Research Interests:
Research Interests:
Research Interests:
Research Interests:
Research Interests:
Research Interests: Cardiology, Medicine, Electrocardiography, Adenosine, Prospective studies, and 12 moreHumans, Internal Medicine, Placebo, Acute Myocardial Infarction, Myocardial Infarction, Public health systems and services research, American Heart Association, Infarct Size, Thrombolytic Therapy, confounding, Thrombolysis, and Cardiovascular medicine and haematology
Research Interests:
Research Interests:
Research Interests:
Research Interests:
Cardiac allograft vasculopathy (CAV), characterized by diffuse intimal thickening and luminal narrowing in the arteries of the allograft, is the leading cause of morbidity and mortality in cardiac transplant recipients. Many transplant... more
Cardiac allograft vasculopathy (CAV), characterized by diffuse intimal thickening and luminal narrowing in the arteries of the allograft, is the leading cause of morbidity and mortality in cardiac transplant recipients. Many transplant centers perform routine annual surveillance coronary angiography. However, angiography can underdiagnose or miss CAV due to its diffuse nature. Intravascular ultrasound (IVUS) is more sensitive than angiography. IVUS provides not only accurate information on lumen size, but also quantification of intimal thickening, vessel wall morphology, and composition. IVUS has evolved as a valuable adjunct to angiography and the optimal diagnostic tool for early detection. Noninvasive testing such as dobutamine stress echocardiography and nuclear stress test have shown considerable accuracy in diagnosing significant CAV. Computed tomographic imaging and cardiac magnetic resonance imaging are promising new modalities but require further study. This article reviews the diagnostic methods that are currently available.
Research Interests:
Background: Heart failure is the most common cause of readmission. Among different methods of identifying patients with risk of readmission, Readmission Risk Calculator® smart phone application dev...
Research Interests:
Research Interests:
The neurohormone arginine vasopressin plays a significant role in the regulation of volume homeostasis, which is mediated via vasopressin type 2 (V2) receptors in the collecting tubules of the kidney. Diseases that are accompanied by... more
The neurohormone arginine vasopressin plays a significant role in the regulation of volume homeostasis, which is mediated via vasopressin type 2 (V2) receptors in the collecting tubules of the kidney. Diseases that are accompanied by abnormal volume homeostasis, including congestive heart failure and cirrhosis, are a frequent cause of hospital admissions and increasing healthcare costs. Recently, several nonpeptide V2 receptor antagonists have emerged as promising agents in the management of these conditions with the advantage of having no electrolyte abnormalities, neurohormonal activation or worsening renal insufficiency. Tolvaptan, a highly selective nonpeptide V2 receptor antagonist, has demonstrated an improvement in the volume status, osmotic balance and haemodynamic profile in preclinical and Phase II trials in patients with congestive heart failure and is currently undergoing testing in Phase III trials. This review discusses the evidence for the potential uses of tolvaptan, and its pharmacology and pharmacokinetics, particularly in congestive heart failure.
Research Interests:
Research Interests: Cardiology, Medicine, Heart Failure, Humans, Internal Medicine, and 12 moreHypertension, Blood Pressure, Chronic Disease, United States, Risk factors, Left Ventricular Dysfunction, Public health systems and services research, Chronic Heart Failure, Risk Factors, Ejection Fraction, Antihypertensive agents, and Cardiovascular medicine and haematology
ST-segment depression (ST-D) on the admission electrocardiogram of patients with non-ST-elevation acute coronary syndromes (NSTEACSs) is associated with higher mortality. However, few studies have evaluated the effect of location of ST-D... more
ST-segment depression (ST-D) on the admission electrocardiogram of patients with non-ST-elevation acute coronary syndromes (NSTEACSs) is associated with higher mortality. However, few studies have evaluated the effect of location of ST-D and T-wave polarity on long-term prognosis of patients with NSTEACS. Electrocardiographic (ECG) and clinical data from 6,770 patients with NSTEACS randomly assigned in the Global Use of Strategies to Open Occluded Coronary Arteries (GUSTO) IIB trial were analyzed retrospectively. One-year mortality was correlated with location of ST-D (leads I and aVL; II, III, and aVF; V1 to V3; or V4 to V6) and T-wave polarity. ST-D in any of the ECG locations was associated with higher mortality compared with patients without ST-D. Patients with ST-D and T-wave inversion in leads V4 to V6 had the highest 1-year mortality rate of all groups (16.2%), significantly higher compared with patients with ST-D without T-wave inversion in those leads (9.0%, p=0.001). Logistic regression analysis showed that age, hyperlipidemia, Killip class>I, history of myocardial infarction, history of heart failure, history of angina pectoris, systolic blood pressure, heart rate, sum of ST-D (odds ratio 1.061, 95% confidence interval 1.035 to 1.087, p<0.001), and ST-D with T-wave inversion in leads V4 to V6 (odds ratio 1.374, 95% CI 1.023 to 1.844, p=0.035) were independent predictors of 1-year mortality. Conversely, ST-D without T-wave inversion in leads V4 to V6 or other ECG presentations were not independent predictors of high 1-year mortality. In conclusion, ST-D with T-wave inversion in leads V4 to V6 on the admission electrocardiogram in patients with NSTEACS identifies those with higher 1-year mortality than for patients with any other ECG presentation.
Research Interests: Cardiology, Epidemiology, Electrocardiography, Analysis, Humans, and 15 moreInternal Medicine, Female, Male, Lead, Aged, Acute Coronary Syndrome, Coronary heart disease, Analysis of Variance, Analisis, Coronary Artery Disease, Logistic Models, Confidence Interval, Coronary artery, Acute Disease, and Cardiovascular medicine and haematology
Research Interests:
Research Interests:
Research Interests:
Research Interests:
Prior research suggests that patients may be entered into clinical trials with different electrocardiographic (ECG) findings than specified by study protocol criteria; the extent and impact of this variability in a large-scale trial have... more
Prior research suggests that patients may be entered into clinical trials with different electrocardiographic (ECG) findings than specified by study protocol criteria; the extent and impact of this variability in a large-scale trial have not been previously described. We evaluated the relationship between case report form (CRF) categorization of the admission ECG and a Core Laboratory and subsequent outcome in a retrospective analysis of a trial of patients with acute ischemia and a broad spectrum of ECG changes (the GUSTO-IIb trial). In 11,037 patients with CRF information and an interpretable ECG, there was agreement in 89.1% of ST-elevation and 81.9% of non-ST-elevation cases. Among patients designated as having no ST elevation on the CRF, 1-year mortality rates were significantly higher in the subgroup of patients with Core Laboratory-determined ST elevation as compared with those where both the CRF and Core Laboratory classification were in agreement (8.8% vs 6.8%, P = .0093). Among patients designated as having ST elevation by the CRF, 1-year mortality rates were similar in both the subgroup of patients with and without Core Laboratory agreement (7.7% vs 8.2%, P = .72). These findings have important implications for clinicians in routine practice because even a simple evaluation (presence or absence of ST elevation) on the admission ECG was often discordant and was associated with adverse clinical outcome.
Research Interests: Cardiology, Medicine, Electrocardiography, Multivariate Analysis, Humans, and 15 moreInternal Medicine, Hospitalization, Female, Male, Laboratory experiment, Laboratory, Aged, Middle Aged, Acute Coronary Syndrome, Electrocardiogram, Myocardial Infarction, Public health systems and services research, Prognosis, Randomized Controlled Trials as Topic, and Cardiovascular medicine and haematology
Chronic obstructive pulmonary disease (COPD) exacerbation is a frequent cause of hospital admissions. In one-third of patients, exacerbations have no known cause. We studied whether the presence of diastolic dysfunction (DD) in this... more
Chronic obstructive pulmonary disease (COPD) exacerbation is a frequent cause of hospital admissions. In one-third of patients, exacerbations have no known cause. We studied whether the presence of diastolic dysfunction (DD) in this subgroup of patients is associated with longer duration of hospitalization and more frequent exacerbations. Retrospective chart review of 139 patients with COPD, 84 with DD, and 55 with normal diastolic function hospitalized for acute COPD exacerbation between November 2004 and December 2007 was done. Diastolic dysfunction was defined by the presence of relaxation, filling, or distensibility abnormalities of the left ventricle on transthoracic echocardiogram. Patients with DD had increased length of stay compared with patients without DD (mean: 4.02 +/- 1.8 days vs 3.24 +/- 1.20 days; P = 0.005). Patients with DD had 1.28 exacerbations requiring hospitalization per patient-year compared with 0.67 in the normal diastolic function group (P = 0.0067). Patients with COPD and DD had prolonged and more frequent hospitalizations for COPD exacerbations. These findings suggest that DD, a surrogate for increased left ventricular filling pressure, is common in patients with COPD exacerbations and may be associated with increased frequency of hospitalization.
Research Interests: Cardiology, Medicine, Humans, COPD, Internal Medicine, and 15 moreFemale, Male, Risk factors, Length of Stay, Aged, Middle Aged, Retrospective Studies, Chronic obstructive pulmonary disease, Risk Factors, Glucocorticoids, Cohort Studies, Exacerbation, Cholinergic antagonists, Diastole, and Pulmonary Disease Chronic Obstructive
Research Interests: Research Design, Medicine, Heart Failure, Prospective studies, Humans, and 13 morePlacebo, Congestive Heart Failure, Hospitalization, Public health systems and services research, Randomized Controlled Trial, Study design, Disease Progression, American Heart Association, Multicenter Study, Tolvaptan, Patient selection, Cardiovascular medicine and haematology, and Arginine Vasopressin
Research Interests: Cardiology, Medicine, Electrocardiography, Humans, Internal Medicine, and 15 moreFemale, Male, Artery, Clinical Sciences, Aged, Cardiac Catheterization, Middle Aged, Coronary Angiography, Myocardial Infarction, Circulation, Ejection Fraction, Left Ventricular Function, Coronary Arteries, Left Ventricular, and Cardiovascular medicine and haematology
Acute Myocardial Infarction and Complete Bundle Branch Block at Hospital Admission: Clinical Characteristics and Outcome in the Thrombolytic Era fn1fn1This study was supported by grants from Bayer Corporation, New York, New York; Genentech, Inc., South San Francisco, California; CIBA-Corning, Med...more
Research Interests: Cardiology, Medicine, Humans, Internal Medicine, Female, and 15 moreMale, Acute Myocardial Infarction, Aged, Middle Aged, Coronary Angiography, Myocardial Infarction, Public health systems and services research, North American, Coronary Artery Disease, Bundle Branch Block, Mortality rate, Coronary artery, Cardiogenic shock, Hospital Admission, and Cardiovascular medicine and haematology
Research Interests:
Research Interests: Cardiology, Emergency Medicine, Electrocardiography, Humans, Internal Medicine, and 15 moreFemale, Male, Acute Myocardial Infarction, Enzyme, Clinical Sciences, Aged, Electrocardiogram, Analysis of Variance, Coronary Artery Disease, Chest Pain, Logistic Models, Bundle Branch Block, Case Control Studies, Coronary artery, and Medical and Health Sciences
ABSTRACT
Research Interests:
Research Interests:
Early postinfarction angina implies an unfavorable prognosis. Most published information on this outcome represents data collected in the prethrombolytic era, in which definitions and populations differed considerably. Our purpose was to... more
Early postinfarction angina implies an unfavorable prognosis. Most published information on this outcome represents data collected in the prethrombolytic era, in which definitions and populations differed considerably. Our purpose was to evaluate the incidence and importance of recurrent ischemia after administration of thrombolytic therapy. We studied patients enrolled in the Thrombolysis and Angioplasty in Myocardial Infarction studies. Patients were enrolled into 5 studies with similar entry criteria; 552 patients were treated with tissue plasminogen activator (t-PA), 293 were treated with urokinase, and 385 received both thrombolytic agents. Recurrent ischemia was defined as symptoms in association with electrocardiographic changes; reinfarction was defined as a reelevation of creatine kinase myocardial band isoenzyme in an appropriate clinical setting. Both recurrent ischemia and reinfarction occurred in 42 patients (3.4%), recurrent ischemia alone occurred in 226 (18%), whereas neither occurred in 964 (78%). Although baseline characteristics were similar among the 3 groups, in-hospital cardiac events (total 73 deaths, 253 heart failure episodes) were not: in-hospital mortality in patients with reinfarction was 21%; with recurrent ischemia, 11%; and with neither event, 4% (p < 0.0001). The in-hospital heart failure rate of patients with reinfarction was 50%; with recurrent ischemia alone, 31%; and with neither event, 17% (p < 0.0001). As expected, median in-hospital costs were highest in patients with reinfarction ($26,802), intermediate for those with recurrent ischemia alone ($18,422), and lowest in patients with neither event ($15,623). Recurrent myocardial ischemia after thrombolytic therapy is a frequent, important, and expensive adverse clinical outcome, making it a critical target for therapeutic intervention.
Research Interests: Cardiology, Heart Failure, Humans, Internal Medicine, Ischemia, and 15 moreHospitalization, Female, Male, Data Collection, Acute Myocardial Infarction, Incidence, Creatine Kinase, Length of Stay, Aged, Chi Square Distribution, Hospital Mortality, Health Care Costs, Angina, Logistic Models, and Cardiovascular medicine and haematology
Background: The use of colchicine has been associated with reduction of adverse cardiac events in patients with coronary artery disease (CAD). The role of this drug after percutaneous coronary intervention (PCI) with bare metal stents... more
Background: The use of colchicine has been associated with reduction of adverse cardiac events in patients with coronary artery disease (CAD). The role of this drug after percutaneous coronary intervention (PCI) with bare metal stents (BMS) has not been evaluated against isolated PCI with drug eluting stents (DES). Aim: The study was designed to test an improved cost-effectiveness with BMS plus colchicine (group BMS+C) compared to DES alone (group DES), provided its noninferiority in terms of major adverse cardiac events (MACE) at 1 year. Methods: This is a prospective, multicenter, randomized controlled trial performed in 4 centers. The trial has been registered at clinicaltrials.gov (NCT04382443). Study protocol and informed consent have been approved by an Independent Ethical and Review Board Committee and were presented to Argentina National regulatory authorities for Health, Technology and Medications. Patients in the BMS+C group received 0.5mg oral doses twice a day of colchic...
Research Interests:
Research Interests:
Research Interests:
Research Interests:
Background: Patients with STEMI who receive rapid diagnosis and reperfusion therapy have improved clinical outcomes. The rate-limiting step in STEMI diagnosis is often the availability of a 12-lead...
Research Interests:
Research Interests:
Research Interests: Cardiology, Medicine, Heart Failure, Internal Medicine, Placebo, and 14 moreAtrial Fibrillation, Dilated cardiomyopathy, Intensive Care Unit, Medical Diagnosis, Cardiomyopathy, Intensive Care Medicine, Ejection Fraction, Mineralocorticoid Receptor, Ventricular Tachycardia, GuideLine, Critically Ill Patients, Tachycardia, Extracorporeal Membrane Oxygenation, and Cardiogenic shock
Research Interests:
Research Interests: Cardiology, Medicine, Humans, Internal Medicine, Risk factors, and 13 moreLeft ventricular hypertrophy, Biological markers, Risk Factors, Muscle hypertrophy, Calcitonin, Graft Rejection, Heart Transplantation, Heart and Lung Transplantation, Case Control Studies, The Heart, Severity of Illness Index, Cardiovascular medicine and haematology, and Calcitonin Gene Related Peptide
Research Interests:
Research Interests: Cardiology, Medicine, Electrocardiography, Electrocardiology, Adenosine, and 12 moreHumans, Internal Medicine, Perfusion, Acute Myocardial Infarction, Single Photon Emission Computed Tomography, Myocardial Infarction, Coronary Circulation, Myocardial Perfusion Imaging, Estimation Method, Thrombolytic Therapy, Combined Modality Therapy, and Cardiovascular medicine and haematology
Previous reports indicate that patients who do not develop Q waves after thrombolytic therapy are a different population with a better long-term survival than those who do develop Q waves. However, the use of resources, quality of life,... more
Previous reports indicate that patients who do not develop Q waves after thrombolytic therapy are a different population with a better long-term survival than those who do develop Q waves. However, the use of resources, quality of life, and health status of this population have not been fully evaluated. Using data from the Economics and Quality of Life subset of the Global Utilization of Streptokinase and tPA for Occluded Arteries study, we examined 30-day and 1-year mortality, use of resources, and quality-of-life measures among 1,830 of 3,000 patients with acute myocardial infarction and ST-segment elevation treated with thrombolytic therapy. At hospital discharge, 555 patients (30.2%) had not developed Q waves. These patients had lower mortality than patients with Q waves at 30 days (1.6% vs 4.5%, p <0.01) and at 1 year (4.7% vs 6.8%, p <0.04). Recurrent chest pain and dyspnea were similar at 30 days and 1 year. Patients without Q waves had significantly more angiography and trends toward higher readmission, revascularization, and use of calcium antagonists at 30 days. Angiography, revascularization, readmission, and quality of life were equivalent from 30 days to 1 year, with no sign of late instability. Logistic regression analysis showed an association between in-hospital revascularization and better survival and quality of life at 1 year. Conversely, there was no association between in-hospital use of calcium antagonists and outcome to explain the lower mortality in non-Q-wave patients. The absence of Q waves after thrombolytic therapy is a marker of success, implying better prognosis and equivalent quality of life, use of resources, and health status than for patients with Q-wave acute myocardial infarction and no sign of long-term unstable clinical course.
Research Interests: Cardiology, Quality of life, Medicine, Electrocardiography, Humans, and 15 moreInternal Medicine, Female, Male, Acute Myocardial Infarction, Length of Stay, Health Status, Recurrence, Aged, Middle Aged, Coronary Angiography, Myocardial Infarction, Prognosis, Revascularization, Cardiovascular medicine and haematology, and Patient readmission
0022-0736/$ – see fro doi:10.1016/j.jelectroc 4 Corresponding a E-mail address: n About 1 million Americans have an acute myocardial infarction each year, yet the event occurs in less than 20% of patients who present with chest pain.... more
0022-0736/$ – see fro doi:10.1016/j.jelectroc 4 Corresponding a E-mail address: n About 1 million Americans have an acute myocardial infarction each year, yet the event occurs in less than 20% of patients who present with chest pain. ST-segment elevation is the one sign that can most immediately and convincingly distinguish impending acute myocardial infarct and indicate the need for emergent reperfusion. However, it is not always specific for infarction and may be subject to a wider interpretation. Unfortunately the time for such interpretation is usually not available. The current guidelines advise immediate reperfusion of patients with an acute ST-segment elevation myocardial infarction (STEMI), in whom symptoms of ongoing ischemia are combined with ST-segment elevation in 2 or more leads (z1 mm in the limb leads and z2 in the precordial leads). Thus, the clinician encountering a patient with suggestive symptoms and ST-segment elevation on the initial electrocardiogram (ECG) must rapidly decide for urgent revascularization and cannot wait for cardiac markers to return from the laboratory. The need for emergency transfer to another facility may further restrict the time available for decision making. Although primary percutaneous intervention (PCI) has become an alternative to thrombolytic therapy for STEMI, it is performed on only a minority (18%) of eligible patients in the United States, and of the nearly 5000 acute care hospitals in this country, only 1200 are capable of performing the procedure, which may require a long-distance transfer if PCI is to be performed at all. In addition, because of the correlation of delay with mortality, recent guidelines require that balloon inflation follow hospital admission by no more than 90 minutes. Finally, it should be added that the struggle to properly interpret ambiguous ST-segment changes has been rendered more problematic by the Center
Research Interests:
The outcome of patients who fail to reperfuse with thrombolytic therapy or percutaneous coronary intervention (PCI) for ST-elevation acute myocardial infarction (STEMI) may be improved with additional pharmacologic and mechanical... more
The outcome of patients who fail to reperfuse with thrombolytic therapy or percutaneous coronary intervention (PCI) for ST-elevation acute myocardial infarction (STEMI) may be improved with additional pharmacologic and mechanical interventions such as rescue PCI or intravenous glycoprotein IIb/IIIa infusion. The standard 12-lead ECG is the most commonly available and suitable tool for routine bedside evaluation of the success of reperfusion therapy for STEMI. This article reviews and discusses the current data on the four ECG markers for prediction of the perfusion status of the ischemic myocardium: ST-segment deviation, T-wave configuration, QRS changes, and reperfusion arrhythmias.