Mark A Hlatky

Lund University, Lund, Skåne, Sweden

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Publications (396)4539.01 Total impact

  • Dhruv S Kazi, Mark A Hlatky
    Journal of the American College of Cardiology 02/2015; 65(5):477-9. · 15.34 Impact Factor
  • Dhruv S Kazi, Mark A Hlatky
    JAMA Internal Medicine 02/2015; 175(2):314-5. · 13.25 Impact Factor
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    ABSTRACT: The revised cardiac risk index (RCRI) holds a central role in preoperative cardiac risk stratification in noncardiac surgery. Its performance in unselected populations, including different age groups, has, however, not been systematically investigated. We assessed the relationship of RCRI with major adverse cardiovascular events in an unselected cohort of patients undergoing elective, noncardiac surgery overall and in different age groups. We followed up all individuals ≥25 years who underwent major elective noncardiac surgery in Denmark (January 1, 2005, to November 30, 2011) for the 30-day risk of major adverse cardiovascular events (ischemic stroke, myocardial infarction, or cardiovascular death). There were 742 of 357 396 (0.2%), 755 of 74 889 (1.0%), 521 of 11 921 (4%), and 257 of 3146 (8%) major adverse cardiovascular events occurring in RCRI classes I, II, III, and IV. Multivariable odds ratio estimates were as follows: ischemic heart disease 3.30 (95% confidence interval, 2.96-3.69), high-risk surgery 2.70 (2.46-2.96), congestive heart failure 2.65 (2.29-3.06), cerebrovascular disease 10.02 (9.08-11.05), insulin therapy 1.62 (1.37-1.93), and kidney disease 1.45 (1.33-1.59). Modeling RCRI classes as a continuous variable, C statistic was highest among age group 56 to 65 years (0.772) and lowest for those aged >85 years (0.683). Sensitivity of RCRI class >I (ie, having ≥1 risk factor) for capturing major adverse cardiovascular events was 59%, 71%, 64%, 66%, and 67% in patients aged ≤55, 56 to 65, 66 to 75, 76 to 85, and >85 years, respectively; the negative predictive values were >98% across all age groups. In a nationwide unselected cohort, the performance of the RCRI was similar to that of the original cohort. Having ≥1 risk factor was of moderate sensitivity, but high negative predictive value for all ages. © 2015 American Heart Association, Inc.
    Circulation Cardiovascular Quality and Outcomes 01/2015; · 5.66 Impact Factor
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    ABSTRACT: Drug-eluting stents (DES) have largely replaced bare-metal stents (BMS) for percutaneous coronary intervention (PCI). It is uncertain, however, whether introduction of DES had a significant impact on the comparative effectiveness of PCI versus coronary artery bypass graft surgery (CABG) for death and myocardial infarction (MI). We identified Medicare beneficiaries aged ≥66 years who underwent multivessel CABG or multivessel PCI and matched PCI and CABG patients on propensity score. We defined the BMS era as January 1999 to April 2003 and the DES era as May 2003 to December 2006. We compared 5-year outcomes of CABG and PCI using Cox proportional hazards models, adjusting for baseline characteristics and year of procedure and tested for a statistically significant interaction (Pint) of DES era with treatment (CABG or PCI). Five-year survival improved from the BMS era to the DES era by 1.2% for PCI and by 1.1% for CABG, and the CABG:PCI hazard ratio was unchanged (0.90 vs 0.90; Pint = .96). Five-year MI-free survival improved by 1.4% for PCI and 1.1% for CABG, with no change in the CABG:PCI hazard ratio (0.81 vs 0.82; Pint = .63). By contrast, survival-free of MI or repeat coronary revascularization improved from the BMS era to the DES era by 5.7% for PCI and 0.9% for CABG, and the CABG:PCI hazard ratio changed significantly (0.50 vs 0.57, Pint ≤ .0001). The introduction of DES did not alter the comparative effectiveness of CABG and PCI with respect to hard cardiac outcomes. Copyright © 2014 Elsevier Inc. All rights reserved.
    American Heart Journal 01/2015; 169(1):149-54. · 4.56 Impact Factor
  • Journal of the American College of Cardiology 12/2014; 64(24):2712. · 15.34 Impact Factor
  • Mark A. Hlatky
    Journal of the American College of Cardiology 11/2014; · 15.34 Impact Factor
  • Source
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    ABSTRACT: Using genome-wide data from 253,288 individuals, we identified 697 variants at genome-wide significance that together explained one-fifth of the heritability for adult height. By testing different numbers of variants in independent studies, we show that the most strongly associated approximately 2,000, approximately 3,700 and approximately 9,500 SNPs explained approximately 21%, approximately 24% and approximately 29% of phenotypic variance. Furthermore, all common variants together captured 60% of heritability. The 697 variants clustered in 423 loci were enriched for genes, pathways and tissue types known to be involved in growth and together implicated genes and pathways not highlighted in earlier efforts, such as signaling by fibroblast growth factors, WNT/beta-catenin and chondroitin sulfate-related genes. We identified several genes and pathways not previously connected with human skeletal growth, including mTOR, osteoglycin and binding of hyaluronic acid. Our results indicate a genetic architecture for human height that is characterized by a very large but finite number (thousands) of causal variants.
    Nature Genetics 10/2014; · 29.65 Impact Factor
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    ABSTRACT: Background Heart failure is an established risk factor for poor outcomes in patients undergoing non-cardiac surgery, yet risk stratification remains a clinical challenge. We developed an index for 30-day mortality risk prediction in this particular group.Methods and resultsAll individuals with heart failure undergoing non-cardiac surgery between October 23 2004 and October 31 2011 were included from Danish administrative registers (n = 16 827). In total, 1787 (10.6%) died within 30 days. In a simple risk score based on the variables from the revised cardiac risk index, plus age, gender, acute surgery, and body mass index category the following variables predicted mortality (points): male gender (1), age 56–65 years (2), age 66–75 years (4), age 76–85 years (5), or age >85 years (7), being underweight (4), normal weight (3), or overweight (1), undergoing acute surgery (5), undergoing high-risk procedures (intra-thoracic, intra-abdominal, or suprainguinal aortic) (3), having renal disease (1), cerebrovascular disease (1), and use of insulin (1). The c-statistic was 0.79 and calibration was good. Mortality risk ranged from <2% for a score <5 to >50% for a score ≥20. Internal validation by bootstrapping (1000 re-samples) provided c-statistic of 0.79. A more complex risk score based on stepwise logistic regression including 24 variables at P < 0.05 performed only slightly better, c-statistic = 0.81, but was limited in use by its complexity.Conclusions For patients with heart failure, this simple index can accurately identify those at low risk for perioperative mortality.
    European Journal of Heart Failure 10/2014; · 6.58 Impact Factor
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    ABSTRACT: Acute kidney injury (AKI) is a known complication after coronary revascularization, but few studies have directly compared the incidence of AKI after coronary artery bypass surgery (CABG) or after percutaneous coronary intervention (PCI) in similar patients.
    Journal of the American College of Cardiology 09/2014; 64(10):985-94. · 15.34 Impact Factor
  • Dhruv S Kazi, Douglas K Owens, Mark A Hlatky
    Annals of internal medicine 09/2014; 161(5):378-9. · 16.10 Impact Factor
  • Mark Hlatky
    Journal of the American College of Cardiology 08/2014; 64(7):741. · 15.34 Impact Factor
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    ABSTRACT: Background The effectiveness of beta-blockers for preventing cardiac events has been questioned for patients who have coronary heart disease (CHD) without a prior myocardial infarction (MI). Objectives The purpose of this study was to assess the association of beta-blockers with outcomes among patients with new-onset CHD. Methods We studied consecutive patients discharged after the first CHD event (acute coronary syndrome or coronary revascularization) between 2000 and 2008 in an integrated healthcare delivery system who did not use beta-blockers in the year before entry. We used time-varying Cox regression models to determine the hazard ratio (HR) associated with beta-blocker treatment and used treatment-by-covariate interaction tests (pint) to determine whether the association differed for patients with or without a recent MI. Results A total of 26,793 patients were included, 19,843 of whom initiated beta-blocker treatment within 7 days of discharge from their initial CHD event. Over an average of 3.7 years of follow-up, 6,968 patients had an MI or died. Use of beta-blockers was associated with an adjusted HR for mortality of 0.90 (95% confidence limits [CL]: 0.84 to 0.96), and an adjusted HR for death or MI of 0.92 (CL: 0.87 to 0.97). The association between beta-blockers and outcomes differed significantly between patients with and without a recent MI (HR for death: 0.85 vs. 1.02, pint = 0.007; and HR for death or MI: 0.87 vs. 1.03, pint = 0.005). Conclusions Use of beta-blockers among patients with new-onset CHD was associated with a lower risk of cardiac events only among patients with a recent MI.
    Journal of the American College of Cardiology 07/2014; 64(3):247–252. · 15.34 Impact Factor
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    ABSTRACT: Percutaneous coronary intervention (PCI) based on fractional flow reserve (FFRcath) measurement during invasive coronary angiography (CAG) results in improved patient outcome and reduced healthcare costs. FFR can now be computed non-invasively from standard coronary CT angiography (cCTA) scans (FFRCT). The purpose of this study is to determine the potential impact of non-invasive FFRCT on costs and clinical outcomes of patients with suspected coronary artery disease in Japan. Clinical data from 254 patients in the HeartFlowNXT trial, costs of goods and services in Japan, and clinical outcome data from the literature were used to estimate the costs and outcomes of 4 clinical pathways: (1) CAG-visual guided PCI, (2) CAG-FFRcath guided PCI, (3) cCTA followed by CAG-visual guided PCI, (4) cCTA-FFRCT guided PCI. The CAG-visual strategy demonstrated the highest projected cost ($10,360) and highest projected 1-year death/myocardial infarction rate (2.4 %). An assumed price for FFRCT of US $2,000 produced equivalent clinical outcomes (death/MI rate: 1.9 %) and healthcare costs ($7,222) for the cCTA-FFRCT strategy and the CAG-FFRcath guided PCI strategy. Use of the cCTA-FFRCT strategy to select patients for PCI would result in 32 % lower costs and 19 % fewer cardiac events at 1 year compared to the most commonly used CAG-visual strategy. Use of cCTA-FFRCT to select patients for CAG and PCI may reduce costs and improve clinical outcome in patients with suspected coronary artery disease in Japan.
    Cardiovascular Intervention and Therapeutics 07/2014;
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    ABSTRACT: Conclusive data about cardiovascular toxicity of nonsteroidal anti-inflammatory drugs (NSAIDs) are sparse. We hypothesized that regular NSAID use is associated with increased risk for cardiovascular events in postmenopausal women, and that this association is stronger with greater cyclooxygenase (cox)-2 when compared with cox-1 inhibition.
    Circulation Cardiovascular Quality and Outcomes 07/2014; · 5.04 Impact Factor
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    ABSTRACT: Atrial fibrillation (AF) is the most common cardiac arrhythmia and is associated with increased risk of stroke and death. Obesity is an independent risk factor for AF, but modifiers of this risk are not well known. We studied the roles of obesity, physical activity, and their interaction in conferring risk of incident AF.
    Journal of the American Heart Association 06/2014; 3(4).
  • Dhruv S Kazi, Mark A Hlatky
    JAMA Internal Medicine 06/2014; · 13.25 Impact Factor
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    ABSTRACT: Objectives To examine the effectiveness of clopidogrel in real-world, medically-managed patients with unstable angina (UA) or non-ST segment elevation MI (NSTEMI). Background Although clinical trials have demonstrated the efficacy of clopidogrel to reduce cardiovascular morbidity and mortality in medically-managed patients with UA/NSTEMI, its effectiveness in actual clinical practice is less certain. Methods We conducted a retrospective cohort study of Kaiser Permanente members without known coronary disease or prior clopidogrel use who presented with UA/NSTEMI between 2003-2008 and were medically managed. Over two years of follow-up, we measured the association between clopidogrel use and all-cause mortality, hospitalization for MI, and a composite endpoint of death or MI using propensity-matched multivariable Cox analyses. Results We identified 16,365 patients with incident UA (35%) or NSTEMI (65%), 36% of who were prescribed clopidogrel within 7 days of discharge. In 8,562 propensity score matched patients, clopidogrel users had lower rates of all-cause mortality (8.3% vs 13.0%, p < 0.01; adjusted hazard ratio (HR) = 0.63, 95% confidence interval (CI) = 0.54 to 0.72) and the composite of death or MI (13.5% vs 17.4%, p < 0.01; HR = 0.74, CI = 0.66 to 0.84), but not of MI alone (6.7% vs. 7.2%, p=0.30; HR= 0.93, CI = 0.78 to 1.11) compared with non-users of clopidogrel. The association between clopidogrel use and the composite of death or MI was significant only among patients presenting with NSTEMI (HR = 0.67, CI = 0.59 to 0.76; pint < 0.01), and not among those presenting with UA (HR = 1.25, CI = 0.94 to 1.67). Conclusion In a large, community-based cohort of patients medically managed after UA/NSTEMI, clopidogrel use was associated with a lower risk of death and MI, particularly among NSTEMI patients.
    Journal of the American College of Cardiology 06/2014; 63(21). · 15.34 Impact Factor
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    ABSTRACT: The findings of the Women's Health Initiative (WHI) estrogen plus progestin (E+P) trial led to a substantial reduction in use of combined hormone therapy (cHT) among postmenopausal women in the United States. The economic effect of this shift has not been evaluated relative to the trial's $260 million cost (2012 U.S. dollars). To estimate the economic return from the WHI E+P trial. Decision model to simulate health outcomes for a "WHI scenario" with observed cHT use and a "no-WHI scenario" with cHT use extrapolated from the pretrial period. Primary analyses of WHI outcomes, peer-reviewed literature, and government sources. Postmenopausal women in the United States, aged 50 to 79 years, who did not have a hysterectomy. 2003 to 2012. Payer. Combined hormone therapy. Disease incidence, expenditure, quality-adjusted life-years, and net economic return. The WHI scenario resulted in 4.3 million fewer cHT users, 126 000 fewer breast cancer cases, 76 000 fewer cardiovascular disease cases, 263 000 more fractures, 145 000 more quality-adjusted life-years, and expenditure savings of $35.2 billion. The corresponding net economic return of the trial was $37.1 billion ($140 per dollar invested in the trial) at a willingness-to-pay level of $100 000 per quality-adjusted life-year. The 95% CI for the net economic return of the trial was $23.1 to $51.2 billion. No evaluation of indirect costs or outcomes beyond 2012. The WHI E+P trial made high-value use of public funds with a substantial return on investment. These results can contribute to discussions about the role of public funding for large, prospective trials with high potential for public health effects. National Heart, Lung, and Blood Institute.
    Annals of internal medicine 05/2014; 160(9):594-602. · 16.10 Impact Factor
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    ABSTRACT: -Biomarkers improve CVD risk prediction but their comparative effectiveness in clinical practice is not known. We sought to compare utilization, spending, and clinical outcomes in asymptomatic Medicare beneficiaries evaluated for cardiovascular disease (CVD) with coronary artery calcium (CAC) or other cardiovascular risk markers. -We used a 20% sample of 2005-2011 Medicare claims to identify fee-for-service beneficiaries aged >=65.5 years with no CVD claims in the prior 6 months. We matched on propensity score CAC patients with patients who received hs-CRP (n=8,358) or lipid screening (n=6,250). CAC was associated with increased noninvasive cardiac testing within 180 days (hazard ratio [HR] 2.22, 95% CI 1.68-2.93, p < 0.001, versus hs-CRP; HR 4.30, CI 3.04-6.06, p < 0.001, versus lipid screening), as well as increased coronary angiography and revascularization. Over three years follow-up, CAC was associated with higher CVD-related spending ($6,525 versus $4,432 for hs-CRP, p < 0.001; $6,500 versus $3,073 for lipid screening, p < 0.001), and fewer CVD-related events compared with hs-CRP (HR 0.74, CI 0.58-0.94, p=0.017) but not compared with lipid screening (HR 0.84, CI 0.64-1.11, p=0.23). -CAC testing among asymptomatic Medicare beneficiaries was associated with increased use of cardiac tests and procedures, higher spending, and slightly improved clinical outcomes compared with hs-CRP testing.
    Circulation Cardiovascular Imaging 04/2014; · 5.80 Impact Factor
  • Circulation 03/2014; · 14.95 Impact Factor

Publication Stats

20k Citations
4,539.01 Total Impact Points

Institutions

  • 2014
    • Lund University
      Lund, Skåne, Sweden
  • 1994–2014
    • Stanford University
      • • Division of Cardiovascular Medicine
      • • Department of Health Research and Policy
      • • Department of Medicine
      • • Department of Radiology
      • • Stanford Prevention Research Center
      Palo Alto, California, United States
  • 1991–2014
    • Stanford Medicine
      • • Department of Health Research and Policy
      • • Stanford Center for Inherited Cardiovascular Disease
      • • Division of Cardiovascular Medicine
      • • Division of Health Services Research
      Stanford, California, United States
  • 2006–2013
    • Kaiser Permanente
      Oakland, California, United States
    • Northwestern University
      • Division of General Internal Medicine and Geriatrics
      Evanston, IL, United States
  • 2012
    • University of East Anglia
      Norwich, England, United Kingdom
  • 2011–2012
    • American College of Cardiology
      Washington, Washington, D.C., United States
  • 2010–2011
    • The University of Arizona
      • College of Nursing
      Tucson, AZ, United States
    • University of Pittsburgh
      • Department of Epidemiology
      Pittsburgh, PA, United States
    • Naval Medical Center San Diego
      • Division of Cardiology
      San Diego, California, United States
    • Brigham and Women's Hospital
      Boston, Massachusetts, United States
  • 1994–2011
    • University of California, San Francisco
      • • Division of Hospital Medicine
      • • School of Nursing
      San Francisco, CA, United States
  • 2007
    • Centers for Disease Control and Prevention
      • National Center for Chronic Disease Prevention and Health Promotion
      Druid Hills, GA, United States
  • 2002–2005
    • Duke University
      • Department of Medicine
      Durham, North Carolina, United States
    • University of Washington Seattle
      • Department of Biostatistics
      Seattle, WA, United States
  • 2003
    • Vanderbilt University
      Нашвилл, Michigan, United States
  • 1999–2002
    • VA Palo Alto Health Care System
      Palo Alto, California, United States
  • 2000
    • Montreal Heart Institute
      Montréal, Quebec, Canada
  • 1983–1994
    • Duke University Medical Center
      • • Department of Medicine
      • • Division of Cardiology
      Durham, North Carolina, United States
    • Robert Wood Johnson University Hospital
      New Brunswick, New Jersey, United States