Publications by authors named "Mitalee Christman"

29 Publications

  • Page 1 of 1

Laser-assisted delivery of tranexamic acid for melasma: Pilot study using a novel 1927 nm fractional thulium fiber laser.

J Cosmet Dermatol 2021 Jan 11;20(1):105-109. Epub 2020 Nov 11.

Laser & Skin Surgery Center of New York, New York, NY, USA.

Background: Melasma can be associated with immense psychosocial stress, which can impact quality of life. One theory suggests that ultraviolet light can increase plasmin activity in keratinocytes, which has led to the investigation of tranexamic acid for treating melasma, since it possesses anti-plasmin properties. The use of laser-assisted drug delivery can also increase the uptake of topical medications.

Aims: A prospective pilot study was performed to assess the utility of combination treatment with low-energy, low-density 1927 nm fractional thulium fiber laser and topical tranexamic acid for melasma.

Patients/methods: A total of 10 subjects were enrolled. Each received 5 treatments to the full face with a low-energy, low-density 1927 nm fractional thulium fiber laser. Immediately following treatment, topical tranexamic acid was applied, and subjects were instructed to apply it twice daily for 7 days. Clinical measures, quality of life, and patient satisfaction were assessed.

Results: Mean improvements in Melasma Area and Severity Index (MASI) scores were 1.1 (P = .0899), 3.5 (P = .0395), and 2.5 (P = .2429) at 30-, 90-, and 180-day follow-up, respectively. Maximum improvement occurred at 90-day follow-up. The mean improvement of Melasma Quality of Life Scale (MELASQOL) score was 9.6 (P = .0024) at 30-day follow-up. In addition to changes in pigmentation, subjects also believed their skin felt better, looked more radiant, and had improvements in skin texture and tone.

Conclusion: Combination of low-energy, low-density 1927 nm fractional thulium fiber laser and topical tranexamic acid improved clinical outcomes and quality of life associated with melasma. This combination treatment was safe, well-tolerated, and well-liked by subjects.
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http://dx.doi.org/10.1111/jocd.13817DOI Listing
January 2021

Dynamic Optical Coherence Tomography of Cutaneous Blood Vessels in Melasma and Vessel Response to Oral Tranexamic Acid.

Lasers Surg Med 2020 Nov 8. Epub 2020 Nov 8.

Laser & Skin Surgery Center of New York, New York, New York.

Background And Objectives: Melasma may be related to aberrant blood vessels, but there has been no report on the utility of dynamic optical coherence tomography (D-OCT) in studying vessel characteristics in melasma. We studied the characteristics of cutaneous blood vessels in melasma and the effects of oral tranexamic acid (TXA) with D-OCT.

Study Design/materials And Methods: Six patients with moderate to severe melasma had a D-OCT scanning of the areas on the face affected by melasma and not affected by it. Three of them had scans within 3 months after starting oral TXA and at a follow-up visit. Blood flow at different depths of the skin and vessel diameter were compared between the melasma and normal skin. For those taking oral TXA, we compared the percent change of blood flow and diameter between the melasma and normal skin.

Results: Dermal blood flow and vessel diameter were greater in the melasma skin than in the normal skin. Oral TXA reduced dermal blood flow in both the melasma and normal skin, but the reduction was more dramatic in the lesional melasma skin.

Conclusions: D-OCT findings that (i) dermal blood vessels in melasma are increased in size and flow and (ii) oral TXA reduced the vessel size and flow, providing evidence supporting the relationship between melasma and cutaneous blood vessels. D-OCT may be utilized in measuring response to treatments targeting melasma. Lasers Surg. Med. © 2020 Wiley Periodicals LLC.
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http://dx.doi.org/10.1002/lsm.23345DOI Listing
November 2020

Tripeptide and hexapeptide topical as adjunct to nonablative fractional resurfacing for photodamage: A randomized split-face trial.

J Cosmet Dermatol 2020 Dec 31;19(12):3245-3250. Epub 2020 Oct 31.

Laser & Skin Surgery Center of New York, New York, NY, USA.

Background: Topical adjuncts have been investigated to improve clinical outcomes associated with laser resurfacing for photodamage and cutaneous aging. One such product is a tripeptide/hexapeptide serum, which has been shown to increase dermal collagen and elastin as well as improve postprocedural recovery following treatments.

Aims: A randomized, blinded, split-face, comparative trial was performed to assess the utility of a tripeptide/hexapeptide serum as a peri-procedural adjunct to nonablative fractional laser resurfacing.

Patients/methods: A total of 20 subjects were enrolled. Each hemiface was randomized to either tripeptide/hexapeptide serum or bland moisturizer for twice daily application starting 14 days prior to first laser treatment and continuing until 60 days after. All subjects received 2 treatments to entire face approximately 1 month apart with 1927 nm thulium nonablative fractional laser. Clinical measures and immediate postprocedural recovery were assessed.

Results: For each hemiface, scores improved for all measures, including global photodamage, lentigines, pores, radiance, texture, and tone at 30 and 60 days. The tripeptide/hexapeptide serum had greater improvements for all measures at both time points, except for radiance at 60 days, which was equal. In cases where clinical ratings differed between sides, tripeptide/hexapeptide serum more frequently had the superior outcome. Overall, subjects were satisfied with tripeptide/hexapeptide serum. No significant adverse events were observed.

Conclusion: Addition of tripeptide/hexapeptide serum as a peri-procedural adjunct to nonablative fractional laser resurfacing improved various clinical measures of photodamage and cutaneous aging and the immediate postprocedural recovery. The tripeptide/hexapeptide serum was demonstrated to be safe, well-tolerated, and well-liked by subjects.
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http://dx.doi.org/10.1111/jocd.13795DOI Listing
December 2020

Paradoxical Hyperplasia After Cryolipolysis in 2 Patients With Diabetes on Insulin Pumps.

Dermatol Surg 2020 Oct 2. Epub 2020 Oct 2.

Skincare Physicians, Chestnut Hill, Massachusetts.

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http://dx.doi.org/10.1097/DSS.0000000000002818DOI Listing
October 2020

Assessment of Treatment Tolerance and Parental Perspective of Outpatient Pulsed-Dye Laser Treatment for Port-Wine Birthmark without General Anesthesia in Infants and Toddlers.

J Am Acad Dermatol 2020 Sep 30. Epub 2020 Sep 30.

Laser & Skin Surgery Center of New York, New York, NY; New York University School of Medicine, The Ronald O. Perelman Department of Dermatology, New York, NY.

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http://dx.doi.org/10.1016/j.jaad.2020.09.056DOI Listing
September 2020

Treatment of Trapdoor Deformity Using Erbium-doped Yttrium Aluminum Garnet Laser.

Plast Reconstr Surg Glob Open 2019 Sep 23;7(9):e2445. Epub 2019 Sep 23.

Laser & Skin Surgery Center of New York, New York, N.Y.

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http://dx.doi.org/10.1097/GOX.0000000000002445DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6908392PMC
September 2019

Successful Treatment of Cosmetic Oral Mucosal Tattoos Using QS 694-nm Ruby Laser and 755-nm Alexandrite Picosecond Laser.

Lasers Surg Med 2020 10 30;52(8):705-707. Epub 2019 Dec 30.

Laser & Skin Surgery Center of New York, 317 E 34th St, 11th Floor, New York, New York, 10016.

Background And Objectives: Q-switched (QS) and picosecond lasers can effectively and safely remove unwanted tattoo pigments. Cosmetic mucosal tattoos are rare and there are only a handful of cases of successful laser tattoo removal, all with QS 1064-nm neodymium-doped yttrium aluminum garnet (Nd:YAG) laser.

Study Design/materials And Methods: A 19-year-old Fitzpatrick skin-type II female presented for treatment of a 6-month-old, black tattoo on the mucosal surface of her lower lip. She underwent six treatment sessions with a QS 694-nm ruby laser on months 0, 1, 3, 5, 7, and 12. A 30-year-old Fitzpatrick skin-type IV male presented for treatment of a 10-year-old black tattoo on his left buccal mucosa. He underwent one treatment with 755-nm alexandrite picosecond lasers.

Results: One month after last treatment, both patients demonstrated marked improvement to the treatment area without scarring or dyspigmentation.

Conclusions: Given the excellent results seen in the patients presented here, the authors recommend that lasers should be the first-line treatment for the removal of unwanted cosmetic mucosal tattoos, which are typically easier to remove than cutaneous tattoos and can be accomplished with various wavelengths in the picosecond and nanosecond domains. Lasers Surg. Med. © 2019 Wiley Periodicals, Inc.
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http://dx.doi.org/10.1002/lsm.23207DOI Listing
October 2020

Treating port wine stain birthmarks using dynamic optical coherence tomography-guided settings.

J Am Acad Dermatol 2019 Aug 19. Epub 2019 Aug 19.

Laser & Skin Surgery Center of New York; The Ronald O. Perelman Department of Dermatology at the New York University School of Medicine.

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http://dx.doi.org/10.1016/j.jaad.2019.08.028DOI Listing
August 2019

Application of cooled hydrogel dressing to minimize dyspigmentation from laser tattoo removal.

J Am Acad Dermatol 2019 Sep 11;81(3):e59-e60. Epub 2019 May 11.

Laser & Skin Surgery Center of New York, New York, New York; Ronald O. Perelman Department of Dermatology, New York University, New York, New York.

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http://dx.doi.org/10.1016/j.jaad.2019.04.070DOI Listing
September 2019

Utilization of optical coherence tomography as a noninvasive, bedside imaging technique to identify residual nodular basal cell carcinoma at a well-healed and clinically unidentifiable biopsy site.

J Am Acad Dermatol 2019 Jul 13;81(1):e9-e10. Epub 2019 Feb 13.

Laser and Skin Surgery Center of New York, New York, New York; The Ronald O. Perelman Department of Dermatology, New York University, New York, New York.

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http://dx.doi.org/10.1016/j.jaad.2019.02.012DOI Listing
July 2019

Botulinum toxin for treatment of Raynaud phenomenon in CREST syndrome.

Dermatol Online J 2018 Dec 15;24(12). Epub 2018 Dec 15.

The Ronald O. Perelman Department of Dermatology, New York University Langone Health, New York, New York Yale University School of Medicine, New Haven, Connecticut.

Calcinosis, Raynaud phenomenon, esophageal dysmotility, sclerodactyly, and telangiectasia (CREST) syndrome is a form of a rare, clinical subtype of systemic sclerosis, known as limited systemic sclerosis. Limited systemic sclerosis, including CREST syndrome, manifests as fibrotic skin changes restricted to the hands and face, with vascular, musculoskeletal, and visceral involvement. We present a case of a 75-year-old woman with a longstanding history of CREST syndrome complicated by a digital ulceration and persistent pain associated with recalcitrant Raynaud phenomenon. After failing a number of first-line pharmacologic therapies such as diltiazem, sildenafil, and topical nitropaste, the patient was started on a trial of botulinum toxin for the left second digit, with 10 unit injections into both webspaces for a total of 20 units. Following injection, the patient reported no further baseline pain in the affected finger and an over fifty-percent improvement in discomfort with manipulation of the digit at a follow-up time of one week. The ulceration started healing within the following three weeks. This result was maintained at a follow-up time of six weeks.
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December 2018

Acquired immune deficiency syndrome-related epidemic Kaposi sarcoma.

Dermatol Online J 2018 Dec 15;24(12). Epub 2018 Dec 15.

The Ronald O. Perleman Department of Dermatology, New York University Langone Health, New York, New York.

Kaposi sarcoma (KS) is a vascular neoplasm that is one of the most common human immunodeficiency virus (HIV)-related malignancies. We present the case of a 42-year-old man with a new diagnosis of HIV and acquired immune deficiency syndrome (AIDS)-related epidemic KS.
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December 2018

Clinical spectrum of cutaneous melanoma morphology.

J Am Acad Dermatol 2019 Jan 28;80(1):178-188.e3. Epub 2018 Aug 28.

Wellman Center for Photomedicine, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts; Department of Dermatology, Massachusetts General Hospital, Boston, Massachusetts. Electronic address:

Background: Melanoma can mimic other cutaneous lesions, but the full spectrum and prevalence of these morphologic variants remain largely unknown.

Objective: To classify nonacral cutaneous melanomas into distinct morphologic clusters and characterize clusters' clinicopathologic features.

Methods: All pathologic melanoma diagnoses (occurring during 2011-2016) were reviewed for routine prebiopsy digital photographs (n = 400). Six dermatologists independently assigned lesions into 1 of 14 diagnostic classes on the basis of morphology. Image consensus clusters were generated by K-means; clinicopathologic features were compared with analysis of variance and χ.

Results: Five morphologic clusters were identified: typical (n = 136), nevus-like (n = 81), amelanotic/nonmelanoma skin cancer (NMSC)-like (n = 70), seborrheic keratosis (SK)-like (n = 68), and lentigo/lentigo maligna (LM)-like (n = 45) melanomas. Nevus-like melanomas were found in younger patients. Nevus-like and lentigo/LM-like melanomas tended to be thinner and more likely identified on routine dermatologic examinations. NMSC-like melanomas were tender, thicker, more mitotically active, and associated with prior NMSC. Typical and SK-like melanomas had similar clinicopathologic features.

Limitations: Cluster subdivision yielded diminished sample sizes. Visual assignment was performed without clinical context.

Conclusion: When primary cutaneous melanomas were assigned into diagnostic groups and subjected to novel consensus clustering, recurrent morphologic patterns emerged. The spectrum of these morphologies was unexpectedly diverse, which might have implications for visual training and possibly clinical diagnosis.
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http://dx.doi.org/10.1016/j.jaad.2018.08.028DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6492030PMC
January 2019

Cold panniculitis: Adverse cutaneous effect of whole-body cryotherapy.

JAAD Case Rep 2018 May 1;4(4):344-345. Epub 2018 Apr 1.

Ronald O. Perelman Department of Dermatology, New York University School of Medicine, New York, New York.

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http://dx.doi.org/10.1016/j.jdcr.2018.02.010DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5911975PMC
May 2018

Dermatology on Instagram: An Analysis of Hashtags.

J Drugs Dermatol 2018 Apr;17(4):482-484

Forty-two percent of Americans search for health-related information on social media platforms, and forty-five percent of consumers report that social media health information influences their decision to seek care.
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http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6831082PMC
April 2018

Papular mucinosis, or localized lichen myxedematosis (LM) (discrete papular type).

Dermatol Online J 2017 Dec 15;23(12). Epub 2017 Dec 15.

New York University Langone Health, New York.

Lichen myxedematosus is condition characterized by localized areas of dermal deposition of mucin, presenting with firm papules localized to few areas of the body. The condition needs to be excluded from scleromyxedema, which, in addition to the firm papular eruption, has areas of induration and is usually associated with a monoclonal gammopathyand systemic symptoms. We present a 62-year-old woman with a several-year history of asymptomatic, firm papules over the face and arms with no evidence of thyroid disease or a monoclonal gammopathy,which is consistent with a diagnosis of localized lichen myxedematosus, the discrete papular variant. The patient is being treated with a topical calcineurininhibitor.
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December 2017

An Anatomical Approach to Evaluating and Treating Cellulite.

J Drugs Dermatol 2017 Jan;16(1):58-61

Cellulite is the common rippling or dimpling of skin of the thighs and buttocks of women, formed from a confluence of skin laxity, tethering fibrous septa, and fat herniation. We describe an anatomical approach to evaluating the cellulite patient and selecting the best treatment from among available non-invasive, minimally invasive, and invasive therapies. It is crucial to consider the anatomy of the patient and the morphology of cellulite while choosing a treatment. Diffuse rippling represents increased adiposity and/or increased skin laxity which may stand to benefit from lipolytic and skin tightening modalities. Dimpling represents tethering by fibrous septa which may stand to improve from subcision by minimally invasive devices such as Cell na. Patients with both morphologies may be treated with a combination of treatments or Cellulaze. Careful evaluation of the patient can help identify the best therapeutic strategy. J Drugs Dermatol. 2017;16(1):58-61..
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January 2017

Dermatomyositis, clinically presenting with cutaneous ulcers, with histopathologic evidence of perforating collagenosis.

Dermatol Online J 2016 Dec 15;22(12). Epub 2016 Dec 15.

Ronald O. Perelman Department of Dermatology, NYU School of Medicine, NYU Langone Medical Center.

Dermatomyositis is a systemic, autoimmune diseasewith a variety of clinical features that often includemyositis and characteristic cutaneous findings. Asubset of patients with dermatomyositis developcutaneous ulcers, often in the setting of vasculitis orvasculopathy. We present a case of dermatomyositiswith cutaneous ulcers that show perforatingcollagenosis on histopathologic examination.Acquired reactive perforating collagenosistypically occurs in the setting of diabetes mellitus,chronic renal failure, and other pruritic conditions,and this case represents a rare association withdermatomyositis, which may ultimately be helpful inelucidating the pathophysiology of this perforatingdisorder.
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December 2016

Darier-White disease.

Dermatol Online J 2016 Dec 15;22(12). Epub 2016 Dec 15.

Ronald O. Perelman Department of Dermatology, NYU School of Medicine, NYU Langone Medical Center.

We present a 58-year-old woman with bipolardisorder and with a longstanding history of yellowbrown,hyperkeratotic papules in a seborrheicdistribution and nail changes. Her father andpaternal grandmother had similar eruptions and alsohad psychiatric disease. Histopathologic examinationshowed acantholysis and dyskeratosis, which wasconsistent with Darier-White disease. Darier-Whitedisease is a rare, hereditary disorder that is inheritedin an autosomal dominant manner and that usuallypresents in adolescence or early adulthood dueto mutations in the SERCA2 calcium pump. Theresultant alterations in calcium homeostasis affectdesmosome assembly and lead to acantholysis andapoptosis, which creates the characteristic eruption.Genetic linkage analysis of affected families showsthat a susceptibility locus for bipolar disorder cosegregateswith genetic markers that are found inthe Darier-White disease region. Treatments, whichinclude topical emollients, mild keratolytics, andtopical or oral retinoids, are aimed at improvingthe appearance of skin, relieving symptoms, andpreventing or treating infectious complications.
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December 2016

Recurrence of herpes simplex encephalitis associated with temozolomide chemoradiation for malignant glioma: a case report and review of the literature.

Oxf Med Case Reports 2014 Apr 12;2014(1):1-4. Epub 2014 Mar 12.

Division of Infectious Diseases , Brigham and Women's Hospital, Harvard Medical School , Boston, MA , USA.

Although herpes simplex encephalitis is not classically considered an opportunistic infection, reactivation of herpes simplex is being seen increasingly in patients with cancer or immunosuppression. The authors present a patient with malignant glioma and HSV-1 encephalitis whose PCR-proven encephalitis recurred after temozolomide (TMZ) chemoradiation despite acyclovir therapy, and summarize details of four other cases of HSV-1 encephalitis associated with TMZ. The similarity among these cases raises the likely need for longer treatment courses and/or oral suppressive therapy in patients at risk for herpes simplex infections who are receiving TMZ.
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http://dx.doi.org/10.1093/omcr/omu001DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4369964PMC
April 2014

How we used a patient visit tracker tool to advance experiential learning in systems-based practice and quality improvement in a medical student clinic.

Med Teach 2016 17;38(1):36-40. Epub 2014 Nov 17.

a Harvard Medical School , USA .

Poorly designed healthcare systems increase costs and preventable medical errors. To address these issues, systems-based practice (SBP) education provides future physicians with the tools to identify systemic errors and implement quality improvement (QI) initiatives to enhance the delivery of cost-effective, safe and multi-disciplinary care. Although SBP education is being implemented in residency programs and is mandated by the Accreditation Council for Graduate Medical Education (ACGME) as one of its core competencies, it has largely not been integrated into undergraduate medical education. We propose that Medical Student-Faculty Collaborative Clinics (MSFCCs) may be the ideal environment in which to train medical students in SBPs and QI initiatives, as they allow students to play pivotal roles in project development, administration, and management. Here we describe a process of experiential learning that was developed within a newly established MSFCC, which challenged students to identify inefficiencies, implement interventions, and track the results. After identifying bottlenecks in clinic operations, our students designed a patient visit tracker tool to monitor clinic flow and implemented solutions to decrease patient visit times. Our model allowed students to drive their own active learning in a practical clinical setting, providing early and unique training in crucial QI skills.
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http://dx.doi.org/10.3109/0142159X.2014.975193DOI Listing
October 2016

Rhabdomyosarcoma arising in a giant congenital melanocytic nevus.

Pediatr Dermatol 2014 Sep-Oct;31(5):584-7. Epub 2014 Jun 9.

Harvard Medical School, Boston, Massachusetts.

A number of lesions have been documented to arise within congenital melanocytic nevi (CMNs). Although the most frequent malignancy arising within a CMN is melanoma, the association between rhabdomyosarcoma and CMN has rarely been documented. We present a case arising in a 4-month-old girl with a giant CMN. She presented for evaluation of a pedunculated lesion at the superior gluteal crease that had been present since birth and exhibited rapid growth. Biopsy of the lesion revealed two distinct components: an expansile proliferation of pleomorphic cells with varying degrees of cellularity and a proliferation of banal-appearing melanocytic nevic cells. The cells of the expansile proliferation displayed a wide range of morphologic features, including nests of round cells, spindle-shaped cells, and more differentiated rhabdomyoblasts within a myxoid, highly vascularized stroma. Cross-striations, a marker of skeletal muscle differentiation, were present. These tumor cells were strongly immunoreactive with desmin, myo-D1, and myogenin. Fluorescence in situ hybridization analysis with PAX3/7-FKHR probes was negative. A diagnosis of embryonal rhabdomyosarcoma in association with CMN was made. Initial excision revealed tumor at the margins, and the patient underwent reexcision with subsequent chemotherapy with vincristine, actinomycin D, and cyclophosphamide. She was disease-free at the 6-year follow-up. It has been postulated that the combination of melanocytic and rhabdomyoblastic cells within the same lesion may imply derivation from a common pluripotent stem cell or neural crest cell. Clinicians following patients with giant CMN should consider rhabdomyosarcoma in the differential diagnosis of lesions arising within the nevus.
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http://dx.doi.org/10.1111/pde.12359DOI Listing
May 2015

Coronary artery disease detected by coronary computed tomographic angiography is associated with intensification of preventive medical therapy and lower low-density lipoprotein cholesterol.

Circ Cardiovasc Imaging 2014 Jul 6;7(4):629-38. Epub 2014 Jun 6.

From the Noninvasive Cardiovascular Imaging Program, Departments of Medicine and Radiology, Brigham and Women's Hospital, Boston, MA (E.H., M.S.B., A.S., D.O., M.P.C., W.O., M.L.S., F.F.R., J.K., J.H., M.F.D.C., R.B.); Cardiology Service, Division of Medicine, Walter Reed National Military Medical Center and Uniformed Services University of Health Sciences, Bethesda, MD (E.H.); Center for Clinical and Epidemiological Research, Division of Internal Medicine, University of São Paulo, São Paulo, Brazil (M.S.B.); Cardiac MR PET CT Program, Department of Radiology, Division of Cardiac Imaging (S.A., T.J.B., U.H., B.B.G.), and Division of Cardiology (Q.A.T.), Massachusetts General Hospital, Harvard Medical School, Boston; Center for Wellness and Prevention Research, Baptist Health South Florida, Miami (K.N.); and Cleveland Clinic Foundation, OH (R.H.).

Background: Coronary computed tomographic angiography (CCTA) is an accurate test for the identification of coronary artery disease (CAD), yet the impact of CCTA results on subsequent medical therapy and risk factors has not been widely reported.

Methods And Results: We identified consecutive patients aged >18 years without prior CAD who underwent CCTA from 2004 to 2011 and had complete data on medications before and after CCTA. CCTA results were categorized as no CAD, <50% stenosis, and ≥50% stenosis. Based on the number of involved segments, extent of disease was categorized as nonextensive (≤4 segments) or extensive CAD (>4 segments). Electronic medical records and patient interviews were reviewed blinded to CCTA findings to assess initiation of aspirin and intensification of lipid-lowering therapies. Survival analysis was performed to evaluate intensification of lipid therapy as a predictor of cardiovascular death or nonfatal myocardial infarction. Among 2839 patients with mean follow-up of 3.6 years, the odds of physician intensification of lipid-lowering therapy significantly increased for those with nonobstructive CAD (odds ratio, 3.6; 95% confidence interval, 2.9-4.9; P<0.001) and obstructive CAD (odds ratio, 5.6; 95% confidence interval, 4.3-7.3; P<0.001). Low-density lipoprotein cholesterol levels declined significantly in association with intensification of lipid-lowering therapy after CCTA in all patient subgroups. In a hypothesis-generating analysis, among patients with nonobstructive but extensive CAD, statin use after CCTA was associated with a reduction in cardiovascular death or myocardial infarction (hazards ratio, 0.18; 95% confidence interval, 0.05-0.66; P=0.01).

Conclusions: Abnormal CCTA findings are associated with downstream intensification in statin and aspirin therapy. In particular, CCTA may lead to increased use of prognostically beneficial therapies in patients identified as having extensive, nonobstructive CAD.
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http://dx.doi.org/10.1161/CIRCIMAGING.113.001564DOI Listing
July 2014

Comparison of the use of downstream tests after exercise treadmill testing by cardiologists versus noncardiologists.

Am J Cardiol 2014 Jul 2;114(2):305-11. Epub 2014 May 2.

Cardiovascular Division, Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts; Department of Radiology, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts. Electronic address:

Although exercise treadmill testing (ETT) is a useful initial test for patients with suspected cardiovascular (CV) disease, there is concern regarding the use of downstream imaging tests especially in the setting of equivocal or positive ETTs. Patients with no history of coronary artery disease who underwent ETT between 2009 and 2010 were prospectively included. Referring physicians were categorized as cardiologists and noncardiologists. Downstream tests included nuclear perfusion imaging, coronary computed tomography angiography, stress echocardiography, stress magnetic resonance, and invasive coronary angiography performed up to 6 months after the ETT. Patients were followed for CV death, myocardial infarction, and coronary revascularization for a median of 2.7 years. Among 3,656 patients, the ETT were negative in 2,876 (79%), positive in 132 (3.6%), and inconclusive in 643 (18%). Cardiologists ordered less downstream tests than noncardiologists (9.5% vs 12.2%, p=0.02), with less noninvasive tests (5.9% vs 10.4%, p<0.0001) and more invasive angiography (3.6% vs 1.8%, p<0.0001). After adjustment for confounding, patients evaluated by cardiologists were less likely to undergo additional testing after equivocal (odds ratio: 0.65, p=0.02) or positive ETT results (odds ratio: 0.39, p=0.02), whereas after negative ETT, the odds ratio was 1.7 (p=0.06). There was no difference in the rate of adverse CV events between patients referred by cardiologists versus noncardiologists. In conclusion, patients referred for ETT by cardiologists are less likely to undergo additional testing, particularly noninvasive tests, than those referred by noncardiologists. The lower rate of tests is driven by a lower rate of tests after positive or inconclusive ETT.
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http://dx.doi.org/10.1016/j.amjcard.2014.04.040DOI Listing
July 2014

Prognostic value of nonobstructive and obstructive coronary artery disease detected by coronary computed tomography angiography to identify cardiovascular events.

Circ Cardiovasc Imaging 2014 Mar 18;7(2):282-91. Epub 2014 Feb 18.

Non-Invasive Cardiovascular Imaging Program, Departments of Medicine and Radiology, Brigham and Women's Hospital, Harvard Medical School, Boston, MA.

Background: The contribution of plaque extent to predict cardiovascular events among patients with nonobstructive and obstructive coronary artery disease (CAD) is not well defined. Our objective was to evaluate the prognostic value of plaque extent detected by coronary computed tomography angiography.

Methods And Results: All consecutive patients without prior CAD referred for coronary computed tomography angiography to evaluate for CAD were included. Examination findings were classified as normal, nonobstructive (<50% stenosis), or obstructive (≥50%). Based on the number of segments with disease, extent of CAD was classified as nonextensive (≤4 segments) or extensive (>4 segments). The cohort included 3242 patients followed for the primary outcome of cardiovascular death or myocardial infarction for a median of 3.6 (2.1-5.0) years. In a multivariable analysis, the presence of extensive nonobstructive CAD (hazard ratio, 3.1; 95% confidence interval, 1.5-6.4), nonextensive obstructive (hazard ratio, 3.0; 95% confidence interval, 1.3-6.9), and extensive obstructive CAD (hazard ratio, 3.9; 95% confidence interval, 2.2-7.2) were associated with an increased rate of events, whereas nonextensive, nonobstructive CAD was not. The addition of plaque extent to a model that included clinical probability as well as the presence and severity of CAD improved risk prediction.

Conclusions: Among patients with nonobstructive CAD, those with extensive plaque experienced a higher rate of cardiovascular death or myocardial infarction, comparable with those who have nonextensive disease. Even among patients with obstructive CAD, greater extent of nonobstructive plaque was associated with higher event rate. Our findings suggest that regardless of whether obstructive or nonobstructive disease is present, the extent of plaque detected by coronary computed tomography angiography enhances risk assessment.
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http://dx.doi.org/10.1161/CIRCIMAGING.113.001047DOI Listing
March 2014

Incremental prognostic value of coronary artery calcium score versus CT angiography among symptomatic patients without known coronary artery disease.

Atherosclerosis 2014 Mar 8;233(1):190-5. Epub 2014 Jan 8.

Non-Invasive Cardiovascular Imaging Program, Departments of Medicine and Radiology, Brigham and Women's Hospital, Harvard Medical School, 75 Francis St, Boston, MA 02115, USA. Electronic address:

Objective: To evaluate the prognostic value and test characteristics of coronary artery calcium (CAC) score for the identification of obstructive coronary artery disease (CAD) in comparison with coronary computed tomography angiography (CCTA) among symptomatic patients.

Methods: Retrospective cohort study at two large hospitals, including all symptomatic patients without prior CAD who underwent both CCTA and CAC. Accuracy of CAC for the identification of ≥ 50% and ≥ 70% stenosis by CCTA was evaluated. Prognostic value of CAC and CCTA were compared for prediction of major adverse cardiovascular events (MACE, defined as non-fatal myocardial infarction, cardiovascular death, late coronary revascularization (>90 days), and unstable angina requiring hospitalization).

Results: Among 1145 included patients, the mean age was 55 ± 12 years and median follow up 2.4 (IQR: 1.5-3.5) years. Overall, 406 (35%) CCTA were normal, 454 (40%) had <50% stenosis, and 285 (25%) had ≥ 50% stenosis. The prevalence of ≥ 70% stenosis was 16%. Among 483 (42%) patients with CAC zero, 395 (82%) had normal CCTA, 81 (17%) <50% stenosis, and 7 (1.5%) ≥ 50% stenosis. 2 (0.4%) patients had ≥ 70% stenosis. For diagnosis of ≥ 50% stenosis, CAC had a sensitivity of 98% and specificity of 55%. The negative predictive value (NPV) for CAC was 99% for ≥ 50% stenosis and 99.6% for ≥ 70% stenosis by CCTA. There were no adverse events among the 7 patients with zero calcium and ≥ 50% CAD. For prediction of MACE, the c-statistic for clinical risk factors of 0.62 increased to 0.73 (p < 0.001) with CAC versus 0.77 (p = 0.02) with CCTA.

Conclusion: Among symptomatic patients with CAC zero, a 1-2% prevalence of potentially obstructive CAD occurs, although this finding was not associated with future coronary revascularization or adverse prognosis within 2 years.
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http://dx.doi.org/10.1016/j.atherosclerosis.2013.12.029DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5536845PMC
March 2014

Yield of downstream tests after exercise treadmill testing: a prospective cohort study.

J Am Coll Cardiol 2014 Apr 5;63(13):1264-1274. Epub 2014 Feb 5.

Department of Medicine (Cardiovascular Division) and Radiology, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts. Electronic address:

Objectives: The purpose of this study was to estimate the frequency and results of downstream testing after exercise treadmill tests (ETTs).

Background: The utility of additional diagnostic testing after ETT is not well characterized.

Methods: We followed consecutive individuals without known coronary artery disease referred for clinical ETT at a large medical center. We measured the frequency and results of downstream imaging tests and invasive angiography within 6 months of ETT and the combined endpoint of survival free from cardiovascular death, myocardial infarction, and coronary revascularization.

Results: Among 3,656 consecutive subjects who were followed for a mean of 2.5 ± 1.1 years, 332 (9.0%) underwent noninvasive imaging and 84 (2.3%) were referred directly to invasive angiography after ETT. The combined endpoint occurred in 76 (2.2%) patients. The annual incidence of the combined endpoint after negative, inconclusive, and positive ETT was 0.2%, 1.3%, and 12.4%, respectively (p < 0.001). Rapid recovery of electrocardiography (ECG) changes during ETT was associated with negative downstream test results and excellent prognosis, whereas typical angina despite negative ECG was associated with positive downstream tests and adverse prognosis (p < 0.001). Younger age, female sex, higher metabolic equivalents of task achieved, and rapid recovery of ECG changes were predictors of negative downstream tests.

Conclusions: Among patients referred for additional testing after ETT, the lowest yield was observed among individuals with rapid recovery of ECG changes or negative ETT, whereas the highest yield was observed among those with typical angina despite negative ECG or a positive ETT. These findings may be used to identify patients who are most and least likely to benefit from additional testing.
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http://dx.doi.org/10.1016/j.jacc.2013.11.052DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4033667PMC
April 2014

Cardiometabolic risk is associated with atherosclerotic burden and prognosis: results from the partners coronary computed tomography angiography registry.

Diabetes Care 2014 Feb 15;37(2):555-64. Epub 2013 Oct 15.

Corresponding author: Edward Hulten,

Objective: Our purpose was to evaluate coronary artery disease (CAD) prevalence and prognosis according to cardiometabolic (CM) risk.

Research Design And Methods: Registry of all patients without prior CAD referred for coronary computed tomography angiography (CCTA). Patients were stratified by groups of increasing CM risk factors (hypertension, low HDL, hypertriglyceridemia, obesity, and dysglycemia) as follows: patients without type 2 diabetes mellitus (T2DM) with fewer than three or with three or more CM risk factors, patients with T2DM not requiring insulin, or those with T2DM requiring insulin. Patients were followed for a primary end point of major adverse cardiovascular events (MACE) composed of unstable angina, late coronary revascularization, myocardial infarction (MI), and cardiovascular mortality.

Results: Among 1,118 patients (mean age 57 ± 13 years) followed for a mean 3.1 years, there were 21 (1.9%) cardiovascular deaths and 13 (1.2%) MIs. There was a stepwise increase in the prevalence of obstructive CAD with increasing CM risk, from 15% in those without diabetes and fewer than three CM risk factors to as high as 46% in patients with T2DM requiring insulin (P < 0.001). Insulin exposure was associated with the highest adjusted hazard of MACE (hazard ratio 3.29 [95% CI 1.28-8.45], P = 0.01), whereas both T2DM without insulin (1.35, P = 0.3) and three or more CM risk factors without T2DM (1.48, P = 0.3) were associated with a similar rate of MACE.

Conclusions: Patients without diabetes who have multiple metabolic risk factors have a similar prognosis and burden of CAD as those with T2DM not requiring insulin. Among patients with diabetes, the need for insulin therapy is associated with greater burden of CAD as well as worse prognosis.
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http://dx.doi.org/10.2337/dc13-1431DOI Listing
February 2014

Adequacy of cancer screening in adult women with congenital heart disease.

ISRN Cardiol 2013 1;2013:827696. Epub 2013 Aug 1.

Massachusetts General Hospital, Harvard Medical School, Boston, MA 02114, USA.

Adults with congenital heart disease (ACHD) face noncardiac healthcare challenges as the population ages. We assessed whether women with ACHD have comparable cancer screening rates to non-ACHD women in a cardiac practice and to the general population. We performed a retrospective review of 175 adult women seen in a cardiac care center in 2009-2011. Data on Pap tests, mammography, and colonoscopies, were collected through electronic medical records and primary care provider records. Adequate documentation was available for 100 individuals with ACHD and 40 comparator cardiac patients. The adequacy of screening was determined using guidelines set forth by the American Cancer Society in 2010. Compared with the national average, ACHD patients had significantly lower rates of Pap tests (60% versus 83%, P < 0.001) and mammography (48% versus 72%, P < 0.001). Compared with non-ACHD women in the same practice, ACHD patients had consistently lower rates of mammography (48% versus 81%, P = 0.02) and colonoscopies (54% versus 82%, P = 0.23). As the population of ACHD individuals ages, attention to cancer screening becomes increasingly important but may be overlooked in this population. Primary care physicians and cardiologists should collaborate to ensure appropriate cancer screening for this growing population.
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http://dx.doi.org/10.1155/2013/827696DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3747419PMC
August 2013