Publications by authors named "Mori J Krantz"

155 Publications

Impact of Sodium-Glucose Cotransporter-2 Inhibitor Initiation in a Safety-net Hospital.

Crit Pathw Cardiol 2021 Nov 17. Epub 2021 Nov 17.

Department of Pharmacy, Denver Health and Hospital Authority, Denver, CO Department of Medicine, Denver Health and Hospital Authority, Denver, CO University of Colorado School of Medicine, Aurora CO.

Sodium-glucose cotransporter-2 inhibitors (SGLT2i) are antihyperglycemic medications with cardiovascular disease (CVD) and renal protective properties. While clinical trials supporting their efficacy, the utility among safety net health system patients with low health literacy has not been evaluated. We sought to assess appropriate monitoring, safety and effectiveness of GLT2i initiation at a safety net hospital. From May 2017 to July 2020, 150 patients were newly initiated on an SGLT2i therapy. We evaluated appropriate initiation, laboratory monitoring, impact on urine microalbumin, mean hemoglobin A1c (HbA1c), and systolic blood pressure (SBP). We also analyzed primary care versus subspecialty prescriber patterns. All patients did not have prohibitive renal dysfunction based on FDA labeling and the majority (N=101, 67%) had renal function testing completed prior to initiation. Improvement in CVD surrogate markers including SBP (mean -3.12 mmHg), albuminuria (mean -3.98 mg/dL). and HbA1c (mean -1.06%) were observed. A total of 94% of the cohort had serum chemistry panels drawn, yet only 4% were performed within the protocol-specified (14-day) period. Primary care and cardiology providers were the sole prescribers; despite the known reno-protective properties no patients were initiated on SGLT2i therapy by a nephrologist. In conclusion, the benefits of SGLT2i drugs reducing SBP, albuminuria, and HbA1c observed in clinical trials were duplicated in our safety-net population. Therefore, ongoing education and promotion to providers to ensure broadened utilization and timely renal function monitoring appears warranted.
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http://dx.doi.org/10.1097/HPC.0000000000000270DOI Listing
November 2021

Huffing and twist: Fatal Torsade de pointes associated with Tetrafluoroethane Inhalation and amphetamine use.

Clin Case Rep 2021 Aug 4;9(8). Epub 2021 May 4.

Department of Medicine Division of Cardiology Denver Health and Hospital Authority Denver CO USA.

Many volatile chemicals inhaled for a recreational high have a chemical structure similar to chloroform and may lead to Ikr blockade and subsequent torsades de pointes. This is one potential mechanism of action for huffing-associated sudden death.
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http://dx.doi.org/10.1002/ccr3.3838DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8385681PMC
August 2021

Low-dose rivaroxaban plus aspirin in older patients with peripheral artery disease undergoing acute limb revascularization: insights from the VOYAGER PAD trial.

Eur Heart J 2021 10;42(39):4040-4048

CPC Clinical Research, 2115 N Scranton Street, Suite 2040, Aurora, CO, USA.

Aims: In this secondary analysis of the VOYAGER trial, rivaroxaban 2.5 mg twice/day plus aspirin 100 mg/day was assessed in older adults. Advanced age is associated with elevated bleeding risk and unfavourable net benefit for dual antiplatelet therapy in chronic coronary artery disease. The risk-benefit of low-dose rivaroxaban in patients ≥75 years with peripheral artery disease (PAD) after lower extremity revascularization (LER) has not been described.

Methods And Results: The primary endpoint was a composite of acute limb ischaemia, major amputation, myocardial infarction, ischaemic stroke, or cardiovascular death. The principal safety outcome was thrombolysis in myocardial infarction (TIMI) major bleeding analysed by the pre-specified age cut-off of 75 years. Of 6564 patients randomized, 1330 (20%) were >75 years. Absolute 3-year Kaplan-Meier cumulative incidence rates for primary efficacy (23.4% vs. 19.0%) and safety (3.5% vs. 1.5%) endpoints were higher in elderly vs. non-elderly patients. Efficacy of rivaroxaban (P-interaction 0.83) and safety (P-interaction 0.38) was consistent irrespective of age. The combination of intracranial and fatal bleeding was not increased in patients >75 years (2 rivaroxaban vs. 8 placebo). Overall, benefits (absolute risk reduction 3.8%, number needed to treat 26 for the primary endpoint) exceeded risks (absolute risk increase 0.81%, number needed to harm 123 for TIMI major bleeding).

Conclusion: Patients ≥75 years with PAD are at both heightened ischaemic and bleeding risk after LER. No excess harm with respect to major, intracranial or fatal bleeding was seen in older patients yet numerically greater absolute benefits were observed. This suggests that low-dose rivaroxaban combined with aspirin should be considered in PAD after LER regardless of age.
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http://dx.doi.org/10.1093/eurheartj/ehab408DOI Listing
October 2021

Cardiovascular Risk Factor Knowledge among Monolingual Hispanics.

J Health Care Poor Underserved 2021 ;32(2):688-699

Hispanics in the United States have worse cardiovascular disease (CVD) risk factor profiles than non-Hispanic Whites. Cardiovascular health literacy is important for health promotion but is not well characterized among monolingual Spanish-speaking Hispanics outside of health care settings. We recruited Hispanic participants (N=235) from a community-based health fair in Denver, Colorado. A total of 182 participants (77%) completed a subsequent language-congruent telephone survey to assess CVD risk-factor knowledge. Of these, 174 self-identified as monolingual Spanish-speaking, and constituted the analysis cohort. Cardiovascular disease risk knowledge score was defined as the number of established risk factors an individual participant could name (out of 10 pre-specified), and multivariable regression analyses were conducted to determine factors independently associated with knowledge. The mean knowledge score for the cohort was 2.2 ± 1.1 out of 10. This suggests an unmet need for tailored educational interventions beyond simple screening events.
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http://dx.doi.org/10.1353/hpu.2021.0098DOI Listing
September 2021

A Point-of-Care Algorithm to Guide Proper Device Selection for Ambulatory Electrocardiography.

Crit Pathw Cardiol 2021 09;20(3):140-142

From the Department of Medicine, Division of Cardiology, Denver Health and Hospital Authority, Denver, CO.

In the outpatient setting, ambulatory electrocardiography is the most frequently used diagnostic modality for the evaluation of patients in whom cardiac arrhythmias or conduction abnormalities are suspected. Proper selection of the device type and monitoring duration is critical for optimizing diagnostic yield and cost-effective resource utilization. However, despite guidance from major professional societies, the lack of systematic guidance for proper test selection in many institutions results in the need for repeat testing, which leads to not only increased resource utilization and cost of care, but also suboptimal patient care. To address this unmet need at our own institution, we formed a multidisciplinary panel to develop a concise, yet comprehensive algorithm, incorporating the most common indications for ambulatory electrocardiography, to efficiently guide clinicians to the most appropriate test option for a given clinical scenario, with the goal of maximizing diagnostic yield and optimizing resource utilization. The algorithm was designed as a single-page, color-coded flowchart to be utilized both as a rapid reference guide in printed form, and a decision support tool embedded within the electronic medical records system at the point of order entry. We believe that systematic adoption of this algorithm will optimize diagnostic efficiency, resource utilization, and importantly, patient care and satisfaction.
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http://dx.doi.org/10.1097/HPC.0000000000000259DOI Listing
September 2021

Cardiovascular Complications of Opioid Use: JACC State-of-the-Art Review.

J Am Coll Cardiol 2021 01;77(2):205-223

Military Cardiovascular Outcomes Research, Cardiology Division, Uniformed Services University, Bethesda Maryland, USA.

Opioids are the most potent of all analgesics. Although traditionally used solely for acute self-limited conditions and palliation of severe cancer-associated pain, a movement to promote subjective pain (scale, 0 to 10) to the status of a "fifth vital sign" bolstered widespread prescribing for chronic, noncancer pain. This, coupled with rising misuse, initiated a surge in unintentional deaths, increased drug-associated acute coronary syndrome, and endocarditis. In response, the American College of Cardiology issued a call to action for cardiovascular care teams. Opioid toxicity is primarily mediated via potent μ-receptor agonism resulting in ventilatory depression. However, both overdose and opioid withdrawal can trigger major adverse cardiovascular events resulting from hemodynamic, vascular, and proarrhythmic/electrophysiological consequences. Although natural opioid analogues are devoid of repolarization effects, synthetic agents may be proarrhythmic. This perspective explores cardiovascular consequences of opioids, the contributions of off-target electrophysiologic properties to mortality, and provides practical safety recommendations.
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http://dx.doi.org/10.1016/j.jacc.2020.11.002DOI Listing
January 2021

The Reply.

Am J Med 2021 01;134(1):e73

Department of Medicine, University of Colorado Health Science Center, Aurora; Eating Recovery Center, Denver Colo.

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http://dx.doi.org/10.1016/j.amjmed.2020.08.007DOI Listing
January 2021

Smartwatch detection of ventricular tachycardia: Case series.

HeartRhythm Case Rep 2020 Oct 18;6(10):800-804. Epub 2020 Aug 18.

Denver Health Medical Center, Denver, Colorado.

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http://dx.doi.org/10.1016/j.hrcr.2020.08.003DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7573479PMC
October 2020

Improving Atraumatic Chest Pain Evaluation in an Urban, Safety-net Hospital Through Incorporation of a Modified HEART Score.

Crit Pathw Cardiol 2020 12;19(4):173-177

Department of Medicine, Denver Health Medical Center, Denver, CO.

Atraumatic chest pain is a common emergency department (ED) presentation and the American College of Cardiology and American Heart Association recommends stress testing within 72 hours. The HEART score predicts major adverse cardiac events (MACE) in ED populations and does not require universal stress testing. An evaluation based solely on history, electrocardiography, and biomarkers, therefore, is an attractive approach to risk stratification in resource-limited settings. The HEART score has not been previously evaluated in a safety net hospital setting. We therefore implemented an interdisciplinary clinical care guideline utilizing the HEART score to stratify patients presenting to our inner-city hospital. During a 6-month study period, 1170 patients were evaluated (521 before and 649 after implementation). Among the 998 patients with confirmed follow-up 6-weeks after the index ED encounter, the prevalence of MACE (all-cause mortality, acute myocardial infarction, or coronary revascularization) was 0% [95% confidence interval (CI), 0%-1%] for low, 9% (95% CI, 7%-12%) for moderate, and 52% (95% CI, 39%-65%) for high-risk groups. Guideline implementation significantly increased admissions (+12%, 95% CI, 7%-17%) primarily in the moderate risk group (+38%, 95% CI, 29%-47%), but significantly decreased median ED length of stay (-37 minutes, 95% CI, 17-58). It also led to an increase in stress testing among moderate and high-risk patients (+10%, 95% CI, 0%-19%). In conclusion, the HEART score effectively stratified risk of MACE in a safety net population, improved evaluation consistency, and decreased ED length of stay. However, implementation was associated with an increase in hospitalizations and stress testing. Although the American Heart Association/American College of Cardiology guideline regarding atraumatic chest pain in the ED recommends universal noninvasive testing, the value of this approach, particularly in conjunction with the HEART score is uncertain in safety net hospitals. Further evaluation of the costs and clinical advantages of this approach are warranted.
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http://dx.doi.org/10.1097/HPC.0000000000000204DOI Listing
December 2020

Subendocardial stress in pre-eclampsia.

Ann Noninvasive Electrocardiol 2021 01 5;26(1):e12769. Epub 2020 Jun 5.

Department of Medicine, University of Colorado School of Medicine, Aurora, CO, USA.

A primigravida 26-year-old woman who had developed pre-eclampsia with malignant hypertension at 30 weeks of gestation suffered acute myocardial infarction two days postpartum. Electrocardiogram demonstrated diffuse ST-segment depression suggestive of subendocardial ischemia. Echocardiography demonstrated focal asymmetric left ventricular hypertrophy, with a characteristic "basal septal bulge", and a left ventricular mid-cavitary gradient of 51 mmHg. Coronary angiography revealed normal coronary arteries and vascular flow. Peripartum acute myocardial infarction is rare and portends a high mortality. However, to date, only one case of acute myocardial infarction associated with asymmetric left ventricular hypertrophy and pre-eclampsia has been described in the literature.
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http://dx.doi.org/10.1111/anec.12769DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7816804PMC
January 2021

Medical complications of anorexia nervosa.

Cleve Clin J Med 2020 06;87(6):361-366

Founder, ACUTE at Denver Health, Denver, CO; Eating Recovery Center, Denver, CO; Professor, Department of Medicine, University of Colorado School of Medicine, Aurora, CO

Anorexia nervosa is a mental illness characterized by self-starvation, marked weight loss, and malnutrition. As the illness worsens, numerous medical complications develop throughout the body. Some of these resolve with effective nutritional rehabilitation and weight gain, whereas others can lead to permanent damage.
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http://dx.doi.org/10.3949/ccjm.87a.19084DOI Listing
June 2020

Dangerous Needle Stick.

Circulation 2020 04 27;141(17):1424-1426. Epub 2020 Apr 27.

Uniformed Services University, Bethesda, MD (T.P.F., M.C.P.H.).

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http://dx.doi.org/10.1161/CIRCULATIONAHA.120.045929DOI Listing
April 2020

Is QTc-Interval Prolongation an Inherent Feature of Eating Disorders? A Cohort Study.

Am J Med 2020 09 9;133(9):1088-1094.e1. Epub 2020 Mar 9.

Department of Medicine, University of Colorado Health Science Center, Aurora; Eating Recovery Center, Denver Colo.

Background: Anorexia nervosa is associated with a markedly increased risk of sudden cardiac death, but the mechanism has not been elucidated. Whether QT prolongation is an intrinsic feature of eating disorders is uncertain because previous studies are limited by small sample size, and extrinsic factors associated with QT prolongation were inconsistently reported. This study set to determine population-mean heart-rate-corrected QT interval (QTc) in an unselected cohort of patients with eating disorders.

Methods: Electrocardiogram (ECG) data from 1026 consecutive adults admitted into residential treatment were stratified by subtype: anorexia nervosa (caloric restriction only), anorexia nervosa binge-purge, and bulimia nervosa. Eating disorders not otherwise specified were excluded. Population-mean Fridericia-corrected QTc and categorical QTc threshold analysis were performed. Multivariable regression, controlling for age sex, duration of illness, body mass index (BMI), hypokalemia, QTc-prolonging drugs, purging behaviors, and laxatives was assessed.

Results: Among 906 patients, population-mean QTc (424 ± 25 standard deviation [SD]) was normal and lowest among patients with anorexia nervosa (417.3 ± 22.3, P <0.001 vs other subgroups). Only 1.2% (N = 11) had marked QTc prolongation (QTc >500 ms); all 11 patients had hypokalemia and were receiving QTc-prolonging medications or laxatives. After controlling for clinically relevant covariates, differences in mean QTc across eating disorder subtypes diminished yet persisted (P = 0.048).

Conclusions: In the largest study of patients with eating disorders, population-mean QTc was normal and varied by subtype. Marked QTc prolongation occurred solely in the presence of extrinsic factors, suggesting that QTc prolongation is not intrinsic to eating disorders. Therefore, further study is needed to define the etiology of sudden death in patients with eating disorders.
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http://dx.doi.org/10.1016/j.amjmed.2020.02.015DOI Listing
September 2020

Long-term cardiac arrhythmia and chronotropic evaluation in patients with severe anorexia nervosa (LACE-AN): A pilot study.

J Cardiovasc Electrophysiol 2020 02 20;31(2):432-439. Epub 2020 Jan 20.

Department of Medicine, Division of Cardiology, Denver Health and Hospital Authority, Denver, Colorado.

Background: Anorexia nervosa (AN) is associated with autonomic dysfunction and carries a high risk of sudden death, putatively attributed to ventricular tachyarrhythmias. To date, long-term cardiac monitoring has not been performed to confirm this speculation.

Methods And Results: We assessed the safety and acceptability of an insertable cardiac monitor (ICM) in patients with severe AN with markedly reduced body mass index (BMI), and investigated heart rate (HR) and rhythm before and after weight restoration. Autonomic function was assessed as HR response to a standardized activity protocol at baseline and four additional visits over 360 days. The Florida Patient Acceptance Survey (FPAS) was used to measure ICM acceptability. During a mean follow-up of 10 months, no ICM-related complications occurred and ICM was well-accepted by the 11 study participants (nine women, aged 19-59 years, baseline BMI = 12.7 ± 1.6 kg/m ). Both resting and peak HR increased with weight restoration and were directly associated with BMI (both P < .001). No ventricular tachyarrhythmias occurred during the study period, but two participants (18%) experienced eight sinus pauses (3.0-7.0 seconds) and three runs of supraventricular tachycardia.

Conclusions: Long-term cardiac rhythm monitoring with an ICM is feasible, safe, and acceptable in patients with severe AN. Autonomic dysfunction in AN results in not only profound resting bradycardia, but also some degree of chronotropic incompetence, both of which improve with weight restoration. Clinically significant bradyarrhythmias are more common than ventricular tachyarrhythmias in AN, and may represent a competing underlying mechanism for the high risk of sudden death in this population.
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http://dx.doi.org/10.1111/jce.14338DOI Listing
February 2020

A case series of profound bradycardia in patients with severe anorexia nervosa: Thou shall not pace?

HeartRhythm Case Rep 2019 Oct 5;5(10):511-515. Epub 2019 Aug 5.

Division of Cardiology, Denver Health and the University of Colorado, Denver, Colorado.

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http://dx.doi.org/10.1016/j.hrcr.2019.07.011DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6831791PMC
October 2019

Man versus machine? Acquired long QT syndrome in a patient with anorexia nervosa.

Ann Noninvasive Electrocardiol 2020 07 24;25(4):e12704. Epub 2019 Sep 24.

Division of Cardiology, School of Medicine, University of Colorado, Aurora, Colorado.

Computer-generated Bazett-corrected QT (QTcB) algorithms are common in clinical practice and can rapidly identify repolarization abnormalities, but accuracy is variable. This report highlights marked rate-corrected QT (QTc) interval prolongation not detected by the computer algorithm. A 26-year-old woman with anorexia nervosa was admitted with severe hypokalemia and ventricular ectopy. Computer-generated QTcB was 485 ms, while manual adjudication yielded a QTcB of 657 ms and a Fridericia-corrected QT (QTcF) interval of 626 ms using digital calipers. Computer-generated QTc intervals may aid in clinical decision-making. However, accuracy is variable, particularly in the setting of ectopy, and requires manual verification.
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http://dx.doi.org/10.1111/anec.12704DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7358829PMC
July 2020

Treatment-Seeking Delay Among Hispanic and Non-Hispanic Women with Acute Myocardial Infarction.

Health Equity 2019 24;3(1):287-296. Epub 2019 Jun 24.

Department of Family Medicine, University of Colorado-Anschutz Medical Campus, Aurora, Colorado.

Women and minorities with acute myocardial infarction (AMI) often fail to recognize prodromal symptoms leading to delays in care. The objective of this study was to conduct a mixed method assessment of the impact of ethnicity on symptom description, recognition, and treatment-seeking behavior in Hispanic and non-Hispanic women before hospitalization for AMI. We explored differences in symptomatology, treatment-seeking behavior, and delay patterns among a convenience sample of 43 women diagnosed with AMI (17 Hispanic women, 26 non-Hispanic women) in seven rural and urban Colorado hospitals. We performed in-depth interviews to establish patterns (typologies) of treatment-seeking behaviors. Chart abstraction provided delay times as a function of ethnicity. Most (28/43) women reported prodromal symptoms in the weeks before their index AMI. Overall, fewer Hispanic women presented within 24 h of symptom onset (3/18, 17% vs. 15/18, 83%, <0.01). A typology of treatment-seeking behavior emerged: women who (1) recognized symptoms and promptly sought care; (2) did not recognize symptoms, yet promptly sought care; (3) recognized symptoms and promptly sought care, but providers misconstrued symptoms as noncardiac; and (4) misinterpreted symptoms due to an underlying chronic disease. Women and primary care providers often underappreciate prodromal AMI symptoms. Hispanic women are more likely to misinterpret ischemic symptoms and delay care, suggesting a need for tailored patient and provider education.
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http://dx.doi.org/10.1089/heq.2018.0046DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6634169PMC
June 2019

A controlled trial of mobile short message service among participants in a rural cardiovascular disease prevention program.

Prev Med Rep 2019 Mar 30;13:126-131. Epub 2018 Nov 30.

Colorado Prevention Center, Community Health Department, Aurora, CO, United States of America.

The statewide Colorado Healthy Heart Solutions (CHHS) program provides cardiovascular disease (CVD) risk factor screening and education to the medically underserved and has been shown to improve CVD risk profiles. We aimed to enhance its effectiveness through addition of a mobile health (mHealth) intervention using SMS messaging (termed Cardio SMS). We conducted a prospective, non-randomized controlled pilot trial of this intervention implemented at 5 rural program sites (number of participants  = 204) compared with a contemporaneous propensity-score matched control group from 14 CHHS sites not receiving the intervention ( = 408) between 2012 and 2014. All participants were free of CVD at baseline, and follow-up time was 12-months. The primary outcome was program engagement, defined as the number of completed interactions with the program during the entire follow-up period. Secondary outcomes were program retention, defined as any interaction during the last two months of the study; change in self-reported healthy behaviors (physical activity, weight loss, smoking cessation, fat intake); and change in CVD risk factors. There were trends for differences between groups across multiple outcomes, but most did not reach statistical significance, except for a greater decrease in self-reported fat intake in the intervention vs. control groups (26.3% vs 10.6%,  = 0.001). In addition, a subset of surveyed participants who viewed the SMS messages as motivating showed greater program retention ( = 0.03). Given the relative ease and scalability of SMS interventions in rural underserved communities, further study of SMS as part of multicomponent strategies for CVD prevention is warranted.
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http://dx.doi.org/10.1016/j.pmedr.2018.11.021DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6299144PMC
March 2019

Contrast-Enhanced Stress Echocardiography and Myocardial Perfusion Imaging in Patients Hospitalized With Chest Pain: A Randomized Study.

Crit Pathw Cardiol 2018 06;17(2):98-104

From the Department of Medicine, Division of Cardiology, Denver Health Medical Center, Denver CO.

Ultrasound contrast-enhanced stress echocardiography improves endocardial visualization, but diagnostic test rates versus stress myocardial perfusion imaging (MPI) have not been studied. A prospective randomized trial was performed between April 2012 and October 2014 at a single-center, safety net hospital. Hospitalized patients referred for noninvasive stress imaging were randomized 1:1 to stress echocardiography or stress MPI. The primary outcome was diagnostic test rate defined as interpretable images and achievement of >85% of age-predicted maximal heart rate (for dobutamine and exercise). Rates were assessed among those completing testing and then based solely on image interpretability. Charges and length of stay were secondary outcomes. A total of 240 patients were randomized, and 229 completed testing. Diagnostic test rates were similar for stress echocardiography versus MPI {89.4% [95% confidence interval (CI), 82.2-94.4] vs. 94.8% [95% CI, 89.1-98.1], P = 0.13} and did not differ with multivariable adjustment. Modalities requiring a diagnostic heart rate criteria were more frequently ordered with stress echocardiography (100% vs. 26%; P < 0.001). Therefore, an imaging-based analysis without the 12 individuals who failed to achieve target heart rate (n = 217) was evaluated with diagnostic test rates of 100% versus 94.8% (95% CI, 89.1%-98.1%; P = 0.03) for stress echocardiography and MPI, respectively. Median length of stay did not differ. Median (interquartile range) test-related charges were lower with stress echocardiography: $2,424 ($2400-$2508) versus $3619 ($3584-$3728), P < 0.0001. Overall, tests were positive for ischemia in 8% of patients. In conclusion, contrast-enhanced stress echocardiography provides comparable diagnostic test rates to MPI with lower associated charges.
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http://dx.doi.org/10.1097/HPC.0000000000000141DOI Listing
June 2018

Critical gaps in the medical knowledge base of eating disorders.

Eat Weight Disord 2018 Aug 21;23(4):419-430. Epub 2018 Apr 21.

ACUTE, at Denver Health, 777 Bannock Street, Denver, CO, 80204, USA.

Eating disorders are unique in that they inherently have much medical comorbidity both as a part of restricting-type eating disorders and those characterized by purging behaviors. Over the last three decades, remarkable progress has been made in the understanding and treatment of the medical complications of eating disorders. Yet, unfortunately, there is much research that is sorely needed to bridge the gap between current medical knowledge and more effective and evidence-based medical treatment knowledge. These gaps exist in many different clinical areas including cardiology, electrolytes, gastrointestinal and bone disease. In this paper, we discuss some of the knowledge gap areas, which if bridged would help develop more effective medical intervention for this population of patients.
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http://dx.doi.org/10.1007/s40519-018-0503-4DOI Listing
August 2018

CHAD is Dead: Pragmatic Utility of the CHADS-VASc Score in Non-Valvular Atrial Fibrillation?

J Gen Intern Med 2018 01;33(1):7-8

Division of Cardiology, University of Colorado School of Medicine, Aurora, CO, USA.

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http://dx.doi.org/10.1007/s11606-017-4148-1DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5756154PMC
January 2018

Reduction in Cardiovascular Risk Among Latino Participants in a Community-Based Intervention Linked With Clinical Care.

Am J Prev Med 2017 Aug 8;53(2):e71-e75. Epub 2017 Jun 8.

Colorado Prevention Center, Community Health Department, Aurora, Colorado; Department of Medicine, University of Colorado Anschutz Medical Campus, Aurora, Colorado; Ambulatory Care Services, Denver Health and Hospital Authority, Denver, Colorado. Electronic address:

Introduction: Community Heart Health Actions for Latinos at Risk is a community health worker-led cardiovascular disease risk reduction program targeting low-income urban Latinos. The impact of community programs linked with clinical care has not been well characterized.

Methods: Community Heart Health Actions for Latinos at Risk provided 12 weeks of lifestyle education. Changes in risk factors were assessed before and after completion. Univariate, bivariate, and multivariate analyses were used to determine factors associated with changes in risk factors.

Results: From 2009 to 2013, a total of 1,099 participants were recruited and 768 had risk factors measured at baseline and 12 weeks. All analyses were performed in 2016. In participants with abnormal baseline risk factors, significant (all p<0.001) median reductions in systolic blood pressure (-11 mmHg, n=244); low-density lipoprotein cholesterol (-14 mg/dL, n=201); glucose (-8 mg/dL, n=454); triglycerides (-57 mg/dL, n=242); and Framingham risk score (-2.3%, n=301) were observed. Program completion (eight of 12 classes) was associated with the reduction in low-density lipoprotein cholesterol (p=0.03) and systolic blood pressure (p=0.01). After adjustment, low-density lipoprotein cholesterol reduction was greatest in participants newly prescribed lipid-lowering drugs (-30%, 95% CI= -48, -15).

Conclusions: A community health worker-led intervention lowered cardiovascular disease risk among vulnerable Latinos. Integration with primary care services was an essential program component.
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http://dx.doi.org/10.1016/j.amepre.2017.04.012DOI Listing
August 2017

Resuscitated sudden cardiac death due to diminutive coronary artery syndrome.

HeartRhythm Case Rep 2017 Feb 30;3(2):141-144. Epub 2016 Nov 30.

Cardiology Division, Department of Medicine, University of Colorado, School of Medicine, and Denver Health Medical Center, Denver, Colorado.

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http://dx.doi.org/10.1016/j.hrcr.2016.11.003DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5420055PMC
February 2017

Refractory Cardiogenic Shock from Right Ventricular Infarction Successfully Managed with Inhaled Epoprostenol.

Am J Case Rep 2017 Mar 16;18:271-275. Epub 2017 Mar 16.

School of Medicine, University of Colorado, Aurora, CO, USA.

BACKGROUND Recognition and appropriate management of right ventricular (RV) infarction is essential, as RV injury increases mortality and substantially alters management during acute coronary syndrome. We report a case of RV infarction presenting with new right bundle branch block (RBBB), and therapeutic use of inhaled epoprostenol to reduce RV afterload and augment cardiac output during refractory cardiogenic shock. CASE REPORT A 53-year-old male presented to our institution in ventricular fibrillation with subsequent development of RBBB in the setting of proximal right coronary artery occlusion. Following percutaneous coronary intervention, the patient developed severe RV dysfunction with refractory cardiogenic shock. This was successfully managed with inhaled epoprostenol with normalization of right ventricular systolic function. CONCLUSIONS Although typically associated with anterior myocardial infarction, new RBBB should be recognized as a potential presenting sign of acute RV infarction. The use of inhaled epoprostenol in the setting of RV infarction has not been previously described, but it may augment right ventricular cardiac output via pulmonary vasodilatation.
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http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5363174PMC
http://dx.doi.org/10.12659/ajcr.901975DOI Listing
March 2017

Severe tricuspid regurgitation due to valvular entrapment of an inferior vena cava stent.

Clin Case Rep 2017 Feb 17;5(2):130-133. Epub 2017 Jan 17.

Denver Health Medical Center Denver Colorado USA.

Endovascular venous stenting is increasingly performed for a variety of conditions. Inferior vena cava stent migration has been reported up to 6 months after placement; stent migration 6 months after implantation is uncommon. To our knowledge, this is only the second reported case of late stent migration with valve entrapment 1.
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http://dx.doi.org/10.1002/ccr3.812DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5290522PMC
February 2017

Potent Inhibition of hERG Channels by the Over-the-Counter Antidiarrheal Agent Loperamide.

JACC Clin Electrophysiol 2016 12 14;2(7):784-789. Epub 2016 Sep 14.

Denver Health and University of Colorado, School of Medicine, Denver, Colorado. Electronic address:

Objectives: The aim of this study was to determine the in vitro electrophysiological properties of loperamide. The authors' hypothesis was that loperamide is a potent blocker of the current carried by the human ether-à-go-go-related gene (hERG) potassium channel.

Background: Loperamide is a peripherally-acting μ-opioid agonist available worldwide as an over-the-counter treatment for diarrhea. Like most opioids, it is not currently known to be proarrhythmic. Recent cases of torsade de pointes in association with high-dose loperamide raise concern given its structural similarity to methadone, another synthetic opioid with an established arrhythmia risk.

Methods: Effects of loperamide on blockade of the hERG potassium channel ion current were assessed in Chinese Hamster Ovary (CHO) cells stably expressing hERG to elucidate current amplitude and kinetics. The concentration required to produce 50% inhibition of hERG current was assessed from the amplitude of tail currents and the impact on action potential duration was assessed in isolated swine ventricular cardiomyocytes.

Results: The 50% inhibitory concentration for loperamide inhibition of hERG ionic tail currents was approximately 40 nmol/l. In current-voltage measurements, loperamide reduced steady and tail currents and shifted the current activation to more negative potentials. Loperamide (10 nmol/l) also increased the action potential duration, assessed at 90% of repolarization, in ventricular myocytes by 16.4 ± 1.7% (n = 6; p < 0.004). The maximum rate of rise of phase 0 of the action potential, however, was not significantly altered at any tested concentration of loperamide.

Conclusions: Loperamide is a potent hERG channel blocker. It significantly prolongs the action potential duration and suggests a causal association between loperamide and recent clinical cases of torsade de pointes.
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http://dx.doi.org/10.1016/j.jacep.2016.07.008DOI Listing
December 2016

Longitudinal Changes in Vascular Risk Markers and Mortality Rates among a Latino Population with Hypertension.

Tex Heart Inst J 2016 Apr 1;43(2):131-6. Epub 2016 Apr 1.

Vascular markers such as pulse-wave velocity and carotid intima-media thickness (CIMT) might improve the prediction of incident cardiovascular disease beyond traditional risk factors. These vascular markers have not been well characterized in minority populations and might be more useful than inflammatory biomarkers. We conducted a prospective, longitudinal cohort study among hypertensive patients in an urban safety-net hospital. We evaluated inflammatory biomarkers, arterial pulse-wave velocity, and carotid intima-media thickness at baseline, 1 year, and 2 years. The primary outcome variable was CIMT. Generalized linear mixed-effects models were used to evaluate associations between CIMT and predictive variables accounting for the correlation of multiple measurements within subjects over time. For our secondary outcome, we used administrative and National Death Index data to determine all-cause death, and univariate relationships were evaluated. Among 175 subjects, 117 were Latino (67%) and 117 were female (67%). Pulse-wave velocity and CIMT regressed over time (both P <0.001) and were highly correlated (P <0.001). Only pulse-wave velocity (P=0.002) and total cholesterol (P=0.03) were associated with CIMT in time-varying covariate analysis. At a median follow-up period of 80 months, 17 of 175 subjects had died (10%). Higher baseline CIMT and pulse-wave velocity were associated with increased mortality rates (both P <0.01). No serum inflammatory marker was significantly correlated with longitudinal changes in CIMT or death. In conclusion, both arterial stiffness and preclinical carotid atherosclerosis were associated with increased mortality rates and might be useful risk-stratification markers among this minority population.
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http://dx.doi.org/10.14503/THIJ-15-5053DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4845581PMC
April 2016

Cardiovascular disorders associated with naloxone monotherapy and in fixed-dose combination with opioids: Data from international safety surveillance.

Int J Cardiol 2016 Jun 24;212:360-3. Epub 2016 Mar 24.

Department of Medicine, Division of Cardiology, University of Colorado Health Sciences Center, United States; Denver Health Medical Center, Cardiology Division, United States. Electronic address:

Background: The widespread use of opioids has resulted in sharp rise of associated complications, particularly opioid-induced constipation (OIC). Opioid receptor antagonists have been proposed to treat OIC, but could precipitate rapid opioid withdrawal. As cardiovascular safety data are lacking, we assessed disproportionate reporting of adverse cardiac events associated with naloxone across large, international pharmacovigilance systems.

Methods: Post-marketing data from the World Health Organization (WHO) and FDA Adverse Events Reporting System (FAERS) were evaluated for naloxone and the synthetic opioids oxycodone and tilidine. The proportional reporting ratio (PRR), a measure of reporting frequency analogous to an odds ratio, was assessed. The primary outcome was reporting frequency of the MedDRA System Organ Class (SOC) 'Cardiac Disorders' for naloxone alone and in fixed-dose combination with opioids. Opioid mono-preparations served as quasi-experimental controls. A PRR greater than 2.0 was considered significant.

Results: In total, 14,827,374 million adverse drug event reports were reviewed. In WHO, there were 1757 reports of SOC cardiac disorders among 10,866 total reports for oxycodone (PRR 2.38 [95% CI 2.28-2.49, χ(2)=1504]). For oxycodone-naloxone, there were 43/453 reports of SOC cardiac disorders (PRR 1.45 [95% CI 1.09-1.92, χ(2)=6.4]). For the synthetic opioid tilidine there were 13/179 reports (PRR 1.13 [95% CI 0.67-1.91, χ(2)=0.2]) and for tilidine-naloxone, 30/505 reports (PRR 0.92 [95% CI 0.65-1.31, χ(2)=0.2]). In FAERS, the PRR for SOC cardiac disorders was 0.95 [95% CI 0.89-1.01, χ(2)=2.1] for naloxone (all administration routes) and 1.16 [95% CI 0.93-1.45, χ(2)=1.3] for naloxone (oral only). In comparison, the PRR was 1.66 [95% CI 1.63-1.69, χ(2)=4278] for oxycodone and 1.52 [CI 1.28-1.80, χ(2)=1500] for oxycodone-naloxone.

Conclusions: Available pharmacovigilance data do not suggest disproportionate reporting of adverse cardiovascular events for opioid antagonists used to treat OIC.
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http://dx.doi.org/10.1016/j.ijcard.2016.03.079DOI Listing
June 2016
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