Publications by authors named "Howard Julien"

21 Publications

  • Page 1 of 1

Incremental prognostic value of visually estimated coronary artery calcium in patients undergoing positron emission tomography imaging.

Open Heart 2021 May;8(1)

Department of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA

Objective: Visually estimated coronary artery calcium (VECAC) from chest CT or attenuation correction (AC)/CT obtained during positron emission tomography (PET)-myocardial perfusion imaging (MPI) is feasible. Our aim was to determine the prognostic value of VECAC beyond conventional risk factors and PET imaging parameters, including coronary flow reserve (CFR).

Methods: We analysed 608 patients without known coronary artery disease who underwent PET-MPI between 2012 and 2016 and had AC/CT and/or chest CT images. We used Cox regression to estimate the association of VECAC categories (≤10, 11-400, >400 Agatston units (AU)) with the primary outcome of all-cause death, acute coronary syndrome or stroke (mean follow-up 4.3±1.8 years). C-statistics assessed the relationship between PET parameters and VECAC with the primary outcome.

Results: Mean age was 58±11 years, 65% were women and 67% were black. VECAC ≤10, 11-400 and >400 AU was observed in 68%, 12% and 20% of subjects, respectively. Compared with VECAC ≤10, VECAC categories 11-400 (HR 2.25, 95% CI 1.24 to 4.08) and >400 AU (HR 3.05, 95% CI 1.87 to 4.98) were associated with the primary outcome after adjusting for traditional risk factors, MPI findings and CFR. Adding VECAC to a model that included PET-MPI, CFR and clinical risk factors improved the prognostic value for the primary outcomes (c-statistic 0.71 to 0.75 with VECAC, p=0.01).

Conclusions: VECAC is a potent predictor of events beyond traditional risk factors and PET imaging markers, including CFR. These data further support the importance for routine VECAC implementation.
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http://dx.doi.org/10.1136/openhrt-2021-001648DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8108688PMC
May 2021

Association of Race/Ethnicity, Gender, and Socioeconomic Status With Sodium-Glucose Cotransporter 2 Inhibitor Use Among Patients With Diabetes in the US.

JAMA Netw Open 2021 Apr 1;4(4):e216139. Epub 2021 Apr 1.

Cardiovascular Division, Perelman School of Medicine at the University of Pennsylvania, Philadelphia.

Importance: Sodium-glucose cotransporter 2 (SGLT2) inhibitors significantly reduce deaths from cardiovascular conditions, hospitalizations for heart failure, and progression of kidney disease among patients with type 2 diabetes. Black individuals have a disproportionate burden of cardiovascular and chronic kidney disease (CKD). Adoption of novel therapeutics has been slower among Black and female patients and among patients with low socioeconomic status than among White or male patients or patients with higher socioeconomic status.

Objective: To assess whether inequities based on race/ethnicity, gender, and socioeconomic status exist in SGLT2 inhibitor use among patients with type 2 diabetes in the US.

Design, Setting, And Participants: This retrospective cohort study of commercially insured patients in the US was performed from October 1, 2015, to June 30, 2019, using the Optum Clinformatics Data Mart. Adult patients with a diagnosis of type 2 diabetes, including those with heart failure with reduced ejection fraction (HFrEF), atherosclerotic cardiovascular disease (ASCVD), or CKD, were evaluated in the analysis.

Main Outcomes And Measures: Prescription of an SGLT2 inhibitor. Multivariable logistic regression models were used to assess the association of race/ethnicity, gender, and socioeconomic status with SGLT2 inhibitor use.

Results: Of 934 737 patients with type 2 diabetes (mean [SD] age, 65.4 [12.9] years; 50.7% female; 57.6% White), 81 007 (8.7%) were treated with an SGLT2 inhibitor during the study period. Between 2015 and 2019, the percentage of patients with type 2 diabetes treated with an SGLT2 inhibitor increased from 3.8% to 11.9%. Among patients with type 2 diabetes and cardiovascular or kidney disease, the rate of SGLT2 inhibitor use increased but was lower than that among all patients with type 2 diabetes (HFrEF: 1.9% to 7.6%; ASCVD: 3.0% to 9.8%; CKD: 2.1% to 7.5%). In multivariable analyses, Black race (adjusted odds ratio [aOR], 0.83; 95% CI, 0.81-0.85), Asian race (aOR, 0.94; 95% CI, 0.90-0.98), and female gender (aOR, 0.84; 95% CI, 0.82-0.85) were associated with lower rates of SGLT2 inhibitor use, whereas higher median household income (≥$100 000: aOR, 1.08 [95% CI, 1.05-1.10]; $50 000-$99 999: aOR, 1.05 [95% CI, 1.03-1.07] vs <$50 000) was associated with a higher rate of SGLT2 inhibitor use. These results were similar among patients with HFrEF, ASCVD, and CKD.

Conclusions And Relevance: In this cohort study, use of an SGLT2 inhibitor treatment increased among patients with type 2 diabetes from 2015 to 2019 but remained low, particularly among patients with HFrEF, CKD, and ASCVD. Black and female patients and patients with low socioeconomic status were less likely to receive an SGLT2 inhibitor, suggesting that interventions to ensure more equitable use are essential to prevent worsening of well-documented disparities in cardiovascular and kidney outcomes in the US.
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http://dx.doi.org/10.1001/jamanetworkopen.2021.6139DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8050743PMC
April 2021

Radionuclide Imaging of Cardiac Amyloidosis.

PET Clin 2021 Apr 12;16(2):285-293. Epub 2021 Feb 12.

Division of Cardiovascular Medicine, Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA; Division of Nuclear Medicine and Clinical Molecular Imaging, Department of Radiology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA; Division of Cardiothoracic Imaging, Department of Radiology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA. Electronic address:

This article provides a review of the latest radiotracers for planar/single-photon emission computed tomography (SPECT) and positron emission tomography (PET)/computed tomography (CT) imaging of cardiac amyloidosis, detailing their affinity, specificity, and sensitivity for cardiac amyloidosis. There are several tracers available that have differing affinities for transthyretin (ATTR) and immunoglobulin light chain (AL), and new developments in technology have allowed for disease burden quantification. Bone scintigraphy is an excellent option for visualizing ATTR cardiac amyloidosis. Negative testing does not exclude the possibility of AL cardiac amyloidosis and absolute quantitation of amyloid burden is limited.
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http://dx.doi.org/10.1016/j.cpet.2020.12.010DOI Listing
April 2021

Patient Characteristics Associated With Telemedicine Access for Primary and Specialty Ambulatory Care During the COVID-19 Pandemic.

JAMA Netw Open 2020 12 1;3(12):e2031640. Epub 2020 Dec 1.

Division of Cardiovascular Medicine, Department of Medicine, Hospital of the University of Pennsylvania, Philadelphia.

Importance: The coronavirus disease 2019 (COVID-19) pandemic has required a shift in health care delivery platforms, necessitating a new reliance on telemedicine.

Objective: To evaluate whether inequities are present in telemedicine use and video visit use for telemedicine visits during the COVID-19 pandemic.

Design, Setting, And Participants: In this cohort study, a retrospective medical record review was conducted from March 16 to May 11, 2020, of all patients scheduled for telemedicine visits in primary care and specialty ambulatory clinics at a large academic health system. Age, race/ethnicity, sex, language, median household income, and insurance type were all identified from the electronic medical record.

Main Outcomes And Measures: A successfully completed telemedicine visit and video (vs telephone) visit for a telemedicine encounter. Multivariable models were used to assess the association between sociodemographic factors, including sex, race/ethnicity, socioeconomic status, and language, and the use of telemedicine visits, as well as video use specifically.

Results: A total of 148 402 unique patients (86 055 women [58.0%]; mean [SD] age, 56.5 [17.7] years) had scheduled telemedicine visits during the study period; 80 780 patients (54.4%) completed visits. Of 78 539 patients with completed visits in which visit modality was specified, 35 824 (45.6%) were conducted via video, whereas 24 025 (56.9%) had a telephone visit. In multivariable models, older age (adjusted odds ratio [aOR], 0.85 [95% CI, 0.83-0.88] for those aged 55-64 years; aOR, 0.75 [95% CI, 0.72-0.78] for those aged 65-74 years; aOR, 0.67 [95% CI, 0.64-0.70] for those aged ≥75 years), Asian race (aOR, 0.69 [95% CI, 0.66-0.73]), non-English language as the patient's preferred language (aOR, 0.84 [95% CI, 0.78-0.90]), and Medicaid insurance (aOR, 0.93 [95% CI, 0.89-0.97]) were independently associated with fewer completed telemedicine visits. Older age (aOR, 0.79 [95% CI, 0.76-0.82] for those aged 55-64 years; aOR, 0.78 [95% CI, 0.74-0.83] for those aged 65-74 years; aOR, 0.49 [95% CI, 0.46-0.53] for those aged ≥75 years), female sex (aOR, 0.92 [95% CI, 0.90-0.95]), Black race (aOR, 0.65 [95% CI, 0.62-0.68]), Latinx ethnicity (aOR, 0.90 [95% CI, 0.83-0.97]), and lower household income (aOR, 0.57 [95% CI, 0.54-0.60] for income <$50 000; aOR, 0.89 [95% CI, 0.85-0.92], for $50 000-$100 000) were associated with less video use for telemedicine visits. These results were similar across medical specialties.

Conclusions And Relevance: In this cohort study of patients scheduled for primary care and medical specialty ambulatory telemedicine visits at a large academic health system during the early phase of the COVID-19 pandemic, older patients, Asian patients, and non-English-speaking patients had lower rates of telemedicine use, while older patients, female patients, Black, Latinx, and poorer patients had less video use. Inequities in accessing telemedicine care are present, which warrant further attention.
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http://dx.doi.org/10.1001/jamanetworkopen.2020.31640DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7772717PMC
December 2020

Diagnostic accuracy of SPECT and PET myocardial perfusion imaging in patients with left bundle branch block or ventricular-paced rhythm.

J Nucl Cardiol 2020 Oct 20. Epub 2020 Oct 20.

Division of Cardiology, Department of Medicine, Hospital of the University of Pennsylvania, 3400 Civic Center Blvd, 11-154 South Pavilion, Philadelphia, PA, 19104, USA.

Background: The difference in diagnostic accuracy of coronary artery disease (CAD) between vasodilator SPECT and PET myocardial perfusion imaging (MPI) in patients with left bundle branch block (LBBB) or ventricular-paced rhythm (VPR) is unknown.

Methods: We identified patients with LBBB or VPR who underwent either vasodilator SPECT or PET MPI and subsequent coronary angiography. LBBB/VPR-related septal and anteroseptal defects were defined as perfusion defects involving those regions in the absence of obstructive CAD in the left anterior descending artery or left main coronary artery.

Results: Of the 55 patients who underwent coronary angiography, 38 (69%) underwent SPECT and 17 patients (31%) underwent PET. PET compared to SPECT demonstrated higher sensitivity (88% vs 60%), specificity (56% vs 14%), positive predictive value (64% vs 20%), negative predictive value (83% vs 50%), and overall superior diagnostic accuracy (AUC .72 (95% CI .50-.93) vs .37 (95% CI .20-.54), P = .01) to detect obstructive CAD. LBBB/VPR-related septal and anteroseptal defects were more common with SPECT compared to PET (septal: 72% vs 17%, P = .001; anteroseptal: 47% vs 8%, P = .02).

Conclusions: PET has higher diagnostic accuracy when compared to SPECT for the detection of obstructive CAD in patients with LBBB or VPR.
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http://dx.doi.org/10.1007/s12350-020-02398-5DOI Listing
October 2020

Telemedicine and the Forgotten America.

Circulation 2020 07 11;142(4):312-314. Epub 2020 Jun 11.

Division of Cardiovascular Medicine, Department of Medicine, Hospital of the University of Pennsylvania, Philadelphia (H.M.J, L.A.E., S.A.).

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http://dx.doi.org/10.1161/CIRCULATIONAHA.120.048535DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7382527PMC
July 2020

Telemedicine Outpatient Cardiovascular Care During the COVID-19 Pandemic: Bridging or Opening the Digital Divide?

Circulation 2020 08 8;142(5):510-512. Epub 2020 Jun 8.

Division of Cardiovascular Medicine, Department of Medicine, Hospital of the University of Pennsylvania, Philadelphia (L.A.E., S.A.M.K., A.S.N., H.M.J., S.A.).

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http://dx.doi.org/10.1161/CIRCULATIONAHA.120.048185DOI Listing
August 2020

Trends in Performance and Opportunities for Improvement on a Composite Measure of Acute Myocardial Infarction Care.

Circ Cardiovasc Qual Outcomes 2019 03;12(3):e004983

Section of Cardiovascular Medicine, Department of Medicine, Yale School of Medicine, New Haven, CT (N.R.D., Y.W., E.S.S., K.D., T.A., A.A., K.E.M., H.M.K., J.P.C.).

Background Despite improvements on individual process of care measures for acute myocardial infarction (AMI), little is known about performance on a composite measure of AMI care that assesses the delivery of many components of high-quality AMI care. We sought to examine trends in patient- and hospital-level performance on a composite defect-free care measure, identify disparities in the performance across sociodemographic groups, and identify opportunities to further improve quality and outcomes. Methods and Results We calculated the proportion of patients in the National Cardiovascular Data Registry-Acute Coronary Treatment and Intervention Outcomes Network Registry-Get With The Guidelines (now known as the Chest Pain - Myocardial Infarction Registry) between January 1, 2010, and December 31, 2017, receiving defect-free AMI care including guideline-recommended pharmacotherapy, timely provision of medical and reperfusion therapy, assessment of ventricular function, referral to cardiac rehabilitation, and smoking cessation counseling for patients with AMI. A total of 522 800 patients at 222 hospitals were included. Overall, the proportion of patients receiving defect-free care significantly increased from 66.0% in 2010 to 77.1% in 2017 ( P<0.001). Improvements in performance were observed across all sociodemographic subgroups, with the greatest absolute improvement observed for black and Hispanic patients ( P<0.001). However, absolute performance was consistently lower among older patients, women, black and Hispanic patients, and those with government insurance in 2017 ( P<0.001 for all). Improvements in care and reduced variation in performance were observed at the hospital level overall (2010, median [IQR] 67.2% [40.7%-76.3%]; 2017, median [IQR] 80.7% [73.1%-88.1%]; P<0.001) as well as across region, safety net status, teaching status, and proportion of patients who are nonwhite and have Medicaid insurance coverage ( P<0.001 for all). Conclusions Despite improvements in the proportion of patients with AMI receiving defect-free care overall and across sociodemographic groups, nearly 1 in 4 patients in 2017 still did not receive optimal care and absolute performance was consistently lower among older patients, women, black, and Hispanic patients. Composite measures of cardiovascular care, which assess the delivery of several evidence-based processes of care, can illuminate opportunities to improve the quality of care beyond that provided by conventional process measures.
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http://dx.doi.org/10.1161/CIRCOUTCOMES.118.004983DOI Listing
March 2019

Thick and thin: Bridging the gap to a better understanding of apical thinning.

J Nucl Cardiol 2020 04 4;27(2):461-464. Epub 2018 Oct 4.

Division of Cardiology, Department of Medicine, Perelman School of Medicine, University of Pennsylvania, 3400 Civic Center Boulevard, 11-154 South Pavilion, Philadelphia, PA, 19104, USA.

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http://dx.doi.org/10.1007/s12350-018-1451-0DOI Listing
April 2020

Lipid Testing and Statin Dosing After Acute Myocardial Infarction.

J Am Heart Assoc 2018 01 25;7(3). Epub 2018 Jan 25.

Duke Clinical Research Institute, Duke University School of Medicine, Durham, NC

Background: The 2013 American College of Cardiology/American Heart Association cholesterol guidelines recommend high-intensity statins for patients after myocardial infarction (MI) rather than treating to a low-density lipoprotein cholesterol goal, as the previous ATP III (Adult Treatment Panel third report) guidelines had advised.

Methods And Results: To evaluate the frequency of postdischarge lipid testing and high-intensity statin use among MI patients discharged on a statin during the ATP III guidelines era, we linked ACTION (Acute Coronary Treatment and Intervention Outcomes Network) Registry data to Medicare claims for 11 046 MI patients aged ≥65 years who were discharged alive on a statin from 347 hospitals (2007-2009). Multivariable regression was used to evaluate the association between lipid testing and 1-year high-intensity statin use. Only 21% of MI patients were discharged on a high-intensity statin. By 90 days after MI, 44% of patients discharged on a statin underwent lipid testing (43% on low- or moderate-intensity statins and 49% on high-intensity statins; =0.001). Follow-up lipid testing rates were 47% among patients with in-hospital low-density lipoprotein cholesterol ≥100 mg/dL and 47% among newly prescribed statin recipients. By 1 year, only 14% of patients were on high-intensity statins. Only 4% of patients discharged on low- or moderate-dose statin were uptitrated to high intensity; postdischarge lipid testing was associated with a slightly higher likelihood of high-intensity statin use by 1 year (5.4% versus 2.9%, adjusted odds ratio: 1.92; 95% confidence interval, 1.52-2.41).

Conclusions: Previous guidelines recommended low-density lipoprotein cholesterol goal-directed statin therapy, but lipid testing and high-intensity statin use were infrequent after MI. The American College of Cardiology/American Heart Association guidelines may promote more intensive cardiovascular risk reduction by eliminating treatment dependence on lipid testing.
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http://dx.doi.org/10.1161/JAHA.117.006460DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5850230PMC
January 2018

Association of US Centers for Medicare and Medicaid Services Hospital 30-Day Risk-Standardized Readmission Metric With Care Quality and Outcomes After Acute Myocardial Infarction: Findings From the National Cardiovascular Data Registry/Acute Coronary Treatment and Intervention Outcomes Network Registry-Get With the Guidelines.

JAMA Cardiol 2017 07;2(7):723-731

Division of Cardiology, University of Texas Southwestern Medical Center, Dallas.

Importance: The US Centers for Medicare and Medicaid Services Hospital Readmissions Reduction Program penalizes hospitals with higher-than-expected risk-adjusted 30-day readmission rates (excess readmission ratio [ERR] > 1) after acute myocardial infarction (MI). However, the association of ERR with MI care processes and outcomes are not well established.

Objective: To evaluate the association between ERR for MI with in-hospital process of care measures and 1-year clinical outcomes.

Design, Setting, And Participants: Observational analysis of hospitalized patients with MI from National Cardiovascular Data Registry/Acute Coronary Treatment and Intervention Outcomes Network Registry-Get With the Guidelines centers subject to the first cycle of the Hospital Readmissions Reduction Program between July 1, 2008, and June 30, 2011.

Exposures: The ERR for MI (MI-ERR) in 2011.

Main Outcomes And Measures: Adherence to process of care measures during index hospitalization in the overall study population and risk of the composite outcome of mortality or all-cause readmission within 1 year of discharge and its individual components among participants with available Centers for Medicare and Medicaid Services-linked data.

Results: The median ages of patients in the MI-ERR greater than 1 and tertiles 1, 2, and 3 of the MI-ERR greater than 1 groups were 64, 63, 64, and 63 years, respectively. Among 380 hospitals that treated a total of 176 644 patients with MI during the study period, 43% had MI-ERR greater than 1. The proportions of patients of black race, those with heart failure signs at admission, and bleeding complications increased with higher MI-ERR. There was no significant association between adherence to MI performance measures and MI-ERR (adjusted odds ratio, 0.94; 95% CI, 0.81-1.08, per 0.1-unit increase in MI-ERR for overall defect-free care). Among the 51 453 patients with 1-year outcomes data available, higher MI-ERR was associated with higher adjusted risk of the composite outcome and all-cause readmission within 1 year of discharge. This association was largely driven by readmissions early after discharge and was not significant in landmark analyses beginning 30 days after discharge. The MI-ERR was not associated with risk for mortality within 1 year of discharge in the overall and 30-day landmark analyses.

Conclusions And Relevance: During the first cycle of the Hospital Readmissions Reduction Program, participating hospitals' risk-adjusted 30-day readmission rates following MI were not associated with in-hospital quality of MI care or clinical outcomes occurring after the first 30 days after discharge.
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http://dx.doi.org/10.1001/jamacardio.2017.1143DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5815085PMC
July 2017

Unrecognized coronary vasospasm in patients referred for percutaneous coronary intervention: Intracoronary nitroglycerin, the forgotten stepchild of cardiovascular guidelines.

Catheter Cardiovasc Interv 2017 Dec 20;90(7):1086-1090. Epub 2017 Mar 20.

Division of Cardiology, Department of Medicine, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania.

Objective: The goal of this study was to demonstrate the importance of intracoronary nitroglycerin (IC NTG) administration during diagnostic coronary angiography and prior to percutaneous coronary intervention (PCI).

Background: PCI has been a mainstay treatment for patients with symptomatic coronary artery disease. While current guidelines emphasize the importance of periprocedural antithrombotic medications, they fail to mention the use of nitroglycerin prior to PCI.

Methods: Retrospective chart and angiographic review was performed to identify patients referred for PCI who had significant angiographic stenoses that resolved after administration of IC NTG.

Results: The study group consisted of 6 patients (3 men, 3 women) with mean age 52 ± 4years (range 46-57 years). All had anginal symptoms and significant (>70%) stenosis on diagnostic coronary angiography. None had documented ST segment elevation. The median interval between diagnostic and staged PCI procedures was 3 days. IC NTG was not administered to any of the patients at the time of diagnostic coronary angiography. In each case, repeat coronary angiography following administration of IC NTG (155 ± 46 mcg) before planned PCI demonstrated resolution of the target stenosis. PCI was deferred and all patients were successfully managed medically.

Conclusion: Coronary artery spasm is an under-recognized cause of chest pain in patients with significant angiographic lesions. Coronary spasm should be suspected especially in younger patients (less than 60 years old) with apparent single vessel disease. IC NTG should be routinely administered during diagnostic angiography and before PCI to avert unnecessary coronary interventions. © 2017 Wiley Periodicals, Inc.
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http://dx.doi.org/10.1002/ccd.27034DOI Listing
December 2017

Pediatric coronary CTA using phenylephrine to lower heart rate.

J Cardiovasc Comput Tomogr 2016 Jul-Aug;10(4):339-40. Epub 2016 Jun 10.

Department of Medicine, Division of Cardiology, Columbia University Medical Center, New York-Presbyterian Hospital, USA; Department of Radiology, Columbia University Medical Center, New York-Presbyterian Hospital, USA. Electronic address:

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http://dx.doi.org/10.1016/j.jcct.2016.06.001DOI Listing
June 2017

Prompt Recognition of Left Ventricular Free-Wall Rupture Aided by the Use of Contrast Echocardiography.

Tex Heart Inst J 2015 Oct 1;42(5):474-8. Epub 2015 Oct 1.

In the modern period of reperfusion, left ventricular free-wall rupture occurs in less than 1% of myocardial infarctions. Typically, acute left ventricular free-wall rupture leads to sudden death from immediate cardiac tamponade. We present the case of a 59-year-old woman who sustained a posterior-wall myocardial infarction and subsequent cardiac arrest with pulseless electrical activity. A bedside transthoracic echocardiogram showed pericardial effusion with cardiac tamponade. Emergency pericardiocentesis yielded 500 mL of blood, and spontaneous circulation returned. Contrast-enhanced echocardiograms revealed inferolateral akinesis and a new, small myocardial slit with systolic extrusion of contrast medium, consistent with left ventricular free-wall rupture. During immediate open-heart surgery, a small hole in an area of necrotic tissue was discovered and repaired. This case highlights the usefulness of bedside contrast-enhanced echocardiography in confirming acute left ventricular free-wall rupture and enabling rapid surgical treatment.
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http://dx.doi.org/10.14503/THIJ-14-4447DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4591892PMC
October 2015

Differential left ventricular outflow tract remodeling and dynamics in aortic stenosis.

J Am Soc Echocardiogr 2015 Nov 22;28(11):1259-66. Epub 2015 Aug 22.

Division of Cardiology, Cardiac Ultrasound Laboratory, Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts. Electronic address:

Background: Left ventricular outflow tract (LVOT) geometry is variable and often elliptical, which can affect aortic valve area calculation in patients with aortic stenosis (AS). Specific differences in LVOT geometry and dynamics between patients with AS and normal control subjects have not been described. The aim of this study was to test the hypothesis that differences in LVOT geometry in patients with AS might relate to variable LVOT remodeling and stiffness relative to normal control subjects.

Methods: In 54 patients with severe AS and 33 control subjects without AS, LVOT geometry, dynamics, remodeling, and stiffness were assessed by three-dimensional transesophageal echocardiography. LVOT stiffness was measured by calculating the distensibility coefficient, defined as the percentage change in LVOT area relative to change in left ventricular pressure. LVOT remodeling was assessed by measuring the posterior LVOT wall thickness. Multivariate linear regression analysis was used to determine independent associations with peak systolic LVOT ellipticity. LVOT area by three-dimensional transesophageal echocardiographic planimetry was compared with areas obtained assuming circular or elliptical geometry.

Results: At end-diastole, LVOT geometry was similar between patients with AS and normal control subjects. In patients with AS, however, the percentage change in cross-sectional area (7.5% vs 14.7%, P < .001) from end-diastole to peak systole was lower compared with normal control subjects, while peak systolic ellipticity index was higher in patients with AS (1.18 vs 1.08, P < .001). Compared with control subjects, patients with AS had lower distensibility coefficients (4.7 ± 1.9 × 10(4) vs 12.5 ± 5.3 × 10(4) mm Hg(-1), P < .001) and higher posterior LVOT wall thickness (3.5 ± 0.8 vs 2.3 ± 0.5 mm, P < .001). In multivariate analysis, posterior LVOT wall thickness and distensibility coefficient were independently associated with peak systolic LVOT ellipticity index. LVOT area underestimation by transthoracic echocardiography was higher in patients with AS when assuming circular geometry (20% vs 12%, P = .001).

Conclusions: The LVOT is less distensible and undergoes remodeling in severe AS. These changes lead to greater peak systolic ellipticity and greater LVOT cross-sectional area underestimation relative to normal control subjects. These findings have important implications for the assessment of AS severity.
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http://dx.doi.org/10.1016/j.echo.2015.07.018DOI Listing
November 2015

COCATS 4: Securing the Future of Cardiovascular Medicine.

J Am Coll Cardiol 2015 May;65(17):1907-14

Division of Cardiovascular Diseases, Mayo Clinic, Rochester, Minnesota.

The latest iteration of the Core Cardiology Training Statement (COCATS 4) [Corrected] provides a potentially transformative advancement in cardiovascular fellowship training intended, ultimately, to improve patient care. This review addressed 3 primary themes of COCATS 4 from the perspective of fellows-in-training: 1) the evolution of training requirements culminating in a competency-based curriculum; 2) the development of novel learning paradigms; and 3) the establishment of task forces in emerging areas of multimodality imaging and critical care cardiology. This document also examined several important challenges presented by COCATS 4. The proposed changes in COCATS 4 should not only enhance the training experience but also improve trainee satisfaction. Because it embraces continual transformation of training requirements to meet evolving clinical needs and public expectations, COCATS 4 will enrich the cardiovascular fellowship training experience for patients, programs, and fellows-in-training.
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http://dx.doi.org/10.1016/j.jacc.2015.03.015DOI Listing
May 2015

CV imaging for fellows in training: challenges and opportunities.

JACC Cardiovasc Imaging 2013 Nov;6(11):1225-6

Division of Cardiovascular Diseases, Mayo Clinic, Rochester, Minnesota.

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http://dx.doi.org/10.1016/j.jcmg.2013.09.013DOI Listing
November 2013

Women, but not men, have prolonged QT interval if depressed after an acute coronary syndrome.

Europace 2012 Feb 27;14(2):267-71. Epub 2011 Jul 27.

Center for Behavioral Cardiovascular Health, Columbia University Medical Center, New York, NY 10032, USA.

Aims: Depression is a mortality risk marker for acute coronary syndrome (ACS) patients. We hypothesized that the QT interval, a predictor for risk of sudden cardiac death, was related to depressive symptoms in ACS.

Methods And Results: We performed an analysis of admission electrocardiograms from hospitalized patients with unstable angina or non-ST elevation myocardial infarction from two prospective observational studies of depression in ACS. Depressive symptoms were assessed with the Beck Depression Inventory (BDI), and depression was defined as BDI score ≥10, compared with <5. Patients with QRS duration ≥120 ms and/or who were prescribed antidepressants were excluded. QT intervals were adjusted for heart rate by two methods. Our analyses included 243 men (40.0% with BDI ≥10) and 139 women (62.0% with BDI ≥ 10). Among women, average QT corrected by Fridericia's method (QTcF) was 435.4 ± 26.6 ms in the depressed group, vs. 408.6 ± 24.3 ms in the non-depressed group (P< 0.01). However, among men, average QTcF was not significantly different between the depressed and non-depressed groups (415.4 ± 23.6 vs. 412.0 ± 25.8 ms, P= 0.29). In multivariable analyses that included hypertension, diabetes, ACS type, left ventricular ejection fraction <0.40, and use of QT-prolonging medication, there was a statistically significant interaction between depressive symptoms and gender (P< 0.001).

Conclusions: In this ACS sample, prolongation of the QT interval was associated with depressive symptoms in women, but not in men. Further investigation of the mechanism of the relationship between depression and abnormal cardiac repolarization, particularly in women, is warranted to develop treatment strategies.
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http://dx.doi.org/10.1093/europace/eur246DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3262404PMC
February 2012

Depressive symptoms and all-cause mortality in unstable angina pectoris (from the Coronary Psychosocial Evaluation Studies [COPES]).

Am J Cardiol 2010 Oct;106(8):1104-7

Center for Behavioral Cardiovascular Health, Columbia University Medical Center, New York, New York, USA.

Although depression is clearly associated with increased mortality after acute myocardial infarction, there is a paucity of data examining the impact of depression on patients with unstable angina (UA). We analyzed the relation between depressive symptoms and all-cause mortality in patients with UA who were enrolled in a prospective multicenter study of depression and acute coronary syndrome (ACS). Depressive symptoms were measured with the Beck Depression Inventory (BDI) within 1 week of the ACS event, and patients were selected for a BDI score 0 to 4 or ≥ 10. Our sample included 209 patients with UA, with 104 (50%) having a BDI score ≥ 10. Proportional hazards analyses adjusted for variables including left ventricular ejection fraction, Global Registry of Acute Coronary Events risk score, and Charlson co-morbidity index. In multivariable analyses, a BDI score ≥ 10 was associated with increased risk of 42-month all-cause mortality (hazard ratio 2.04, 95% confidence interval 1.20 to 3.46, p = 0.008) compared to a BDI score 0 to 4. In conclusion, our results confirm and extend previous evidence linking depression to worse outcomes in UA and suggest that interventions that address depression may be worth examining across the spectrum of risk in ACS.
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http://dx.doi.org/10.1016/j.amjcard.2010.06.015DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2950828PMC
October 2010