Publications by authors named "Tushar Acharya"

29 Publications

  • Page 1 of 1

Comprehensive Management of Cardiovascular Risk Factors for Adults With Type 2 Diabetes: A Scientific Statement From the American Heart Association.

Circulation 2022 Jan 10:CIR0000000000001040. Epub 2022 Jan 10.

Cardiovascular disease remains the leading cause of death in patients with diabetes. Cardiovascular disease in diabetes is multifactorial, and control of the cardiovascular risk factors leads to substantial reductions in cardiovascular events. The 2015 American Heart Association and American Diabetes Association scientific statement, "Update on Prevention of Cardiovascular Disease in Adults With Type 2 Diabetes Mellitus in Light of Recent Evidence," highlighted the importance of modifying various risk factors responsible for cardiovascular disease in diabetes. At the time, there was limited evidence to suggest that glucose-lowering medications reduce the risk of cardiovascular events. At present, several large randomized controlled trials with newer antihyperglycemic agents have been completed, demonstrating cardiovascular safety and reduction in cardiovascular outcomes, including cardiovascular death, myocardial infarction, stroke, and heart failure. This AHA scientific statement update focuses on (1) the evidence and clinical utility of newer antihyperglycemic agents in improving glycemic control and reducing cardiovascular events in diabetes; (2) the impact of blood pressure control on cardiovascular events in diabetes; and (3) the role of newer lipid-lowering therapies in comprehensive cardiovascular risk management in adults with diabetes. This scientific statement addresses the continued importance of lifestyle interventions, pharmacological therapy, and surgical interventions to curb the epidemic of obesity and metabolic syndrome, important precursors of prediabetes, diabetes, and comorbid cardiovascular disease. Last, this scientific statement explores the critical importance of the social determinants of health and health equity in the continuum of care in diabetes and cardiovascular disease.
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http://dx.doi.org/10.1161/CIR.0000000000001040DOI Listing
January 2022

Cardiovascular Impact of Race and Ethnicity in Patients With Diabetes and Obesity: JACC Focus Seminar 2/9.

J Am Coll Cardiol 2021 12;78(24):2471-2482

Department of Medicine, University of California, San Francisco, California, USA. Electronic address:

Obesity and type 2 diabetes mellitus are highly prevalent and increasing in the United States among racial/ethnic minority groups. Type 2 diabetes mellitus, which is driven by many factors including elevated levels of adiposity, is an exemplar health disparities disease. Pervasive disparities exist at every level from risk factors through outcomes for U.S. racial/ethnic minority groups, including African American, Hispanic/LatinX American, and Asian American populations. Disparities in clinical care exist including hemoglobin A1c control, lower prescription rates of newer antihyperglycemic medications, along with greater rates of complications postbariatric surgery. Underpinning these disparities are the social determinants of health affecting provider-patient interactions, access to resources, and healthy built environments. We review the best practices to address cardiometabolic disparities in the current cardiovascular guidelines and describe recommendations for cross-cutting strategies to advance equity in obesity and type 2 diabetes across U.S. racial/ethnic groups.
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http://dx.doi.org/10.1016/j.jacc.2021.06.020DOI Listing
December 2021

Statin-Induced Triad of Autoimmune Myocarditis, Myositis, and Transaminitis.

Case Rep Cardiol 2021 8;2021:6660362. Epub 2021 Apr 8.

Division of Cardiology, Department of Internal Medicine, USA.

Despite well-established cardiovascular benefits, statins have been associated with myopathic side effects ranging from myalgias to rhabdomyolysis and autoimmune necrotizing myositis. Statins have not been previously shown to cause myocarditis. Our case highlights this rare entity.
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http://dx.doi.org/10.1155/2021/6660362DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8052178PMC
April 2021

Imaging in heart failure with preserved ejection fraction: insights into echocardiography and cardiac magnetic resonance imaging.

Rev Cardiovasc Med 2021 Mar;22(1):11-24

Department of Internal Medicine, University of Arizona College of Medicine, Tucson, AZ 85724, USA.

Heart failure with preserved ejection fraction (HFpEF) is increasingly prevalent and represents more than half of all heart failure cases. It is defined by the presence of heart failure signs and symptoms, identification of cardiac structural abnormalities leading to high left ventricular filling pressures, and an EF > 50%. Common imaging findings in HFpEF include left ventricular hypertrophy, diastolic dysfunction, left atrial enlargement, and elevated pulmonary artery pressure (> 35 mm Hg). Echocardiography is the primary imaging modality for diagnosing HFpEF. It can be complemented by cardiac magnetic resonance (CMR) when further characterization is needed. Advances like real-time 3-dimensional echocardiography and speckle-tracking derived strain, as well as tissue characterization by CMR, have furthered our understanding of the mechanisms and aided in making the diagnosis of a diverse group of conditions that can present as HFpEF. This review aims to touch upon the imaging methods of characterizing HFpEF and discuss their role in specific disease entities.
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http://dx.doi.org/10.31083/j.rcm.2021.01.134DOI Listing
March 2021

Incidental isolated septal infarct in a young patient with colon cancer.

Eur Heart J 2021 07;42(26):2613

University of Arizona College of Medicine, Tucson, AZ, USA.

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http://dx.doi.org/10.1093/eurheartj/ehaa537DOI Listing
July 2021

Performance of single-energy metal artifact reduction in cardiac computed tomography: A clinical and phantom study.

J Cardiovasc Comput Tomogr 2020 Nov - Dec;14(6):510-515. Epub 2020 Apr 16.

National Heart, Lung, and Blood Institute, National Institutes of Health, Bethesda, MD, USA. Electronic address:

Background: To investigate the performance of a reconstruction algorithm, single-energy metal artifact reduction (SEMAR), against standard reconstruction in cardiac computed tomography (CT) studies of patients with implanted metal and in a defibrillator lead phantom.

Methods: From a retrospective, cross-sectional clinical study with institutional review board approval of 118 patients with implanted metal, 122 cardiac CT studies from November 2009 to August 2016 performed on a 320-detector row scanner with standard and SEMAR reconstructions were included. The maximum beam hardening artifact radius, artifact attenuation variation surrounding the implanted metal, and image quality on a 4-point scale (1-no/minimal artifact to 4-severe artifact) were assessed for each reconstruction. A defibrillator lead phantom study was performed at different tube potentials and currents with both reconstruction methods. Maximum beam hardening artifact radius and average artifact attenuation variation were measured.

Results: In the clinical study, SEMAR markedly reduced the maximum beam hardening artifact radius by 77% (standard: 14.8 mm [IQR 9.7-22.2] vs. SEMAR: 3.4 mm [IQR 2.2-7.1], p < 0.0001) and artifact attenuation variation by 51% (standard: 130.0 HU [IQR 75.9-184.4] vs. SEMAR: 64.3 HU [IQR 48.2-89.2], p < 0.0001). Image quality improved with SEMAR (standard: 3 [IQR 2-3.5] vs. SEMAR: 2 [IQR 1-2.5], p < 0.0001). The defibrillator lead phantom study confirmed these results across varying tube potentials and currents.

Conclusions: SEMAR reconstruction achieved superior image quality and markedly reduced maximum beam hardening artifact radius and artifact attenuation variation compared to standard reconstruction in 122 clinical cardiac CT studies of patients with implanted metal and in a defibrillator lead phantom study.
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http://dx.doi.org/10.1016/j.jcct.2020.04.005DOI Listing
January 2021

Comparison of professional medical society guidelines for appropriate use of coronary computed tomography angiography.

J Cardiovasc Comput Tomogr 2020 Nov - Dec;14(6):478-482. Epub 2020 Feb 3.

Laboratory of Cardiovascular CT, Cardiovascular Branch, National Heart, Lung, and Blood Institute, National Institutes of Health, Bethesda, MD, USA. Electronic address:

Background: Multiple appropriate use criteria (AUC) exist for the evaluation of coronary artery disease (CAD), but there is little data on the agreement between AUC from different professional medical societies. The aim of this study is to compare the appropriateness of coronary computed tomography angiography (CCTA) exams assessed using multimodality AUC from the American College of Cardiology Foundation (ACCF) versus the American College of Radiology (ACR).

Methods: In a single-center prospective cohort study from June 2014 to 2016, 1005 consecutive subjects referred for evaluation of known or suspected CAD received a contrast-enhanced CCTA. The primary outcome was the agreement of appropriateness ratings using ACCF and ACR guidelines, measured by the kappa statistic. A secondary outcome was the rate of obstructive CAD by appropriateness rating.

Results: Among 1005 subjects, the median (5-95th percentile) age was 59 (37-76) years with 59.0% male. The ACCF criteria classified 39.6% (n = 398) appropriate, 24.2% (n = 243) maybe appropriate, and 36.2% (n = 364) rarely appropriate. The ACR guidelines classified 72.3% (n = 727) appropriate, 2.6% (n = 26) maybe appropriate, and 25.1% (n = 252) rarely appropriate. ACCF and ACR appropriateness ratings were in agreement for 55.0% (n = 553). Overall, there was poor agreement (kappa 0.27 [95% confidence interval 0.23-0.31]). By both AUC methods, a low rate of obstructive CAD was observed in the rarely appropriate exams (ACCF 7.1% [n = 26 of 364] and ACR 13.5% [n = 34 of 252]).

Conclusions: Compared to ACCF criteria, the ACR guidelines of appropriateness were broader and classified significantly more CCTA exams as appropriate. The poor agreement between appropriateness ratings from the ACCF and ACR AUC guidelines evokes implications for reimbursement and future test utilization.
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http://dx.doi.org/10.1016/j.jcct.2020.01.014DOI Listing
January 2021

Cardiovascular outcome trials of the newer anti-diabetic medications.

Prog Cardiovasc Dis 2019 Jul - Aug;62(4):342-348. Epub 2019 Aug 21.

University of California, San Francisco, United States of America. Electronic address:

Concerns of elevated cardiovascular disease (CVD) risk with some anti-diabetic medications warranted phase 4 clinical trials to demonstrate CVD safety of newly marketed anti-diabetic drugs. Although initially designed to evaluate safety, some of these CVD outcome trials (CVOTs) have in fact shown CVD benefits. New medication classes, like glucagon-like peptide 1 (GLP-1) analogues and sodium-glucose co-transporter 2 (SGLT2) inhibitors, have shown reductions in the risk of major adverse cardiovascular events (MACE) including, myocardial infarction, stroke, CV death, and heart failure (HF). Perhaps more importantly, SGLT2 inhibitors demonstrated reduction in the risk of HF hospitalizations, being the first class of anti-diabetic drugs to do so. Conversely, dipeptidyl peptidase 4 (DPP-4) inhibitors did not significantly affect atherosclerotic CVD end-points and some actually increased the risk of HF hospitalizations. Further, the adverse/beneficial CVD effects of these medications may not be class specific. This review focuses on the main results of these CVOTs while highlighting the heterogeneity of CVD end-points within each class and discusses important mechanistic insights and adverse effect profiles.
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http://dx.doi.org/10.1016/j.pcad.2019.08.003DOI Listing
December 2019

Interpreting the Prognostic Value of Unrecognized Myocardial Infarction Among Older Adults-Reply.

JAMA Cardiol 2019 04;4(4):391-392

National Heart, Lung, and Blood Institute, National Institutes of Health, Bethesda, Maryland.

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http://dx.doi.org/10.1001/jamacardio.2019.0207DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7458130PMC
April 2019

Cardiovascular Protection with Anti-hyperglycemic Agents.

Am J Cardiovasc Drugs 2019 Jun;19(3):249-257

Division of Cardiology, Department of Medicine, Sarver Heart Center, University of Arizona College of Medicine, Tucson, AZ, 85724-5037, USA.

Diabetes mellitus is a major risk factor for cardiovascular (CV) disease. Conversely, CV disease is responsible for a majority of the deaths in patients with diabetes. Many drug trials have concentrated on blood glucose (hemoglobin A) reduction. This strategy, while reducing microvascular outcomes like nephropathy and neuropathy, has little or no effect on reducing macrovascular events like heart attack, stroke, and heart failure. It has been postulated that hypoglycemia may counterbalance some of the beneficial effects of anti-hyperglycemic agents, but this is not proven. Further, trial evidence for thiazolidinediones (rosiglitazone and pioglitazone) showed increased risk of heart failure and raised concerns about increased myocardial infarction. This heightened awareness of potentially harmful CV effects of otherwise effective hypoglycemic drugs resulted in regulatory mandates for CV outcome trials to ascertain the safety of newer anti-hypoglycemic agents appearing on the market. Three new classes of anti-hyperglycemic agents have been introduced in recent years. While dipeptidyl peptidase-4 (DPP-4) inhibitors exhibited increased heart failure hospitalization in the SAVOR-TIMI 53 trial evaluating saxagliptin and in the secondary analysis of the EXAMINE trial for alogliptin, the effects of glucagon-like peptide-1 (GLP-1) analogs and sodium-glucose co-transporter-2 (SGLT2) inhibitors on CV outcomes in diabetes have largely been positive. The LEADER and SUSTAIN-6 trials evaluating the safety and efficacy of the GLP-1 analogs liraglutide and semaglutide, respectively, showed a statistically significant reduction in the primary outcome (major adverse cardiac events [MACE]: CV death, myocardial infarction, and stroke) and the secondary combined outcome when compared to placebo. Results of the TECOS trial for sitagliptin were, however, neutral (no net CV benefit or harm), questioning the class effect of GLP-1 analogs. Results of the SGLT2 inhibitor trials were more uniform. While EMPA-REG (evaluating empagliflozin) and CANVAS (evaluating canagliflozin) showed a reduction in the MACE end point, dapagliflozin had a net neutral effect on MACE in DECLARE-TIMI 58. All three SGLT2 inhibitors, however, showed a significant reduction in heart failure hospitalizations. Although initially designed to keep potentially harmful anti-hyperglycemic agents off the market, the CV outcome trials have provided clinicians with a new set of anti-hyperglycemic drugs with proven CV benefit in patients with diabetes and CV disease, thus expanding the field of CV secondary prevention. There is a need to inculcate GLP-1 analogs and SGLT2 inhibitors that reduce major CV events and heart failure hospitalizations (alongside lifestyle management and metformin) in the treatment of patients with diabetes and CV disease.
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http://dx.doi.org/10.1007/s40256-019-00325-9DOI Listing
June 2019

Myocardial segmental thickness variability on echocardiography is a highly sensitive and specific marker to distinguish ischemic and non-ischemic dilated cardiomyopathy in new onset heart failure.

Int J Cardiovasc Imaging 2019 May 29;35(5):791-798. Epub 2018 Dec 29.

Division of Cardiology, UCSF Fresno, 155 N Fresno St, Fresno, CA, USA.

The aim of this study was to determine non-invasive diagnostic markers by echocardiography that differentiate ischemic dilated (ICM) from non-ischemic dilated cardiomyopathy (NICM) in patients with new onset heart failure. We identified 100 consecutive new heart failure patients with dilated cardiomyopathy (valvular etiology excluded). Clinical risk factors, medication history, serum biomarkers, ECG and echocardiographic variables were compared between the ICM and NICM groups (as confirmed by coronary angiography). Mean age, left ventricular size and ejection fraction were 56 years, 6.1 cm and 26% respectively. A total of 24% had ICM. Patients with ICM were older (65 vs. 53 years; P < 0.001). No significant difference was observed between ICM and NICM among 18 clinical variables, 7 laboratory tests, 6 EKG parameters and 10 of the 13 echocardiographic markers evaluated. Segmental wall thickness variability, regional wall motion abnormality and RV enlargement on echocardiogram (echo) differentiated ICM from NICM. Segmental thickness variability outperformed wall motion abnormality in diagnosing ICM with a sensitivity and specificity of 79.2 and 98.7% versus 62.5 and 84.2% respectively. RV enlargement was not sensitive but 90.6% specific for predicting NICM. Myocardial segmental thickness variability on echo, resulting from thinned infarcted or hibernating myocardium, is a highly sensitive and specific marker to differentiate ICM from NICM in new onset heart failure.
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http://dx.doi.org/10.1007/s10554-018-01515-3DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6486529PMC
May 2019

Association of Unrecognized Myocardial Infarction With Long-term Outcomes in Community-Dwelling Older Adults: The ICELAND MI Study.

JAMA Cardiol 2018 11;3(11):1101-1106

National Heart, Lung, and Blood Institute, National Institutes of Health, Bethesda, Maryland.

Importance: Cardiac magnetic resonance (CMR) imaging can identify unrecognized myocardial infarction (UMI) in the general population. Unrecognized myocardial infarction by CMR portends poor prognosis in the short term but, to our knowledge, long-term outcomes are not known.

Objective: To determine the long-term outcomes of UMI by CMR compared with clinically recognized myocardial infarction (RMI) and no myocardial infarction (MI).

Design, Setting, And Participants: Participants of the population-based, prospectively enrolled ICELAND MI cohort study (aged 67-93 years) were characterized with CMR at baseline (from January 2004-January 2007) and followed up for up to 13.3 years. Kaplan-Meier time-to-event analyses and a Cox regression were used to assess the association of UMI at baseline with death and future cardiovascular events.

Main Outcomes And Measures: The primary outcome was all-cause mortality. Secondary outcomes were a composite of major adverse cardiac events (MACE: death, nonfatal MI, and heart failure).

Results: Of 935 participants, 452 (48.3%) were men; the mean (SD) age of participants with no MI, UMI, and RMI was 75.6 (5.3) years, 76.8 (5.2) years, and 76.8 (4.7) years, respectively. At 3 years, UMI and no MI mortality rates were similar (3%) and lower than RMI rates (9%). At 5 years, UMI mortality rates (13%) increased and were higher than no MI rates (8%) but still lower than RMI rates (19%). By 10 years, UMI and RMI mortality rates (49% and 51%, respectively) were not statistically different; both were significantly higher than no MI (30%) (P < .001). After adjusting for age, sex, and diabetes, UMI by CMR had an increased risk of death (hazard ratio [HR], 1.61; 95% CI, 1.27-2.04), MACE (HR, 1.56; 95% CI, 1.26-1.93), MI (HR, 2.09; 95% CI, 1.45-3.03), and heart failure (HR, 1.52; 95% CI, 1.09-2.14) compared with no MI and statistically nondifferent risk of death (HR, 0.99; 95% CI, 0.71-1.38) and MACE (HR, 1.23; 95% CI, 0.91-1.66) vs RMI.

Conclusions And Relevance: In this study, all-cause mortality of UMI was higher than no MI, but within 10 years from baseline evaluation was equivalent with RMI. Unrecognized MI was also associated with an elevated risk of nonfatal MI and heart failure. Whether secondary prevention can alter the prognosis of UMI will require prospective testing.
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http://dx.doi.org/10.1001/jamacardio.2018.3285DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6353564PMC
November 2018

The pulmonary embolism that wasn't: a case of pulmonary pseudosequestration.

Eur Heart J Cardiovasc Imaging 2018 11;19(11):1310

National Heart, Lung, and Blood Institute, National Institutes of Health, 10 Center Drive, MSC 1061 Building 10, Room B1D416, Bethesda, MD, USA.

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http://dx.doi.org/10.1093/ehjci/jey094DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6458896PMC
November 2018

Dynamic nature of caseous mitral annular calcification.

J Cardiovasc Comput Tomogr 2018 Sep - Oct;12(5):444-446. Epub 2018 May 24.

Advanced Cardiovascular Imaging Laboratory, Cardiovascular and Pulmonary Branch, National Heart, Lung, and Blood Institute, National Institutes of Health, Bethesda, MD, USA. Electronic address:

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http://dx.doi.org/10.1016/j.jcct.2018.05.012DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6177286PMC
January 2019

Fibrosis as measured by the biomarker, tissue inhibitor metalloproteinase-1, predicts mortality in Age Gene Environment Susceptibility-Reykjavik (AGES-Reykjavik) Study.

Eur Heart J 2017 Dec;38(46):3423-3430

Department of Health and Human Services, National Heart, Lung, and Blood, National Institutes of Health, Building 10, Room B1D416, MSC 1061, 10 Center Drive, Bethesda, MD 20892-1061, USA.

Background: Fibrosis is a key pathological process in many chronic inflammatory disease states.

Aims: We hypothesized that tissue inhibitor metalloproteinase-1 and matrix metalloproteinase-9 (TIMP-1 and MMP-9), biomarkers of fibrosis, would predict all-cause mortality and we assessed the incremental value of these biomarkers when adjusting for clinical and other biomarkers.

Methods: The cohort included 5511 community-dwelling participants in the AGES-Reykjavik Study. The baseline Cox proportional hazards regression model was based on the Framingham Risk Score variables; we added TIMP-1, MMP-9, serum high-sensitivity C-reactive protein (hsCRP), and estimated glomerular filtration rate (eGFR). The primary outcome was all-cause 10-year mortality. Cause of death was categorized as cardiovascular death (CVD), cancer death, and other causes.

Results: Participants averaged 76 years and 43% were male. Ten-year mortality was 41% (2263 deaths). Of these, 915 (16.6%) died of cardiovascular disease (CVD), 543 (9.9%) with cancer, and 805 (14.6%) from other causes. For 10-year mortality, age was the strongest predictor (log likelihood χ2 = 798.7, P < 0.0001), followed by TIMP-1 (χ2 = 125.2, P < 0.0001), female gender, current smoker, diabetes mellitus, total cholesterol, eGFR (χ2 16.7, P < 0.0001), body mass index, and hsCRP (χ2 11.3, P = 0.0008) in that order. TIMP-1 and hsCRP had the highest continuous net reclassification improvement over the baseline model for 5-year survival [net reclassification index (NRI) 0.28 and 0.19, respectively, both P < 0.0001] and for 10-year survival (NRI 0.19 and 0.11, respectively, both statistically significant).

Conclusion: TIMP-1 is the strongest predictor of all-cause mortality after age. The metabolic pathways regulating extracellular matrix homeostasis and fibrogenic processes appear pathologically relevant and are prognostically important.
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http://dx.doi.org/10.1093/eurheartj/ehx510DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5837193PMC
December 2017

Hearty Breakfast for Healthier Arteries.

J Am Coll Cardiol 2017 10;70(15):1843-1845

Advanced Cardiovascular Imaging, National Heart, Lung, and Blood Institute, Washington, DC.

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http://dx.doi.org/10.1016/j.jacc.2017.08.054DOI Listing
October 2017

In-Hospital Outcomes of Percutaneous Coronary Intervention in America's Safety Net: Insights From the NCDR Cath-PCI Registry.

JACC Cardiovasc Interv 2017 08;10(15):1475-1485

University of California, San Francisco, Fresno, California. Electronic address:

Objectives: This study compared risk-adjusted percutaneous coronary intervention (PCI) outcomes of safety-net hospitals (SNHs) and non-SNHs.

Background: Although risk adjustment is used to compare hospitals, SNHs treat a disproportionate share of uninsured and underinsured patients, who may have unmeasured risk factors, limited health care access, and poorer outcomes than patients treated at non-SNHs.

Methods: Using the National Cardiovascular Data Registry CathPCI Registry from 2009 to 2015, we analyzed 3,746,961 patients who underwent PCI at 282 SNHs (hospitals where ≥10% of PCI patients were uninsured) and 1,134 non-SNHs. The relationship between SNH status and risk-adjusted outcomes was assessed.

Results: SNHs were more likely to be lower volume, rural hospitals located in the southern states. Patients treated at SNHs were younger (63 vs. 65 years), more often nonwhite (17% vs. 12%), smokers (33% vs. 26%), and more likely to be admitted through the emergency department (48% vs. 38%) and to have an ST-segment elevation myocardial infarction (20% vs. 14%) than non-SNHs (all p < 0.001). Patients undergoing PCI at SNHs had higher risk-adjusted in-hospital mortality (odds ratio: 1.23; 95% confidence interval: 1.17 to 1.32; p < 0.001), although the absolute risk difference between groups was small (0.4%). Risk-adjusted bleeding (odds ratio: 1.05; 95% confidence interval: 1.00 to 1.12; p = 0.062) and acute kidney injury rates (odds ratio: 1.01; 95% confidence interval: 0.96 to 1.07; p = 0.51) were similar.

Conclusions: Despite treating a higher proportion of uninsured patients with more acute presentations, risk-adjusted PCI-related in-hospital mortality of SNHs is only marginally higher (4 additional deaths per 1,000 PCI cases) than non-SNHs, whereas risk-adjusted bleeding and acute kidney injury rates are comparable.
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http://dx.doi.org/10.1016/j.jcin.2017.05.042DOI Listing
August 2017

Compliance with guideline-directed therapy in diabetic patients admitted with acute coronary syndrome: Findings from the American Heart Association's Get With The Guidelines-Coronary Artery Disease (GWTG-CAD) program.

Am Heart J 2017 May 23;187:78-87. Epub 2017 Feb 23.

Brigham and Women's Hospital Heart & Vascular Center and Harvard Medical School, Boston, MA.

Background: To evaluate and compare baseline characteristics, outcomes and compliance with guideline based therapy at discharge among diabetic and non-diabetic patients admitted with acute coronary syndromes (ACS).

Methods And Results: Study population consisted of 151,270 patients admitted with ACS from 2002 through 2008 at 411 sites participating in the American Heart Association's Get with the Guidelines (GWTG) program. Demographic variables, physical exam findings, laboratory data, left ventricular ejection fraction, length of stay, in-hospital mortality and discharge medications were compared between diabetic and non-diabetic patients. Temporal trends in compliance with guidelines directed therapy were evaluated. Of 151,270 patients, 48,938 (32%) had diabetes. Overall, diabetic patients were significantly older and more likely non-white. They had significantly more hypertension, atherosclerotic disease, CKD, and LV dysfunction and were more likely to present as NSTEMI. They had longer hospital stay and higher hospital mortality than non-diabetic patients. Diabetic patients were less likely to get LDL checks (65% vs 70%) and less frequently prescribed statins (85% vs 89%), RAAS blockers for LV dysfunction (80% vs 84%) and dual-antiplatelet therapy (69% vs 74%). Diabetic patients were less likely to achieve BP goals before discharge (75% vs 82%). Fewer diabetic patients met first medical contact to PCI time for STEMI (44% vs 52%). Temporal trends, however, showed continued progressive improvement in most performance measures from 2002 to 2008 (all P<.001).

Conclusions: These data from a large cohort of ACS patients demonstrate gaps in compliance with guidelines directed therapy in diabetic patients but also indicate significant and continued improvement in most performance measures over time. Concerted efforts are needed to continue this positive trend.
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http://dx.doi.org/10.1016/j.ahj.2017.02.025DOI Listing
May 2017

Anticoagulation in Atrial Fibrillation: Is the Paradigm Really Shifting?

J Am Coll Cardiol 2017 02;69(7):786-788

Advanced Cardiovascular Imaging Laboratory, Cardiovascular and Pulmonary Branch, National Heart, Lung, and Blood Institute, National Institutes of Health, Bethesda, Maryland.

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http://dx.doi.org/10.1016/j.jacc.2016.11.062DOI Listing
February 2017

Finding the High-Risk Patient in Primary Prevention Is Not as Easy as a Conventional Risk Score!

Am J Med 2016 Dec 24;129(12):1329.e1-1329.e7. Epub 2016 Aug 24.

University of California, San Francisco, Fresno.

Patients with coronary artery disease or its equivalent are an appropriate target for guideline-directed therapy. However, finding and treating the individuals at risk for myocardial infarction or sudden death in primary prevention has been problematic. Most initial cardiovascular events are acute syndromes, and only a minority of these occurs in those deemed high risk by contemporary algorithms. Even newer noninvasive modalities cannot detect a majority of those at risk. Furthermore, accurate and early detection of high risk/vulnerability does not guarantee event prevention. Until new tools can be identified, one should consider a few simplistic solutions. In addition to a greater emphasis on lifestyle, earlier use of statins than currently recommended and a direct assault on tobacco could go a long way in reducing acute syndromes and cardiovascular mortality. To achieve the tobacco goal, the medical community would have to be directly and communally engaged.
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http://dx.doi.org/10.1016/j.amjmed.2016.07.014DOI Listing
December 2016

Mechanical Circulatory Support and Rationale for Future Research-Reply.

JAMA Intern Med 2016 05;176(5):715-6

Division of Cardiology, University of California-San Francisco, San Francisco2Department of Internal Medicine, University of California-San Francisco, San Francisco.

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http://dx.doi.org/10.1001/jamainternmed.2016.0813DOI Listing
May 2016

Left Atrial Area and Right Ventricle Dimensions in Non-gated Axial Chest CT can Differentiate Pulmonary Hypertension Due to Left Heart Disease from Other Causes.

J Cardiovasc Comput Tomogr 2016 May-Jun;10(3):246-50. Epub 2016 Jan 30.

UCSF Fresno, Cardiovascular Division, 2823 Fresno St, Fresno, CA 93721, USA.

Background: It is unknown whether axial non-gated CT can distinguish World Health Organization Group 2 pulmonary hypertension (pulmonary hypertension due to left heart disease) from non-Group 2 pulmonary hypertension.

Objective: The study was performed to identity imaging parameters in non-gated chest CT that differentiate Group 2 from non-Group 2 pulmonary hypertension.

Methods: Among 158 patients who underwent right heart catheterization for evaluation of pulmonary hypertension, 112 had sufficient data and chest CT for review. Invasive hemodynamic data and numerous variables obtained from axial CT images (maximum diameters of main, right, left pulmonary arteries, ascending aorta, main pulmonary artery to ascending aorta diameter ratio, right atrial diameter, left atrial area and right ventricular size) were collected. CT variables were validated against hemodynamic data to identify parameters that would allow to differentiate pulmonary hypertension due to left heart disease (Group 2) from non-Group 2 pulmonary hypertension.

Results: Based on right heart catheterization data, we identified 53 patients with Group 2 pulmonary hypertension, 50 patients with non-Group 2 pulmonary hypertension, and 9 subjects with no pulmonary hypertension. In patients with a dilated pulmonary artery (n = 84), the ROC curve for left atrial area (area under the ROC curve 0.76 ± 0.06) independently distinguished patients with Group 2 pulmonary hypertension (n = 42) from patients with non-Group 2 pulmonary hypertension (n = 42). A dilated left atrium (>20 mm(2)) in combination with a normal right ventriuclar size had a sensitivity of 77% and specificity of 94% for Group 2 pulmonary hypertension.

Conclusions: In patients with a dilated pulmonary artery on chest CT, left atrial area and right ventricular dimensions may aid to diagnose pulmonary hypertension and to distinguish underlying cardiac disease from other causes.
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http://dx.doi.org/10.1016/j.jcct.2016.01.014DOI Listing
April 2017

Statin Use and the Risk of Kidney Disease With Long-Term Follow-Up (8.4-Year Study).

Am J Cardiol 2016 Feb 2;117(4):647-655. Epub 2015 Dec 2.

Department of Medicine, VA North Texas Health Care System, Dallas, Texas; Department of Internal Medicine, University of Texas Southwestern Medical Center, Dallas, Texas; Department of Clinical Sciences, University of Texas Southwestern Medical Center, Dallas, Texas. Electronic address:

Few studies have examined long-term effects of statin therapy on kidney diseases. The objective of this study was to determine the association of statin use with incidence of acute and chronic kidney diseases after prolonged follow-up. In this retrospective cohort study, we analyzed data from the San Antonio area military health care system from October 2003 through March 2012. Statin users were propensity score matched to nonusers using 82 baseline characteristics including demographics, co-morbidities, medications, and health care utilization. Study outcomes were acute kidney injury, chronic kidney disease (CKD), and nephritis/nephrosis/renal sclerosis. Of the 43,438 subjects included, we propensity score matched 6,342 statin users with 6,342 nonusers. Statin users had greater odds of acute kidney injury (odds ratio [OR] 1.30, 95% confidence interval [CI] 1.14 to 1.48), CKD (OR 1.36, 95% CI 1.22 to 1.52), and nephritis/nephrosis/renal sclerosis (OR 1.35, 95% CI 1.05 to 1.73). In a subset of patients without co-morbidities, the association of statin use with CKD remained significant (OR 1.53, 95% CI 1.27 to 1.85). In a secondary analysis, adjusting for diseases/conditions that developed during follow-up weakened this association. In conclusion, statin use is associated with increased incidence of acute and chronic kidney disease. These findings are cautionary and suggest that long-term effects of statins in real-life patients may differ from shorter term effects in selected clinical trial populations.
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http://dx.doi.org/10.1016/j.amjcard.2015.11.031DOI Listing
February 2016

Frequent Atrial Premature Complexes and Their Association With Risk of Atrial Fibrillation.

Am J Cardiol 2015 Dec 3;116(12):1852-7. Epub 2015 Oct 3.

Department of Internal Medicine, Division of Cardiology, Veterans Administration Central California Health Care System and University of California, San Francisco, Fresno, California; Department of Internal Medicine, Veterans Administration Central California Health Care System and University of California, San Francisco, Fresno, California.

Identification of precursors of atrial fibrillation (AF) may lead to early detection and prevent associated morbidity and mortality. This study aimed to examine the association between frequent atrial premature complexes (APCs) and incidence of AF. For this retrospective cohort study, we analyzed Holter recordings obtained from 2000 to 2010 of 1,357 veterans free of AF at baseline. All pertinent data in electronic medical records were reviewed to ascertain baseline characteristics. Holter groups with frequent (≥100/day) and infrequent (<100/day) APCs were compared for development of new AF over a median follow-up of 7.5 years. Multivariate Cox regression analyses were performed before and after propensity score matching. Mean age was 64 years with 93% men. Mean body mass index, hemoglobin A1C, low-density lipoprotein, left atrial size, and heart rate were 31.24 kg/m(2), 6.42%, 107.92 mg/dl, 4.26 cm, and 73 beats/min, respectively. AF was noted in 21.8% of patients with frequent APCs compared to 5.6% of those with infrequent APCs. After adjusting for demographics, medication use, co-morbidities, and laboratory and echocardiographic findings, multivariate Cox regression analyses confirmed frequent APCs to be independently associated with higher incidence of AF (hazard ratio [HR] 2.97, 95% confidence interval [CI] 1.85 to 4.80; p <0.001). In propensity-matched groups, this association remained significant (HR 2.87, 95% CI 1.65 to 4.98; p <0.001). Additionally, atrial couplets (≥50/day), atrial bigeminy (≥50/day), frequent runs of ≥3 APCs (≥20 runs/day), and longer runs (≥10 beats/run) were significantly associated with AF (HR 3.11, 3.67, 2.94, and 1.73, respectively, all p <0.05). In conclusion, frequent APCs (≥100/day) are associated with greater risk of AF.
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http://dx.doi.org/10.1016/j.amjcard.2015.09.025DOI Listing
December 2015

Is Increased Use of Mechanical Circulatory Support Devices Justified? A Cause for Concern.

JAMA Intern Med 2015 Dec;175(12):1982-3

Division of Cardiology, Department of Internal Medicine, University of California San Francisco, Fresno.

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http://dx.doi.org/10.1001/jamainternmed.2015.6093DOI Listing
December 2015

An evidence-based review of edoxaban and its role in stroke prevention in patients with nonvalvular atrial fibrillation.

Core Evid 2015 28;10:63-73. Epub 2015 May 28.

Division of Cardiology, Department of Internal Medicine, University of California, San Francisco, Fresno, CA, USA.

Atrial fibrillation is the most common arrhythmia in the elderly. It is responsible for significant morbidity and mortality from cardioembolic complications like stroke. As a result, atrial fibrillation patients are risk-stratified using the CHADS2 or CHA2DS2-VASc scoring systems. Those at intermediate-to-high risk have traditionally been treated with therapeutic anticoagulation with warfarin for stroke prevention. Although effective, warfarin use is fraught with multiple concerns, such as a narrow therapeutic window, drug-drug and drug-food interactions, and excessive bleeding. Novel oral anticoagulant agents have recently become available as viable alternatives for warfarin therapy. Direct thrombin inhibitor dabigatran and factor Xa inhibitors like rivaroxaban and apixaban have already been approved by the US Food and Drug Administration (FDA) for stroke prevention in patients with nonvalvular atrial fibrillation. Edoxaban is the latest oral direct factor Xa inhibitor studied in the largest novel oral anticoagulant trial so far: ENGAGE AF-TIMI 48. Treatment with a 30 mg or 60 mg daily dose of edoxaban was found to be noninferior to dose-adjusted warfarin in reducing the rate of stroke and systemic embolism in patients with nonvalvular atrial fibrillation, with a lower incidence of bleeding complications and cardiovascular deaths. Edoxaban was recently reviewed by an FDA advisory committee and recommended as a stroke-prophylaxis agent. Once approved, it promises to provide another useful alternative to warfarin therapy.
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http://dx.doi.org/10.2147/CE.S61441DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4422295PMC
May 2015

Resistant hypertension and associated comorbidities in a veterans affairs population.

J Clin Hypertens (Greenwich) 2014 Oct 19;16(10):741-5. Epub 2014 Sep 19.

Primary Care Service, VA Central California Health Care System, Fresno, CA; Department of Medicine, University of California San Francisco-Fresno Medical Education Program, Fresno, CA.

Resistant hypertension (RH) is understudied and its reported prevalence varies with study populations. The authors sought to determine its prevalence and association with certain comorbid conditions in a Veterans Affairs population. This cross-sectional study utilized demographic and clinical data from 17,466 patients. Chi-square or t test was used for comparing groups with and without RH. Multivariate logistic regression analysis was used to determine independent associations. Overall, the prevalence of RH was 9%, and 13% of all hypertensive patients met criteria for RH. After adjusting for confounding variables, RH was significantly associated with older age (odds ratio [OR], 1.007), higher body mass index (OR, 1.04), Framingham score (OR, 1.14), and coexisting coronary artery disease, cerebrovascular accident/transient ischemic attack, peripheral vascular disease, congestive heart failure, chronic kidney disease, diabetes mellitus, erectile dysfunction, and metabolic syndrome (OR, 1.3, 1.32, 1.29, 2.88, 2.13, 1.2, 1.12, and 1.2, respectively; all P<.05). Our results indicate a complex interplay of certain comorbid conditions among patients with RH and suggest the need for multifaceted interventions in this high-risk population to prevent cardiovascular events.
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http://dx.doi.org/10.1111/jch.12410DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8031950PMC
October 2014

Reducing acute coronary events: the solution is not so difficult!

Am J Med 2015 Feb 3;128(2):105-6. Epub 2014 Sep 3.

Division of Cardiology, Department of Internal Medicine, University of California San Francisco, Fresno.

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http://dx.doi.org/10.1016/j.amjmed.2014.08.017DOI Listing
February 2015

Association of antidepressant and atypical antipsychotic use with cardiovascular events and mortality in a veteran population.

Pharmacotherapy 2013 Oct 17;33(10):1053-61. Epub 2013 Jun 17.

Primary Care Service, Veterans Administration Central California Health Care System, Fresno, California; Department of Medicine, University of California, San Francisco, Fresno Medical Education Program, Fresno, California.

Study Objectives: To determine the patterns of antidepressant and atypical antipsychotic use in a veteran population with depression, and to determine if an association exists between specific antidepressant classes and atypical antipsychotics and the occurrence of cardiovascular events and all-cause mortality.

Design: Retrospective, cross-sectional study.

Setting: Primary care clinic at a Veterans Affairs hospital.

Patients: A total of 1136 patients diagnosed with depression who were receiving antidepressant monotherapy (664 patients) or no antidepressant therapy (472 patients [controls]) between June 2009 and December 2010.

Measurements And Main Results: Data on patient demographics, disease diagnoses, laboratory data, and drug therapy profiles were collected through medical record review. Of the 1136 patients, the mean patient age was 61 years, 90% were men, and 77% were smokers. Mean body mass index was 30.4 kg/m(2) , blood pressure 126/73 mm Hg, hemoglobin A1c 6%, low-density lipoprotein cholesterol level 106.7 mg/dl, and Framingham score 17. Patients receiving antidepressant monotherapy were grouped according to antidepressant class; selective serotonin reuptake inhibitors (SSRIs) were most common. Concomitant use of atypical antipsychotics was more common with the serotonin-norepinephrine reuptake inhibitor (venlafaxine), SSRI, and serotonin receptor antagonist (trazodone) classes (p=0.0067). After adjusting for demographics, concomitant drugs, and comorbidities, SSRI use was significantly associated with lower all-cause mortality (odds ratio [OR] 0.37, 95% confidence interval [CI] 0.19-0.71, p=0.0028). Notably, noradrenergic and specific serotonergic antidepressant (mirtazapine) use was significantly associated with higher prevalence of heart failure (OR 3.26, 95% CI 1.029-10.38, p=0.0445). Use of atypical antipsychotics was significantly associated with a higher prevalence of cerebrovascular events (OR 2.23, 95% CI 1.29-3.83, p=0.0036) and all-cause mortality (OR 2.05, 95% CI 1.03-4.1, p=0.04).

Conclusion: Our results favor treatment of depression with SSRIs among patients at increased cardiovascular risk due to the potential mortality benefit of this class of drugs. Atypical antipsychotics should be used with caution in the elderly population. Mirtazapine use in patients with heart failure and depression deserves further investigation.
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http://dx.doi.org/10.1002/phar.1311DOI Listing
October 2013
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