinical factors such as DM and FFR. Results In non-diabetics (n=450), higher FFR values were associated with less cardiovascular events (hazard ratio (HR) for death and myocardial infarction (MI) [95% confidence interval (CI)], 0.61[0.44 to 0.86] per 0.1 increase in FFR, p=0.007; HR for revascularization [95%CI], 0.66[0.49 to 0.9] per 0.1 increase in FFR, p=0.006). In diabetics (n=180), there was no difference in death and MI across the range of FFR values. Among those patients with an FFR >0.85, diabetics had a more than two-fold higher risk of death and MI than non-diabetics (HR [95% CI], 2.20 [1.19 to 4.01], p=0.015). Conclusion Among non-diabetic patients with deferred PCI, a higher FFR was associated with lower rates of death, MI and revascularization. On the contrary in diabetic patients with deferred revascularization, FFR was not able to differentiate the risk of cardiovascular events. more...
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- 2016
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48. Pharmacoinvasive and Primary Percutaneous Coronary Intervention Strategies in ST-Elevation Myocardial Infarction (from the Mayo Clinic STEMI Network)
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Konstantinos C. Siontis, Bernard J. Gersh, Malcolm R. Bell, R. Scott Wright, Jody L. Holmen, Ryan J. Lennon, and Gregory W. Barsness
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Male ,medicine.medical_specialty ,Time Factors ,Minnesota ,medicine.medical_treatment ,030204 cardiovascular system & hematology ,Electrocardiography ,03 medical and health sciences ,Percutaneous Coronary Intervention ,0302 clinical medicine ,Fibrinolytic Agents ,Internal medicine ,Fibrinolysis ,medicine ,Humans ,Thrombolytic Therapy ,Hospital Mortality ,Registries ,030212 general & internal medicine ,Myocardial infarction ,Retrospective Studies ,business.industry ,Cardiogenic shock ,Hazard ratio ,Percutaneous coronary intervention ,Retrospective cohort study ,Middle Aged ,medicine.disease ,Confidence interval ,Survival Rate ,Treatment Outcome ,Practice Guidelines as Topic ,Conventional PCI ,Cardiology ,ST Elevation Myocardial Infarction ,Female ,Cardiology and Cardiovascular Medicine ,business ,Follow-Up Studies - Abstract
The effectiveness of a pharmacoinvasive strategy consisting of fibrinolysis and transfer for percutaneous coronary intervention (PCI) compared to primary PCI (PPCI) in patients presenting to non-PCI-capable hospitals with ST-elevation myocardial infarction (STEMI) is not well defined. We analyzed data from the Mayo Clinic STEMI database of patients treated with a pharmacoinvasive strategy (favored in those presenting early after symptom onset) or PPCI in a regional STEMI network from 2004 to 2012. A total of 364 and 1,337 patients were included in the pharmacoinvasive and PPCI groups, respectively. Patients in the PPCI group were older and more frequently had cardiogenic shock at the time of presentation (12.1% vs 7.7%, p = 0.018). Death from any cause occurred in 58 (16%) and 314 (23%) patients in the pharmacoinvasive and PPCI groups, respectively (median follow-up 3.9 and 4.4 years, respectively). In multivariate analyses adjusting for age, gender, and other variables for which the 2 groups differed at baseline, there was no significant difference between the 2 strategies for 30-day (hazard ratio 0.66, 95% confidence interval 0.36 to 1.21) or overall mortality (hazard ratio 0.84, 95% confidence interval 0.63 to 1.12). Shorter door-to-balloon time was associated with increased effectiveness of PPCI (p for trend = 0.015), but there was no difference between the 2 strategies even when considering only the patients with door-to-balloon time in the lowest quartile. In conclusion, fibrinolysis followed by transfer for PCI represents a reasonable alternative when PPCI is not readily available especially in patients presenting early after symptom onset. more...
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- 2016
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49. Clinical outcomes of patients with hypothyroidism undergoing percutaneous coronary intervention
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Rajiv Gulati, Amir Lerman, Malcolm R. Bell, Yasushi Matsuzawa, Hossein Gharib, Jaskanwal D. Sara, Ming Zhang, and Lilach O. Lerman
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endocrine system ,medicine.medical_specialty ,endocrine system diseases ,medicine.medical_treatment ,Myocardial Infarction ,Coronary Artery Disease ,030204 cardiovascular system & hematology ,Lower risk ,Coronary artery disease ,03 medical and health sciences ,Percutaneous Coronary Intervention ,0302 clinical medicine ,Hypothyroidism ,Risk Factors ,Interquartile range ,Internal medicine ,medicine ,Humans ,030212 general & internal medicine ,Myocardial infarction ,business.industry ,Hazard ratio ,Percutaneous coronary intervention ,medicine.disease ,Surgery ,Treatment Outcome ,Heart failure ,Conventional PCI ,Commentary ,Cardiology ,Cardiology and Cardiovascular Medicine ,business ,hormones, hormone substitutes, and hormone antagonists - Abstract
Aims The aim of this study was to investigate the association between hypothyroidism and major adverse cardiovascular and cerebral events (MACCE) in patients undergoing percutaneous coronary intervention (PCI). Methods and results Two thousand four hundred and thirty patients who underwent PCI were included. Subjects were divided into two groups: hypothyroidism ( n = 686) defined either as a history of hypothyroidism or thyroid-stimulating hormone (TSH) ≥5.0 mU/mL, and euthyroidism ( n = 1744) defined as no history of hypothyroidism and/or 0.3 mU/mL ≤ TSH < 5.0 mU/mL. Patients with hypothyroidism were further categorized as untreated ( n = 193), or those taking thyroid replacement therapy (TRT) with adequate replacement (0.3 mU/mL ≤ TSH < 5.0 mU/mL, n = 175) or inadequate replacement (TSH ≥ 5.0 mU/mL, n = 318). Adjusted hazard ratios (HRs) were calculated using Cox proportional hazards models. Median follow-up was 3.0 years (interquartile range, 0.5–7.0). After adjustment for covariates, the risk of MACCE and its constituent parts was higher in patients with hypothyroidism compared with those with euthyroidism (MACCE: HR: 1.28, P = 0.0001; myocardial infarction (MI): HR: 1.25, P = 0.037; heart failure: HR: 1.46, P = 0.004; revascularization: HR: 1.26, P = 0.0008; stroke: HR: 1.62, P = 0.04). Compared with untreated patients or those with inadequate replacement, adequately treated hypothyroid patients had a lower risk of MACCE (HR: 0.69, P = 0.005; HR: 0.78, P = 0.045), cardiac death (HR: 0.43, P = 0.008), MI (HR: 0.50, P = 0.0004; HR: 0.60, P = 0.02), and heart failure (HR: 0.50, P = 0.02; HR: 0.52, P = 0.017). Conclusion Hypothyroidism is associated with a higher incidence of MACCE compared with euthyroidism in patients undergoing PCI. Maintaining adequate control on TRT is beneficial in preventing MACCE. more...
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- 2016
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50. Early Natural History of Spontaneous Coronary Artery Dissection
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Bradley R. Lewis, Charanjit S. Rihal, Malcolm R. Bell, Bernard J. Gersh, Sharonne N. Hayes, Mandeep Singh, Marysia S. Tweet, Thomas M. Waterbury, Rajiv Gulati, Mackram F. Eleid, Patricia J.M. Best, and Amir Lerman more...
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Adult ,Male ,medicine.medical_specialty ,Acute coronary syndrome ,Time Factors ,Coronary Vessel Anomalies ,030204 cardiovascular system & hematology ,Conservative Treatment ,Coronary Angiography ,03 medical and health sciences ,0302 clinical medicine ,Hematoma ,Predictive Value of Tests ,Risk Factors ,Internal medicine ,Coronary Circulation ,medicine ,Humans ,030212 general & internal medicine ,Myocardial infarction ,Registries ,Vascular Diseases ,Artery dissection ,Retrospective Studies ,medicine.diagnostic_test ,Mechanism (biology) ,business.industry ,Middle Aged ,medicine.disease ,Coronary Vessels ,Natural history ,Treatment Outcome ,Angiography ,Cardiology ,Disease Progression ,Female ,Cardiology and Cardiovascular Medicine ,Scad ,business ,Tomography, Optical Coherence - Abstract
Background: Risks and mechanisms of extension of conservatively managed spontaneous coronary artery dissection (SCAD) remain incompletely understood. Study objectives were to (1) evaluate mechanisms of early SCAD evolution through serial angiographic analysis, and (2) determine predictors of early SCAD progression. Methods and Results: Retrospective registry study of patients with SCAD managed with an initial conservative strategy (n=240). Patients who experienced significant SCAD progression within 14 days, defined as clinical worsening plus new critical coronary obstruction on repeat angiography, were compared with remaining controls. A total of 42 of 240 (17.5%) experienced significant SCAD progression after index conservative approach; 91% by day 6. Isolated intramural hematoma (IMH) at baseline (no intimal dissection) was observed more frequently in those experiencing progression compared with controls (69.1% versus 44.4%; P =0.004). Multivariable predictors of SCAD progression included lesion severity, multivessel involvement, and isolated IMH. To investigate mechanisms of SCAD evolution, all repeat angiograms ≤14 days were compared with corresponding baselines (n=82 patient angiogram pairs). Of those with isolated IMH at baseline, 20% developed intimal dissection at repeat study. IMH was associated with greater longitudinal lesion extension (11.5 versus 2.8 mm; P =0.01), worsening Thrombolysis in Myocardial Infarction flow (−0.8 versus 0.1; P =0.003), and a nonsignificant lower rate of angiographic improvement (20.0% versus 31.3%; P =0.16) compared with the group with baseline intimal dissection. Optical coherence tomography subgroup analysis (n=17) indicated intimo-medial thickness to be lowest at the midpoint of IMH. Conclusions: Conservatively managed SCAD carries a 1:6 hazard for serious deterioration within 6 days. The risk was higher in those with isolated IMH at baseline. IMH often precedes development of intimal dissection, which has implications for mechanisms of SCAD. more...
- Published
- 2018
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