Publications by authors named "Waqas T Qureshi"

73 Publications

Predictors of Complications Secondary to Infective Endocarditis and Their Associated Outcomes: A Large Cohort Study from the National Emergency Database (2016-2018).

Infect Dis Ther 2021 Nov 24. Epub 2021 Nov 24.

Division of Pulmonary and Critical Medicine, Detroit Medical Center Wayne State University, Detroit, MI, USA.

Introduction: Literature regarding outcomes and predictors of complications secondary to infective endocarditis (IE) is limited. We aimed to study the outcomes and predictors of complications of IE.

Methods: Data from a national emergency department sample, which constitutes 20% sample of hospital-owned emergency departments in the USA, were analyzed for hospital visits for IE. Complications of endocarditis were obtained by using ICD codes. Multivariable generalized linear method was used to evaluate predictors of in-hospital mortality and complications.

Results: Out of 255,838 adult IE patients (mean age 60.3 ± 20.1 years, 48.5% females), 97,803 (38.2%) patients developed one or more major complications. The major complications were cardiovascular system complications [57,900 (22.6%)], neurologic [42,851 (16.7%)] complications, and renal [16,236 (6.4%)] complications. These included cardiogenic shock [3873 (1.5%)], septic shock [25,798 (10.1%)], acute heart failure [35,602 (14%)], systemic thromboembolism (STE) [21,390 (8.36%)], heart block [11,430 (4.47%)], in-hospital dialysis [2880 (1.1%)], and disseminated intravascular coagulation (DIC) [2704 (1.1%)]. Patients with complicated IE had risk of mortality (adjusted RR 1.12, 95% CI 1.11-1.13, p < 0.001). The complications strongly associated with mortality were septic shock (RR 1.29, 95% CI 1.27-1.30, p < 0.001), cardiogenic shock (RR 1.24, 95% CI 1.20-1.29, p < 0.001), DIC (RR 1.4, 95% CI 1.35-1.46, p < 0.001), and STE (RR 1.07, 95% CI 1.05-1.08, p < 0.001). Staphylococci were the predominant causative organisms (30.8%) among the complicated IE subgroups with higher associated mortality (42.8%). The main predictors of complications from IE were congenital heart disease, history of congestive heart failure, high Elixhauser comorbidity profile, staphylococcal infection, and fungal infections. The prevalence of cardiogenic shock increased over the study years from 1.13 to 1.98% (p-trend 0.04).

Conclusion: Complicated IE is not uncommon and is associated with significant mortality. Staphylococcal infections were associated with high mortality rates. There has been an increasing trend of cardiogenic shock among IE patients across the US. Further research is needed to improve the outcomes of complicated endocarditis.
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http://dx.doi.org/10.1007/s40121-021-00563-yDOI Listing
November 2021

ST-Elevation Myocardial Infarction Among Septic Shock and Coronary Interventions: A National Emergency Database Study.

J Intensive Care Med 2021 Nov 23:8850666211061731. Epub 2021 Nov 23.

University of California, Mather, CA, USA.

Objective: To study coronary interventions and mortality among patients with ST-elevated myocardial infarction (STEMI) who were admitted with septic shock.

Methods: Data from the national emergency department sample (NEDS) that constitutes 20% sample of hospital-owned emergency departments in the United States was analyzed for the septic shock related visits from 2016 to 2018. Septic shock was defined by the ICD codes.

Results: Out of 1 375 507 adult septic shock patients, 521 300 had a primary diagnosis of septic shock (mean age 67.41±15.67 years, 51.1% females) in the national emergency database for the years 2016 to 2018. Of these patients, 2768 (0.53%) had STEMI recorded during the hospitalization. Mortality rates for STEMI patients were higher than patients without STEMI (52.3% vs 23.5%). Mortality rates improved with PCI among STEMI patients (43.8% vs 56.2%). Coronary angiography was performed among 16% of patients of which percutaneous coronary intervention (PCI) rates were 7.7% among patients with STEMI septic shock. PCI numerically improved mortality, however, had no significant difference than patients without PCI on multivariate logistic regression and univariate logistic regression post coarsened exact matching of baseline characteristics among STEMI patients. Among the predictors, STEMI was a significant predictor of mortality in septic shock patients (OR 2.87, 95% CI 2.37-3.49; <.001). Age, peripheral vascular disease, were predominant predictors of mortality in STEMI with septic shock subgroup ( <.001). Pneumonia was the predominant underlying infection among STEMI (36.4%) and without STEMI group (29.5%).

Conclusion: STEMI complicating septic shock worsens mortality. PCI and coronary angiography numerically improved mortality, however, had no significant difference from patients without PCI. More research will be needed to improve mortality in such a critically ill subgroup of patients.
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http://dx.doi.org/10.1177/08850666211061731DOI Listing
November 2021

Predictors and Outcomes of Cardiac Arrest in the Emergency Department and In-patient Settings in the United States (2016 - 2018).

Resuscitation 2021 Nov 18. Epub 2021 Nov 18.

Division of Cardiology, University of Massachusetts School of Medicine, Worcester, MA, USA.

Background: Outcomes of cardiac arrest (CA) remain dismal despite therapeutic advances. Literature is limited regarding outcomes of CA in emergency departments (ED).

Objective: To study the possible causes, predictors, and outcomes of CA in ED and in-patient settings throughout the United States (US).

Methods: Data from the US national emergency department sample (NEDS) was analyzed for the episodes of CA for 2016-2018. In-hospital CA was divided into in-patient (IPCA) and in the ED (EDCA). Only patients who had cardiopulmonary resuscitation (CPR) within the hospital were included in the study (out-of-hospital were excluded).

Results: A total of 1,068,847 CA (mean age 63.7±19.4 years, 24%females), of whom 325,062(30.4%) EDCA and 177,104(16.6%) IPCA were included in the study. Patients without CPR, 743,785(69.6%), were excluded. Survival was higher among IPCA 55,821(31.6%) than the EDCA 32,516(10%). IPCA encounters had multifactorial associated etiologies including respiratory failure(73%), acidosis(38.7%) sepsis(36.8%) and ST-elevated myocardial infarction (STEMI)(7.3%). Majority of ED arrests (67.1%) had no possible identifiable cause. The predominant known causes include intoxication(7.5%), trauma (6.4%), respiratory failure(5%), and STEMI(2.7%). Cardiovascular interventions had significant survival benefits in IPCA on univariate logistic regression after coarsened exact matching for comorbidities. IPCA had higher intervention rates than EDCA. For all live discharges, a total of 40% of patients were discharged to hospice.

Conclusion: Survival remains dismal among CA patients especially those occurring in the ED. Given that there are considerable variations in the etiology between the two studied cohorts, more research is required to improve the understanding of these factors, which may improve survival outcomes.
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http://dx.doi.org/10.1016/j.resuscitation.2021.11.009DOI Listing
November 2021

Cardiac and Obstetric Outcomes Associated With Mitral Valve Prolapse.

Am J Cardiol 2021 Oct 21. Epub 2021 Oct 21.

Division of Cardiovascular Medicine, University of Massachusetts Memorial Healthcare. Electronic address:

Mitral valve prolapse (MVP) is the most common valvular heart disease in women of reproductive age. Whether MVP increases the likelihood of adverse outcomes in pregnancy is unknown. The study objective was to examine the cardiac and obstetric outcomes associated with MVP in pregnant women. This retrospective cohort study, using the Healthcare Cost and Utilization Project National Readmission Sample database between 2010 and 2017, identified all pregnant women with MVP using the International Classification of Disease, Ninth and Tenth Revisions codes. The maternal cardiac and obstetric outcomes in pregnant women diagnosed with MVP were compared with women without MVP using multivariable logistic and Cox proportional hazard regression models adjusted for baseline demographic characteristics. There were 23,000 pregnancy admissions with MVP with an overall incidence of 16.9 cases per 10,000 pregnancy admissions. Pregnant women with MVP were more likely to die during pregnancy (adjusted hazard ratio 5.13, 95% confidence interval [CI] 1.09 to 24.16), develop cardiac arrest (adjusted odds ratio [aOR] 4.44, 95% CI 1.04 to 18.89), arrhythmia (aOR 10.96, 95% CI 9.17 to 13.12), stroke (aOR 6.90, 95% CI 1.26 to 37.58), heart failure (aOR 5.81, 95% CI 3.84 to 8.79), or suffer a coronary artery dissection (aOR 25.22, 95% CI 3.42 to 186.07) compared with women without MVP. Pregnancies with MVP were also associated with increased risks of preterm delivery (aOR 1.21, 95% CI 1.02 to 1.44) and preeclampsia/hemolysis, elevated liver enzymes, and low platelets syndrome (aOR 1.22, 95% CI 1.05 to 1.41). In conclusion, MVP in pregnancy is associated with adverse maternal cardiac outcomes and higher obstetric risks.
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http://dx.doi.org/10.1016/j.amjcard.2021.09.014DOI Listing
October 2021

Outcomes of intravascular ultrasound versus optical coherence tomography guided percutaneous coronary angiography: A meta regression-based analysis.

Catheter Cardiovasc Interv 2021 Oct 20. Epub 2021 Oct 20.

Cardiology, Detroit Medical Center, Detroit, Michigan, USA.

Background: Studies comparing clinical outcomes with intravascular ultrasound (IVUS) versus optical coherence tomography (OCT) guidance for percutaneous coronary intervention (PCI) in patients presenting with coronary artery disease, including stable angina or acute coronary syndrome, are limited.

Methods: We performed a detailed search of electronic databases (PubMed, Embase, and Cochrane) for randomized controlled trials and observational studies that compared cardiovascular outcomes of IVUS versus OCT. Data were aggregated for the primary outcome measure using the random-effects model as pooled risk ratio (RR). The primary outcome of interest was major adverse cardiac events (MACE), cardiac mortality, and all-cause mortality. Secondary outcomes included myocardial infarction (MI), stent thrombosis (ST), target lesion revascularization (TLR), and stroke.

Results: A total of seven studies met the inclusion criteria, comprising 5917 patients (OCT n = 2075; IVUS n = 3842). OCT-PCI versus IVUS-guided PCI comparison yielded no statistically significant results for all the outcomes; MACE (RR 0.78; 95% confidence interval [CI], 0.57-1.09; p = 0.14), cardiac mortality (RR 0.97; 95% CI, 0.27-3.46; p = 0.96), all-cause mortality (RR 0.74; 95% CI, 0.39-1.39; p = 0.35), MI (RR 1.27; 95% CI, 0.52-3.07; p = 0.60), ST (RR 0.70; 95% CI, 0.13-3.61; p = 0.67), TLR (RR 1.09; 95% CI, 0.53-2.25; p = 0.81), and stroke (RR 2.32; 95% CI, 0.42-12.90; p = 0.34). Furthermore, there was no effect modification on meta-regression including demographics, comorbidities, lesion location, lesion length, and stent type.

Conclusions: In this meta-analysis, OCT-guided PCI was associated with no difference in clinical outcomes compared with IVUS-guided PCI.
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http://dx.doi.org/10.1002/ccd.29976DOI Listing
October 2021

Prognostic Value of Cardiorespiratory Fitness in Patients with Chronic Kidney Disease: The FIT (Henry Ford Exercise Testing) Project.

Am J Med 2021 Sep 9. Epub 2021 Sep 9.

Department of Cardiology, Houston Methodist Hospital, Houston, Texas. Electronic address:

Purpose: We conducted this study to investigate the association of cardiorespiratory fitness and all-cause mortality among patients with chronic kidney disease.

Methods: We studied a retrospective cohort of patients from the Henry Ford Health System who underwent clinically indicated exercise stress testing with baseline cardiorespiratory fitness and estimated glomerular filtration rate measurement. Cardiorespiratory fitness was expressed as metabolic equivalents of task, and kidney function was categorized into stages according to estimated glomerular filtration rate. Multivariable-adjusted Cox proportional hazard models were used to examine the association between metabolic equivalents of task and all-cause mortality among patients with chronic kidney disease stages 3-5. Discrimination of mortality was assessed using receiver operating characteristic curves, while reclassification was evaluated using net reclassification index (NRI).

Results: Among 50,121 participants, the mean age was 55 ± 12.6 years; 47.5% were women, 64.5% were white, and 6877 (13.7%) participants had chronic kidney disease stage 3-5. Over a median follow-up of 6.7 years, 6308 participants died (12.6%). Each 1-unit higher metabolic equivalents of task was associated with a significant 15% reduction in all-cause mortality (hazard ratio 0.85; 95% confidence interval [CI], 0.84-0.87). Metabolic equivalents of task improved discriminatory ability of mortality prediction when added to traditional risk factors and estimated glomerular filtration rate (area under the curve 0.7996; 95% CI, 0.789-0.810 vs 0.759; 95% CI, 0.748-0.770, respectively; P < .001). The addition of metabolic equivalents of task to traditional risk factors resulted in significant reclassification (6% for events, 5% for non-events: NRI = 0.13, P < .001).

Conclusions: Cardiorespiratory fitness improves mortality risk prediction among patients with chronic kidney disease. Cardiorespiratory fitness provides incremental prognostic information when added to traditional risk factors and may help guide treatment options among patients with renal dysfunction.
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http://dx.doi.org/10.1016/j.amjmed.2021.07.042DOI Listing
September 2021

Non-ST elevation myocardial infarction and cardiac arrest: The United States Nationwide Emergency Department Sample.

J Cardiol 2021 Aug 29. Epub 2021 Aug 29.

Division of Cardiology, University of Massachusetts School of Medicine, Worcester, MA, USA.

Background: Literature regarding outcomes of cardiac arrest with associated NSTEMI is limited. We aim to study the predictors and survival outcomes of cardiac arrest patients presenting to the emergency department who were diagnosed with non-ST elevated myocardial infarction (NSTEMI).

Methods: Data from the nationwide emergency department sample (NEDS) that constitutes 20% sample of hospital-owned emergency departments in the United States was analyzed for the cardiac arrest related visits from 2009-2018. Cardiac arrest was defined by the ICD codes.

Results: Out of 3,235,555 cardiac arrests (mean age 64.0 ± 19.5 years, 40.7% females) there were 163,970 (5.1%) patients diagnosed with NSTEMI during the years 2009-2018. Among cardiac arrest patients, the survival for NSTEMI patients was higher than patients without NSTEMI (46.7% vs. 22.7%). These patients were more likely to be males and elderly. Among the predictors for NSTEMI cardiac arrests, hypertension (OR 1.12, p < 0.001), peripheral vascular disease (OR 1.16, p < 0.001), prior-coronary artery bypass graft (OR 1.20, p < 0.001) were the predominant ones. Cardiovascular interventions were more common in NSTEMI cardiac arrests and were associated with lower mortality rates (p < 0.001). However, trend for coronary interventions remained steady over study years. We observed an increase in prevalence of NSTEMI cardiac arrests with a worsening trend in survival from 2009-2018.

Conclusions: NSTEMI was not uncommon in patients with cardiac arrest. NSTEMI cardiac arrest had a better prognosis than patients without NSTEMI. Cardiovascular interventions might have survival benefits. More research is required to identify NSTEMI in cardiac arrest patients and further evaluate the effect of cardiovascular interventions on survival.
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http://dx.doi.org/10.1016/j.jjcc.2021.08.016DOI Listing
August 2021

Brain Natriuretic Peptide as a Marker of Adverse Neurological Outcomes Among Survivors of Cardiac Arrest.

J Intensive Care Med 2021 Aug 30:8850666211034728. Epub 2021 Aug 30.

Wake Forest Baptist Hospital, North Carolina, USA.

Background: Neurological prognosis after cardiac arrest remains ill-defined. Plasma brain natriuretic peptide (BNP) may relate to poor neurological prognosis in brain-injury patients, though it has not been well studied in survivors of cardiac arrest.

Methods: We performed a retrospective review and examined the association of BNP with mortality and neurological outcomes at discharge in a cohort of cardiac arrest survivors enrolled from January 2012 to December 2016 at the Wake Forest Baptist Hospital, in North Carolina. Cerebral performance category (CPC) and modified Rankin scales were calculated from the chart based on neurological evaluation performed at the time of discharge. The cohort was subdivided into quartiles based on their BNP levels after which multivariable adjusted logistic regression models were applied to assess for an association between BNP and poor neurological outcomes as defined by a CPC of 3 to 4 and a modified Rankin scale of 4 to 5.

Results: Of the 657 patients included in the study, 254 patients survived until discharge. Among these, poor neurological status was observed in 101 (39.8%) patients that had a CPC score of 3 to 4 and 97 patients (38.2%) that had a modified Rankin scale of 4 to 5. Mean BNP levels were higher in patients with poor neurological status compared to those with good neurological status at discharge ( = .03 for CPC 3-4 and  = .02 for modified Rankin score 4-5). BNP levels however, did not vary significantly between patients that survived and those that expired ( = .22). BNP did emerge as a significant discriminator between patients with severe neurological disability at discharge when compared to those without. The area under the curve for BNP predicting a modified Rankin score of 4 to 5 was 0.800 (95% confidence interval [CI] 0.756-0.844,  < .001) and for predicting CPC 3 to 4 was 0.797 (95% CI 0.756-0.838,  < .001). BNP was able to significantly improve the net reclassification index and integrated discriminatory increment ( < .05). BNP was not associated with long-term all-cause mortality ( > .05).

Conclusions: In survivors of either inpatient or out-of-hospital cardiac arrest, increased BNP levels measured at the time of arrest predicted severe neurological disability at discharge. We did not observe an independent association between BNP levels and long-term all-cause mortality. BNP may be a useful biomarker for predicting adverse neurological outcomes in survivors of cardiac arrest.
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http://dx.doi.org/10.1177/08850666211034728DOI Listing
August 2021

Trends and complications associated with acute new-onset heart failure: a National Readmissions Database-based cohort study.

Heart Fail Rev 2021 Jul 28. Epub 2021 Jul 28.

Division of Cardiology, Promedica Toledo, Toledo, OH, USA.

Literature regarding recent trends and outcomes of acute new-onset heart failure (AHF) with preserved ejection fraction (AHFpEF) and reduced ejection fraction (AHFrEF) is limited. The objective of this study is to study the outcomes of AHFpEF and AHFrEF in the USA. Data from the National Readmissions Database (NRD) sample that constitutes 49.1% of the stratified sample of all hospitals in the USA, representing more than 95% of the national population, were analyzed for hospitalization visits for acute heart failure. ICD-9 and ICD-10 codes were used to identify AHF. A total of 2,559,102 adult index AHF patients (mean age 70.79 ± 14.58 years, 49.4% females), 1,028,970 (40.2%) AHFpEF and 1,330,999 (52%) AHFrEF, were recorded in the National Readmissions Database for the years 2016-2018. A total of 152,465 (5.96%) acute heart failure, 47,271 (4.6%) AHFpEF and 91,973 (6.91%) AHFrEF, died during hospitalization, and 45,810 (1.9%) were readmitted in 30 days among alive discharges. Higher complication rates which included ventricular arrhythmias, acute coronary, and cerebrovascular events were observed among AHFrEF than AHFpEF. Higher proportion of patients with AHFrEF needed intensive care unit and ventilatory support during the hospitalization. The trend of incidence of AHFrEF, mortality among AHFrEF, and overall mortality worsened while AHFpEF improved over the study years 2012-2018 (p-trend < 0.05). Coronary procedures improved mortality rates among AHFpEF and AHFrEF. AHF is very common and is associated with significant mortality. The incidence of AHFrEF and mortality among AHFrEF had worsened, which calls for urgent intervention. Improved recognition of AHF is needed, and guideline-directed treatment of underlying risk factors including coronary artery disease can improve mortality. Graphic abstract of the analysis presented (created with BioRender.com).
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http://dx.doi.org/10.1007/s10741-021-10152-3DOI Listing
July 2021

Bilateral vas deferens calcification in a patient with multi-vessel coronary artery disease and severe aortic stenosis: linking infertility with cardiovascular disease.

J Community Hosp Intern Med Perspect 2021 10;11(3):376-378. Epub 2021 May 10.

Division of Cardiovascular Medicine, University of Massachusetts Medical School, Worcester, MA, USA.

Vas deferens calcification is a chronic arterio-sclerotic process that develops over many years and is strongly associated with infertility. Incidental findings on imaging are the most common means of diagnosing this condition. We report a case of a 56-year man who likely has male factor infertility and was found to have bilateral vas deferens calcification on CT imaging. This was performed during pre-procedural workup for transcatheter aortic valve replacement (TAVR) for management of severe aortic stenosis (AS). The patient was also had severe calcific multi-vessel coronary artery disease requiring percutaneous coronary intervention with atherectomy. This case highlights a novel clinical association linking infertility with coronary and valvular heart disease. It is possible that this association exists in larger numbers than previously recognized. Closer monitoring of pelvic imaging for TAVR access planning in patients with severe AS may bring more cases to light.
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http://dx.doi.org/10.1080/20009666.2021.1898085DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8118445PMC
May 2021

Meta-analysis of minimalist versus standard care approach for transcatheter aortic valve replacement.

Expert Rev Cardiovasc Ther 2021 Jun 19;19(6):565-574. Epub 2021 May 19.

Division of Cardiovascular Medicine, University of Massachusetts Medical School, Worcester, MA, USA.

Background: The change in practice of transcatheter aortic valve replacement (TAVR) to a minimalist approach is a debate.

Methods: Online database search for studies that compared the minimalist approach with the standard approach for TAVR were searched from inception through September 2020. We calculated pooled odds ratios (ORs) and 95% confidence intervals (CIs) using the fixed or random-effects model.

Results: A total of 9 studies with 2,880 TAVR patients (minimalist TAVR;1066 and standard TAVR; 1,814) were included. Compared to standard approach, there were no significant differences in in-hospital mortality, 30-day mortality, or hospital readmissions. However, there was a reduced risk of acute kidney injury (OR0.49;95%CI0.27-0.89), major bleeding (OR0.21;95%CI0.12-0.38) and major vascular complications (OR0.60,95%CI0.39-0.91) associated with the minimalist TAVR group. There was comparatively shorter hospital length of stay (mean difference -2.41;95%CI-2.99,-1.83) days, procedural time (mean difference -43.99;95%CI-67.25,-20.75) minutes, fluoroscopy time (mean difference -2.69;95%CI-3.44,-1.94) minutes and contrast volume (mean difference -26.98;95%CI-42.18,-11.79) ml in the minimalist TAVR group.

Conclusions: This meta-analysis demonstrated potential benefits of the minimalist TAVR approach over the standard approach regarding some adverse clinical outcomes as well as procedural outcomes without significant differences in mortality or readmission rates.
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http://dx.doi.org/10.1080/14779072.2021.1920926DOI Listing
June 2021

Bioresorbable polymer and durable polymer metallic stents in coronary artery disease: a meta-analysis.

Expert Rev Cardiovasc Ther 2021 May 22;19(5):445-456. Epub 2021 Apr 22.

Cardiovascular Medicine, Detroit Medical Center, Wayne State University, Detroit, MI, USA.

Background: Literature on bioresorbable-polymer-stents (BPS) and second-generation durable-polymer-stents (DPS) in percutaneous coronary intervention (PCI) for all comer CAD is conflicting.

Methods: Randomized controlled studies comparing PCI among BPS and second-generation DPS were identified up until May-2020 from online databases.  Primary outcomes included are all-cause myocardial infarction (MI), cardiac-death, target-vessel-revascularization (TVR), target-vessel MI (TVMI), and stent-thrombosis (ST). Random effect method of risk ratio and confidence interval of 95% was used.

Results: 25 prospective randomized controlled trials with 31,822 patients (BPS = 17,065 and DPS = 14,757) were included in the study. Follow-up ranged between a minimum of 6 months to more than 5 years. Cardiac death (RR 1.02, 95% CI 0.89-1.45, = 0.16) was comparable in BPS and second-generation DPS. Risk of all-cause MI was similar between BPS and DPS (RR 0.97, 95% CI 0.84-1.11, = 0.73). TVMI (RR 0.88, 95% CI 0.69-1.11, = 0.33) and ST rates were also comparable in BPS and DPS groups (RR 1.06, 95% CI 0.80-1.40, = 1.00). Overall TVR had comparable outcomes between BPS and DPS (RR 0.95, 95% CI 0.79-1.14, < 0.001); however, higher TVR was seen among BPS group at follow-up of ≥5 years (RR 1.39, 95% CI 1.12-1.14, = 0.02). Bias was low and heterogeneity was moderate.

Conclusion: Patients undergoing PCI treated with BPS had comparable outcomes in terms of cardiac death, TVR, ST, TVMI, and all-cause MI to patients treated with second-generation DPS; however, BPS had higher rates of TVR for follow-up of ≥5-years.
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http://dx.doi.org/10.1080/14779072.2021.1915769DOI Listing
May 2021

Meta-analysis of direct oral anticoagulants compared with vitamin K antagonist for left ventricle thrombus.

Cardiovasc Revasc Med 2021 Mar 9. Epub 2021 Mar 9.

Division of Cardiology, University of Massachusetts School of Medicine, Worcester, MA, USA. Electronic address:

Background: The use of direct oral anticoagulants (DOAC) in preference to vitamin K antagonists (VKA) as a treatment of left ventricle (LV) thrombus is controversial.

Methods: Literature search for full-text articles and conference abstracts was performed using PubMed, EMBASE databases search was performed to identify articles that compared use of DOAC vs. VKA in patients with LV thrombus. The primary outcome was composite failure or adverse effects of DOAC and VKA. Other outcomes were resolution of thrombus, systemic thromboembolism, major bleeding, and mortality. Pooled odds ratio (OR) with 95% confidence interval (CI) were computed using random effects model.

Results: Seven studies with 1003 patients (mean age DOAC = 58.8 years and VKA = 58.9 year, 55.5% males) were included in this study. There were 306 (30.5%) patients that were treated with DOAC and 697 (69.5%) patients were treated with VKA. Overall, there were no significant differences between both agents in terms of composite failure/adverse effects, resolution of thrombus, systemic embolism, major bleeding, or mortality.

Conclusion: In this pooled analysis, outcomes in patients on DOAC were comparable to VKA. The hypothesis generated could suggest DOAC could be used interchangeably with VKA in patients with LV thrombus. Randomized trials are needed for generalization of results.
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http://dx.doi.org/10.1016/j.carrev.2021.03.001DOI Listing
March 2021

Post-PCI outcomes in STEMI patients with coronary ectasia: meta-analysis.

Expert Rev Cardiovasc Ther 2021 Apr 14;19(4):349-356. Epub 2021 Apr 14.

Department of Cardiology,University of Massachusetts School of Medicine, Worcester, MA, USA.

Background: Coronary ectasia (CE) is defined as dilation of the coronary artery, 1.5 times that of the surrounding vessel. Outcomes of percutaneous intervention (PCI) in patients with CE presenting as ST-elevated myocardial infarction (STEMI) remain a topic of debate.

Methods: Studies comparing outcomes of PCI in CE versus no-ectasia (NE) STEMI patients were identified. Baseline angiographic characteristics include thrombolysis in myocardial infarction (TIMI) 0-1 flow, right coronary artery (RCA) involvement, and primary outcomes including thrombus aspiration, no-reflow, mortality, and TIMI-3 post-PCI. Odds ratio (OR) and 95% confidence interval (CI) were calculated.

Results: Six studies (n = 5746, CE-340 and NE-5406) qualified for the analysis. RCA involvement was more common in CE than NE, OR-1.39 (95%CI1.06-1.82, p-0.02). Pre-procedure TIMI-0-1 was of comparable results between the groups (p-1.13). Higher thrombus aspiration for CE (OR 2.18, 95%CI1.44-3.32;p-<0.001). CE had higher incidence of no-reflow (OR 4.07, 95%CI2.42-6.84;p-<0.001). TIMI-3 flow post-PCI was achieved less commonly in the CE group (OR-0.64, 95%CI-0.48-0.86;p-<0.001). Mortality on follow-up was comparable (0.83, 95%CI0.39-1.78;p-0.63). Metaregression analysis did not show confounding effects from comorbidities.

Conclusion: Coronary ectasia patients with STEMI had higher rates of PCI failure and no-reflow than NE; however, mortality during follow-up was comparable.
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http://dx.doi.org/10.1080/14779072.2021.1889370DOI Listing
April 2021

Meta-Analysis of Prospective Studies of Risk stratification by Syntax Score for Unprotected Left Main Coronary Artery Revascularization.

Am J Cardiol 2021 05 10;146:138-139. Epub 2021 Feb 10.

Department of Internal Medicine, University of Connecticut, Hartford, Connecticut.

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http://dx.doi.org/10.1016/j.amjcard.2021.02.003DOI Listing
May 2021

Outcomes of in-hospital cardiac arrest in COVID-19 patients: A proportional prevalence meta-analysis.

Catheter Cardiovasc Interv 2021 Feb 4. Epub 2021 Feb 4.

University of Massachusetts School of Medicine, Worcester, Massachusetts, USA.

Background: Limited epidemiological data are available on the outcomes of in-hospital cardiac arrest (CA) in COVID-19 patients.

Methods: We performed literature search of PubMed, EMBASE, Cochrane, and Ovid to identify research articles that studied outcomes of in-hospital cardiac arrest in COVID-19 patients. The primary outcome was survival at discharge. Secondary outcomes included return of spontaneous circulation (ROSC) and types of cardiac arrest. Pooled percentages with a 95% confidence interval (CI) were calculated for the prevalence of outcomes.

Results: A total of 7,891 COVID patients were included in the study. There were 621 (pooled prevalence 8%, 95% CI 4-13%) cardiac arrest patients. There were 52 (pooled prevalence 3.0%; 95% CI 0.0-10.0%) patients that survived at the time of discharge. ROSC was achieved in 202 (pooled prevalence 39%;95% CI 21.0-59.0%) patients. Mean time to ROSC was 7.74 (95% CI 7.51-7.98) min. The commonest rhythm at the time of cardiac arrest was pulseless electrical activity (pooled prevalence 46%; 95% 13-80%), followed by asystole (pooled prevalence 40%; 95% CI 6-80%). Unstable ventricular arrhythmia occurred in a minority of patients (pooled prevalence 8%; 95% CI 4-13%).

Conclusion: This pooled analysis of studies showed that the survival post in-hospital cardiac arrest in COVID patients is dismal despite adequate ROSC obtained at the time of resuscitation. Nonshockable rhythm cardiac arrest is commoner suggesting a non-cardiac cause while cardiac related etiology is uncommon. Future studies are needed to improve the survival in these patients.
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http://dx.doi.org/10.1002/ccd.29525DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8014883PMC
February 2021

Angled Microcatheter Assisted Antegrade Dissection Re-Entry Technique for Tortuous Totally Occluded Coronary Arteries.

Cardiovasc Revasc Med 2021 07 7;28S:127-131. Epub 2021 Jan 7.

Division of Cardiovascular Medicine, University of Massachusetts Medical School, Worcester, MA, USA.

Background: Subacute total occlusion in the setting of a tortuous vessel can be a therapeutic challenge. we demonstrate a safe and successful approach to deploy drug eluting stent of this complex lesion by using angled microcatheter.

Case Presentation: A 61-year-old male with multiple atherosclerotic risk factors diagnosed with NSTEMI secondary to subacute total occlusion of the mid right coronary artery (RCA) with collaterals filling from septal perforators arising from mid left anterior descending artery. Due to severe tortuosity of RCA, the wire inside of Corsair microcatheter kept directing away from the lumen. Therefore, Corsair was exchanged for 90-degree SuperCross™ angled microcatheter that was rotated to direct its opening towards the lumen. A Confianza pro 12 wire was used to puncture into the lumen from the subinitimal position. SuperCross™ microcatheter was advanced over the wire into the lumen and eventually drug eluting stents were deployed successfully.

Conclusion: While facing subacute total occlusion with proximal end in a tortuous artery, SuperCross™ microcatheter assisted dissection reentry could be attempted after failure of antegrade wire escalation technique.

Learning Objective: Facilitate the use of SuperCross™ microcatheter assisted dissection reentry as a successful approach for subacute total occlusion in tortuous vessels.
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http://dx.doi.org/10.1016/j.carrev.2021.01.004DOI Listing
July 2021

Equipment entrapment during redo-TAVR with successful BASILICA procedure.

Catheter Cardiovasc Interv 2021 08 23;98(2):E320-E323. Epub 2021 Jan 23.

Division of Cardiovascular Medicine, University of Massachusetts Medical School, Worcester, Massachusetts, USA.

Transcatheter aortic valve replacement (TAVR) for transcatheter heart valve failure has been suggested for high-risk patients. TAVR-in-TAVR, however, may lead to complex leaflet interactions causing coronary ostial obstruction, which is a devastating complication. Coronary protection with provisional stent placement may be challenging. We describe the first percutaneous transaxillary case of TAVR-in-TAVR with Bioprosthetic Aortic Scallop Intentional Laceration to prevent Iatrogenic Coronary Artery obstruction (BASILICA) where guide catheters used for coronary protection were entrapped between the valve frames. We describe anatomical predictors and management considerations. Operators should be aware of this important complication during TAVR-in-TAVR valve placement.
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http://dx.doi.org/10.1002/ccd.29485DOI Listing
August 2021

Comparison of Prevalence, Presentation, and Prognosis of Acute Coronary Syndromes in ≤35 years, 36 - 54 years, and ≥ 55 years Patients.

Am J Cardiol 2021 02 6;140:1-6. Epub 2020 Nov 6.

Division of Cardiovascular Medicine, University of Massachusetts Medical School, Worcester, Massachusetts. Electronic address:

Whether very young patients (≤35-year-old) differ in the prevalence, presentation and prognosis of ACS is not well known. Of 43,446 patients who were referred to a tertiary care cardiac catheterization laboratory between January 1, 2006 and June 30, 2017, 26,545 patients were ACS (defined as ST Elevation MI, Non-ST Elevation MI or unstable angina pectoris). Detailed chart review was performed and characteristics at baseline were compared for ages ≤35 years, ages 36 to 54 years and ages ≥55 years. A total of 291 (1.1%) were ≤35-year-old, 7,649 (28.8) were 36 to 54-year-old and 18,605 (70.1%) were ≥55-year-old. ACS patients aged ≤35-year-old, were more likely to be men, Caucasian white, smoker, obese, and have family history of coronary artery disease and less likely to have comorbidities such as hypertension, diabetes mellitus, and hyperlipidemia compared with older patients. They were also more likely to present with elevated troponin levels than other groups. They also tended to present with late ST elevation myocardial infarction and were more likely to receive bare metal stents than older patients. The prevalence of 2- and 3-vessel disease was lower compared with older patients. They also had higher prevalence of cardiogenic shock. Compared with 36 to 54-year-old patients, ≤35-year-old were at significant higher risk of 30-day mortality in a multivariable adjusted regression model (Odds ratio 5.65, 95% confidence interval 2.49 to 12.82, p <0.001). Very young patients comprised ∼1% of all ACS cases but had much more prevalence of modifiable risk factors and significantly worse mortality. Modifying these risk factors may mitigate the risk in these patients and should be studied in the future.
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http://dx.doi.org/10.1016/j.amjcard.2020.10.054DOI Listing
February 2021

Evaluation of ECG-gated and Fast Low-Angle Shot (FLASH) Dual Source Computed Tomography Scanning Protocols for Transcatheter Aortic Valve Replacement.

Acad Radiol 2021 12 22;28(12):1669-1674. Epub 2020 Sep 22.

Division of Cardiovascular Medicine, University of Massachusetts Medical School, Worcester, MA 01655. Electronic address:

Background: Transcatheter aortic valve replacement (TAVR) procedural success relies heavily on volumetric reconstruction imaging, particularly ECG-gated multi-detector row computed tomography. We postulated that single examination using fast low-angle shot (FLASH) dual source CT scanning (DS-CTA) could provide lower dose than ECG-gated CTA while maintaining the image quality.

Methods: In this single-centre cohort study, all patients who underwent ECG-gated and FLASH DS-CTA were evaluated. Volumetric reconstructions were performed for both ECG-gated and FLASH DS-CTA to obtain nonsagittal views of the structures. ECG-gated cardiac CT was obtained to evaluate the aortic annular size while FLASH DS-CTA was obtained to examine the aortic and iliac vasculature as part of TAVR imaging protocol. We evaluated measures of aortic annulus, coronaries and sinus of Valsalva using ECG-gated and FLASH DS-CTA scanning protocols. Image quality assessments were performed using aortic root region-of-interest signal-to-noise ratio.

Results: A total of 130 patients (mean age 81.5 ± 9.2 years, 46.2% female, and 99.2% white) underwent both ECG-gated CT and FLASH DS-CTA. There were excellent correlations between aortic annular area (R = 0.934) and aortic annular perimeter (R = 0.923) measured by the two protocols. Only 2 (1.5%) patients had >10% difference between aortic annular measurements by ECG-gated and FLASH DS-CTA, while none of the patients had a >10% difference between aortic annular perimeter measured by ECG-gated and FLASH DS-CT scans. There was no significant difference in signal-to-noise ratio between the two methods (mean difference 13.4; 95% CI -2.1-28.8, p = 0.09). There was significantly lower radiation dose for FLASH DS-CTA than ECG-gated CT scan (mean dose-length product difference 404.38; 95% CI 328.9-479.87, p <0.001). The measurements by the two scans led to the same transcatheter valve size selection in majority of the 128 (98.5%) patients by balloon expandable valve sizing recommendations and 130 (100%) of patients by self-expanding valve sizing recommendations.

Conclusion: Overall, FLASH DS-CTA and ECG-gated CT scans provided comparable image quality and aortic annular dimensions for pre-TAVR evaluation. DS-CTA additionally provided the necessary angiographic imaging of the aorta and peripheral access vessels while still maintaining a lower radiation dose. We propose that a single non-ECG gated FLASH DS-CTA could be utilized to provide all the necessary pre-TAVR imaging information without a gated CT scan.
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http://dx.doi.org/10.1016/j.acra.2020.08.027DOI Listing
December 2021

Post-Myocardial Infarction Complications During the COVID-19 Pandemic - A Case Series.

Cardiovasc Revasc Med 2021 07 10;28S:253-258. Epub 2020 Aug 10.

Division of Cardiovascular, Department of Internal Medicine, University of Massachusetts School of Medicine, Worcester, MA, United States of America.

We report 4 cases of post myocardial infarction complications due to the delay in presentation during COVID-19 era. We highlighted the need for auscultating the chest for early diagnosis. Through this case series, we urge to raise awareness among cardiac patients to access healthcare despite the fear of COVID-19.
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http://dx.doi.org/10.1016/j.carrev.2020.08.005DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7416682PMC
July 2021

Characteristics and outcomes of cardiac arrest survivors with acute pulmonary embolism.

Resuscitation 2020 10 9;155:6-12. Epub 2020 Jul 9.

Department of Medicine, Division of Cardiology, University of Massachusetts, Worcester, MA, USA.

Introduction: The characteristics and outcomes of patients that suffer cardiac arrest due to acute pulmonary embolism (PE) are not well studied. We compared the characteristics and outcomes of cardiac arrest survivors that suffered PE with other forms of cardiac arrest.

Methods: Consecutive cardiac arrest survivors were enrolled that were able to survive for 24 h post cardiopulmonary resuscitation. Diagnosis of PE was confirmed by CT angiogram or high-probability of PE on ventilation perfusion scan after the successful resuscitation from cardiac arrest. Survival curves were examined and predictors of mortality in PE patients were examined in an adjusted Cox proportional hazard model.

Results: Among the 996 cardiac arrest patients (mean age 62.6 ± 14.8 years, females 39.4%), 87 (8.7%) patients were found to have acute PE. The mortality rate of cardiac arrest survivors with and without acute PE was not significant different (68.3% vs. 64%). There were no significant differences in mortality among PE patients that received thrombolytics versus those who did not. Out of 87 patients, 33 (37.9%) required transfusion and had a bleeding complication. The risk of mortality in PE patients was predicted by older age, female sex, history of diabetes mellitus, end-stage renal disease and use of targeted temperature management.

Conclusion: Cardiac arrest survivors with PE did not have significantly better survival than patients with non-PE related cardiac arrest. In addition, use of thrombolytics did not improve survival but these patients ended up requiring transfusion that could have off set the benefit of thrombolytics.
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http://dx.doi.org/10.1016/j.resuscitation.2020.06.029DOI Listing
October 2020

Incidence, Predictors, and Prognosis of Acute Kidney Injury Among Cardiac Arrest Survivors.

J Intensive Care Med 2021 May 3;36(5):550-556. Epub 2020 Apr 3.

Division of Cardiovascular Medicine, Department of Internal Medicine, 164186University of Massachusetts School of Medicine, Worcester, MA, USA.

Background: Acute kidney injury (AKI) is common among cardiac arrest survivors. However, the outcomes and predictors are not well studied.

Methods: This is a cohort study of cardiac arrest patients enrolled from January 2012 to December 2016 who were able to survive for 24 hours post-cardiopulmonary resuscitation. Patients with anuria, chronic kidney disease (stage 5), and end-stage renal disease were excluded. Acute kidney injury (stage 1) or higher was defined using Kidney Disease: Improving Global Outcomes classification. Multivariable adjusted regression models were used to compute hazard ratio (HR) for association of AKI with risk of mortality and odds ratio (OR) with risk of poor neurological outcomes after adjusting for demographics, comorbidities, and medical therapy. Multivariable logistic regression model was used to compute OR for association of various predictors with AKI.

Results: Of 842 cardiac arrest survivors, 588 (69.8%) developed AKI. Among AKI patients, 69.4% died compared with 52.0% among non-AKI patients. In multivariable adjusted Cox proportional hazard model, development of AKI post-cardiac arrest was significantly associated with mortality (HR: 1.35; 95% confidence interval [CI]: 1.07-1.71, = .01) and poor neurological outcomes defined as cerebral performance category >2 (OR: 2.27; 95% CI: 1.45-3.57, < .001) and modified Rankin scale >3 (OR: 2.22; 95% CI: 1.43-3.45, < .001). Postdischarge dialysis was also associated with increased risk of mortality (HR: 2.57; 95% CI: 1.57-4.23, < .001). Use of vasopressors was strongly associated with development of AKI and continued need for postdischarge dialysis.

Conclusions: Acute kidney injury was associated with increased risk of mortality and poor neurological outcomes. There is need for further studies to prevent AKI in cardiac arrest survivors.
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http://dx.doi.org/10.1177/0885066620911353DOI Listing
May 2021

Cardiovascular Outcomes with Transcatheter vs. Surgical Aortic Valve Replacement in Low-Risk Patients: An Updated Meta-Analysis of Randomized Controlled Trials.

Cardiovasc Revasc Med 2020 04 15;21(4):453-460. Epub 2019 Aug 15.

Division of Cardiovascular Medicine, University of Massachusetts Medical School, Worcester, MA, United States.

Background: TAVR is an established treatment option in high and intermediate-risk patients with severe AS. There is less data regarding the efficacy of TAVR in low-risk patients. This meta-analysis evaluated efficacy and safety outcomes of transcatheter aortic valve replacement (TAVR) in comparison to surgical aortic valve replacement (SAVR) in low-risk patients with severe aortic stenosis (AS).

Methods: Databases were searched for randomized controlled trials (RCTs) that compared TAVR with SAVR for the treatment of low-risk patients with severe AS. We calculated pooled odds ratios (ORs) and 95% confidence intervals (CIs) using the random-effects model.

Results: The final analysis included 2953 patients from 5 studies. Compared to SAVR, TAVR was associated with similar mid-term mortality [OR 0.67; 95% CI 0.37-1.21; p = 0.18], as well as similar short-term mortality [OR 0.51; 95% CI 0.24-1.11; p = 0.09]. Randomization to TAVR was associated with a reduced risk of developing acute kidney injury [OR 0.26; 95% CI 0.13-0.52; p < 0.001], short-term major bleeding [OR 0.27; 95% CI 0.12-0.60; p < 0.001] and new-onset atrial fibrillation [OR 0.17; 95% CI 0.14-0.21; p < 0.001]. However, TAVR was associated with a higher risk of requiring permanent pacemaker implantation [OR 4.25; 95% CI 1.86-9.73; p < 0.001]. There was no significant difference in the risk of myocardial infarction, stroke, endocarditis or aortic valve re-intervention between the two groups.

Conclusions: Our meta-analysis showed that TAVR has similar clinical efficacy to SAVR, with a more favorable safety profile, in patients with severe AS who are at low-surgical risk.
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http://dx.doi.org/10.1016/j.carrev.2019.08.009DOI Listing
April 2020

Risk of Mortality Associated With Therapeutic Hypothermia Among Sudden Cardiac Arrest Survivors With Known Heart Failure.

Am J Cardiol 2019 09 6;124(5):751-755. Epub 2019 Jun 6.

Division of Hospitalist Medicine, Department of Internal Medicine, Wake Forest University School of Medicine, Winston Salem, North Carolina.

Current guidelines do not inform about use of therapeutic hypothermia among heart failure (HF) patients who suffer from cardiac arrest. We assessed the risk of mortality associated with hypothermia among cardiac arrest survivors with HF. This analysis includes 1,416 comatose patients with cardiac arrest who achieved return of spontaneous circulation on admission and had a left ventricular ejection fraction (LVEF) assessment or HF admission within the previous year. HF was defined as either previous episode of HF or presence of left ventricular ejection fraction <50%. Hazard ratios (HR) and 95% confidence intervals (CI) for association of hypothermia and mortality among patients with and without HF were computed using Cox proportional hazard models adjusted for several risk factors. A propensity score matched analysis was also performed. There were 624 patients (44%) with pre-existing HF and 467 patients (33.0%) received hypothermia. The mortality rate was higher in HF patients treated with hypothermia compared with patients without hypothermia (75.4% vs 53.2%, p <0.0001). Hypothermia was associated with increased mortality among HF patients (HR 1.69; 95% CI 1.27, 2.24, p <0.001) and was not associated with mortality among non-HF patients (HR 1.21; 95% CI 0.93, 1.56, p = 0.15). The association of hypothermia with mortality was higher among HF patients who presented with shockable rhythm compared with nonshockable rhythm (interaction p value = 0.0495). Hypothermia is associated with increased mortality among cardiac arrest survivors with known HF.
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http://dx.doi.org/10.1016/j.amjcard.2019.05.055DOI Listing
September 2019

The Interplay of the Global Atherosclerotic Cardiovascular Disease Risk Scoring and Cardiorespiratory Fitness for the Prediction of All-Cause Mortality and Myocardial Infarction: The Henry Ford ExercIse Testing Project (The FIT Project).

Am J Cardiol 2019 08 28;124(4):511-517. Epub 2019 May 28.

Division of Cardiovascular Medicine, Henry Ford Hospital, Detroit, Michigan; Houston Methodist Hospital, Houston, Texas. Electronic address:

Cardiorespiratory fitness (CRF) is inversely associated with atherosclerotic cardiovascular disease (ASCVD) risk. It is unclear whether the prognostic value of CRF differs by baseline estimated ASCVD risk. We studied a retrospective cohort of patients without known heart failure or myocardial infarction (MI) who underwent treadmill stress testing. CRF was measured by metabolic equivalents of task (METs) and ASCVD risk was calculated using the Pooled Cohorts Equations. Multivariable-adjusted Cox regressions analyses examined the association between METs and incident all-cause mortality and MI outcomes stratified by baseline ASCVD risk. The C-index evaluated risk discrimination while net reclassification improvement evaluated reclassification with CRF added to the ASCVD risk score. Our study population consisted of 57,999 patients of mean age 53 (13) years, 49% women, 64% white, 29% black. Over a median follow-up 11 years (interquartile range 8 to 14 years) there were 6,670 (11%) deaths, while there were 1,757 (3.0%) MIs over a median follow-up of 6 years (interquartile range 3 to 8 years). Among patients with ASCVD risk ≥20%, those with METs ≥12 had a 77% lower risk of all-cause mortality (Hazard ratio 0.23 95% confidence interval = 0.20, 0.27) and 67% lower risk of MI (Hazard ratio 0.33 95% confidence interval = 0.24, 0.46) compared to METs <6. Similar results were obtained for those with ASCVD risk <5%. Addition of METs to ASCVD risk score improved the C-statistic from 0.778 to 0.798 for all-cause mortality and 0.726 to 0.733 for MI (both p <0.001). Addition of METs to ASCVD risk score significantly reclassified risk of all-cause mortality (p <0.001) but not MI (p = 0.052). In conclusion, CRF is inversely associated with risk of all-cause mortality and MI at all levels of ASCVD risk, and provides incremental risk discrimination and reclassification beyond the ASCVD risk score.
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http://dx.doi.org/10.1016/j.amjcard.2019.05.033DOI Listing
August 2019

Associations of circulating very-long-chain saturated fatty acids and incident type 2 diabetes: a pooled analysis of prospective cohort studies.

Am J Clin Nutr 2019 04;109(4):1216-1223

Cardiovascular Health Research Unit.

Background: Saturated fatty acids (SFAs) of different chain lengths have unique metabolic and biological effects, and a small number of recent studies suggest that higher circulating concentrations of the very-long-chain SFAs (VLSFAs) arachidic acid (20:0), behenic acid (22:0), and lignoceric acid (24:0) are associated with a lower risk of diabetes. Confirmation of these findings in a large and diverse population is needed.

Objective: We investigated the associations of circulating VLSFAs 20:0, 22:0, and 24:0 with incident type 2 diabetes in prospective studies.

Methods: Twelve studies that are part of the Fatty Acids and Outcomes Research Consortium participated in the analysis. Using Cox or logistic regression within studies and an inverse-variance-weighted meta-analysis across studies, we examined the associations of VLSFAs 20:0, 22:0, and 24:0 with incident diabetes among 51,431 participants.

Results: There were 14,276 cases of incident diabetes across participating studies. Higher circulating concentrations of 20:0, 22:0, and 24:0 were each associated with a lower risk of incident diabetes. Pooling across cohorts, the RR (95% CI) for incident diabetes comparing the 90th percentile to the 10th percentile was 0.78 (0.70, 0.87) for 20:0, 0.84 (0.77, 0.91) for 22:0, and 0.75 (0.69, 0.83) for 24:0 after adjustment for demographic, lifestyle, adiposity, and other health factors. Results were fully attenuated in exploratory models that adjusted for circulating 16:0 and triglycerides.

Conclusions: Results from this pooled analysis indicate that higher concentrations of circulating VLSFAs 20:0, 22:0, and 24:0 are each associated with a lower risk of diabetes.
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http://dx.doi.org/10.1093/ajcn/nqz005DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6500926PMC
April 2019

Updated meta-analysis of closure of patent foramen ovale versus medical therapy after cryptogenic stroke.

Cardiovasc Revasc Med 2019 03 13;20(3):187-193. Epub 2018 Jun 13.

Division of Cardiovascular Medicine, Wake Forest University, Winston Salem, NC, United States of America.

Background: Among patients with cryptogenic stroke, PFO closure has remained controversial. We hypothesized that with the cumulative number of subjects in randomized controlled trials (RCTs), there is now sufficient power to ascertain whether PFO closure in patients with cryptogenic stroke improves the risk of stroke.

Methods: We performed an updated meta-analysis by including newer RCTs that examined the benefit of PFO closure compared with medical therapy for improvement in risk of stroke. We utilized random effects models to compute the association and performed subgroup analyses by medical therapy, shunt size and presence/absence of atrial septal aneurysm.

Results: Overall, 6 RCTS were included with 1839 patients that underwent PFO closure and 1671 patients that received medical therapy and were followed for a period of 2-6 years. The incidence of recurrent stroke was 1.52% among PFO closure group and 3.94% among medical therapy group. There was decreased risk of stroke in PFO closure group (OR 0.34, 95% CI 0.15-0.79, p = 0.012). Patients with larger shunt size derived more benefit from PFO closure than smaller or moderate sized shunts. There was no difference in outcomes by presence or absence of atrial septal aneurysm or type of medical therapy used i.e. antiplatelet therapy only vs. antiplatelet + anticoagulant therapy.

Conclusion: This meta-analysis of 6 RCTs demonstrated benefits of PFO closure for secondary prevention of stroke among patients with cryptogenic stroke and small increase in risk of new onset atrial fibrillation.
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http://dx.doi.org/10.1016/j.carrev.2018.06.001DOI Listing
March 2019

Circulating Very Long-Chain Saturated Fatty Acids and Heart Failure: The Cardiovascular Health Study.

J Am Heart Assoc 2018 11;7(21):e010019

10 Friedman School of Nutrition Science & Policy Tufts University Boston MA.

Background Circulating very-long-chain saturated fatty acids ( VLSFAs ) are integrated biomarkers of diet and metabolism that may point to new risk pathways and potential targets for heart failure ( HF ) prevention. The associations of VLSFA to HF in humans are not known. Methods and Results Using a cohort study design, we studied the associations of serially measured plasma phospholipid VLSFA with incident HF in the Cardiovascular Health Study. We investigated the associations of time-varying levels of the 3 major circulating VLSFAs , lignoceric acid (24:0), behenic acid (22:0), and arachidic acid (20:0), with the risk of incident HF using Cox regression. During 45030 person-years among 4249 participants, we identified 1304 cases of incident HF , including 489 with preserved and 310 with reduced ejection fraction. Adjusting for major HF risk factors and other circulating fatty acids, higher levels of each VLSFAs were associated with lower risk of incident HF ( P trend≤0.0007 each). The hazard ratio comparing the highest quintile to the lowest quintile was 0.67 (95% confidence interval, 0.55-0.81) for 24:0, 0.72 (95% confidence interval, 0.60-0.87) for 22:0 and 0.72 (95% confidence interval, 0.59-0.88) for 20:0. The associations were similar in subgroups defined by sex, age, body mass index, coronary heart disease, and diabetes mellitus. Among those with ejection fraction data, the associations appeared similar for those with preserved and with reduced ejection fraction. Conclusions Higher levels of circulating VLSFAs are associated with lower risk of incident HF in older adults. These novel associations should prompt further research on the role of VLSFA in HF , including relevant new risk pathways. Clinical Trial Registration URL : https://www.clinicaltrials.gov . Unique identifier: NCT 00005133.
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http://dx.doi.org/10.1161/JAHA.118.010019DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6404213PMC
November 2018

Using machine learning on cardiorespiratory fitness data for predicting hypertension: The Henry Ford ExercIse Testing (FIT) Project.

PLoS One 2018 18;13(4):e0195344. Epub 2018 Apr 18.

King Saud bin Abdulaziz University for Health Sciences, Riyadh, Saudi Arabia.

This study evaluates and compares the performance of different machine learning techniques on predicting the individuals at risk of developing hypertension, and who are likely to benefit most from interventions, using the cardiorespiratory fitness data. The dataset of this study contains information of 23,095 patients who underwent clinician- referred exercise treadmill stress testing at Henry Ford Health Systems between 1991 and 2009 and had a complete 10-year follow-up. The variables of the dataset include information on vital signs, diagnosis and clinical laboratory measurements. Six machine learning techniques were investigated: LogitBoost (LB), Bayesian Network classifier (BN), Locally Weighted Naive Bayes (LWB), Artificial Neural Network (ANN), Support Vector Machine (SVM) and Random Tree Forest (RTF). Using different validation methods, the RTF model has shown the best performance (AUC = 0.93) and outperformed all other machine learning techniques examined in this study. The results have also shown that it is critical to carefully explore and evaluate the performance of the machine learning models using various model evaluation methods as the prediction accuracy can significantly differ.
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http://journals.plos.org/plosone/article?id=10.1371/journal.pone.0195344PLOS
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5905952PMC
July 2018
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