Mark A Hlatky

Stanford Medicine, Stanford, California, United States

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Publications (433)5023.28 Total impact

  • [Show abstract] [Hide abstract]
    ABSTRACT: Cardiac resynchronization therapy (CRT) reduces mortality and heart failure hospitalizations in patients with mild heart failure. To estimate the cost-effectiveness of adding CRT to an implantable cardioverter-defibrillator (CRT-D) compared with implantable cardioverter-defibrillator (ICD) alone among patients with left ventricular systolic dysfunction, prolonged intraventricular conduction, and mild heart failure. Markov decision model. Clinical trials, clinical registries, claims data from Centers for Medicare & Medicaid Services, Centers for Disease Control and Prevention life tables. Patients age 65 years or older with a left ventricular ejection fraction (LVEF) of 30% or less, QRS duration of 120 milliseconds or more, and New York Heart Association (NYHA) class I or II symptoms. Lifetime. Societal. CRT-D or ICD alone. Life-years, quality-adjusted life-years (QALYs), costs, and incremental cost-effectiveness ratios (ICERs). Use of CRT-D increased life expectancy (9.8 years versus 8.8 years), QALYs (8.6 years versus 7.6 years), and costs ($286 500 versus $228 600), yielding a cost per QALY gained of $61 700. The cost-effectiveness of CRT-D was most dependent on the degree of mortality reduction: When the risk ratio for death was 0.95, the ICER increased to $119 600 per QALY. More expensive CRT-D devices, shorter CRT-D battery life, and older age also made the cost-effectiveness of CRT-D less favorable. The estimated mortality reduction for CRT-D was largely based on a single trial. Data on patients with NYHA class I were limited. The cost-effectiveness of CRT-D in patients with NYHA class I symptoms remains uncertain. In patients with an LVEF of 30% or less, QRS duration of 120 milliseconds or more, and NYHA class II symptoms, CRT-D appears to be economically attractive relative to ICD alone when a reduction in mortality is expected. National Institutes of Health, University of Copenhagen, U.S. Department of Veterans Affairs.
    Annals of internal medicine 08/2015; DOI:10.7326/M14-1804 · 16.10 Impact Factor
  • Clinical Infectious Diseases 06/2015; DOI:10.1093/cid/civ517 · 9.42 Impact Factor
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    ABSTRACT: Conclusive evidence is lacking regarding the benefits and risks of performing off-pump versus on-pump coronary artery bypass graft (CABG) for patients with diabetes. This study aims to compare clinical outcomes after off-pump and on-pump procedures for patients with diabetes. The Bypass Angioplasty Revascularization Investigation 2 Diabetes (BARI 2D) trial enrolled patients with type 2 diabetes and documented coronary artery disease, 615 of whom underwent CABG during the trial. The procedural complications, 30-day outcomes, long-term clinical and functional outcomes were compared between the off-pump and on-pump groups overall and within a subset of patients matched on propensity score. On-pump CABG was performed in 444 (72%) patients, and off-pump CABG in 171 (28%). The unadjusted 30-day rate of death/myocardial infarction (MI)/stroke was significantly higher after off-pump CABG (7.0 vs 2.9%, P = 0.02) despite fewer complications (10.3 vs 20.7%, P = 0.003). The long-term risk of death [adjusted hazard ratio (aHR): 1.41, P = 0.2197] and major cardiovascular events (death, MI or stroke) (aHR: 1.47, P = 0.1061) did not differ statistically between the off-pump and on-pump patients. Within the propensity-matched sample (153 pairs), patients who underwent off-pump CABG had a higher risk of the composite outcome of death, MI or stroke (aHR: 1.83, P = 0.046); the rates of procedural complications and death did not differ significantly, and there were no significant differences in the functional outcomes. Patients with diabetes had greater risk of major cardiovascular events long-term after off-pump CABG than after on-pump CABG. © The Author 2015. Published by Oxford University Press on behalf of the European Association for Cardio-Thoracic Surgery. All rights reserved.
    European journal of cardio-thoracic surgery: official journal of the European Association for Cardio-thoracic Surgery 05/2015; DOI:10.1093/ejcts/ezv170 · 2.81 Impact Factor
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    ABSTRACT: Insulin resistance is associated with diabetes mellitus, but it is uncertain whether it improves cardiovascular disease (CVD) risk prediction beyond traditional cardiovascular risk factors. We identified 15 288 women from the Women's Health Initiative Biomarkers studies with no history of CVD, atrial fibrillation, or diabetes mellitus at baseline (1993-1998). We assessed the prognostic value of adding fasting serum insulin, HOMA-IR (homeostasis model assessment-insulin resistance), serum-triglyceride-to-serum-high-density lipoprotein-cholesterol ratio TG/HDL-C, or impaired fasting glucose (serum glucose ≥110 mg/dL) to traditional risk factors in separate Cox multivariable analyses and assessed risk discrimination and reclassification. The study end point was major CVD events (nonfatal and fatal coronary heart disease and ischemic stroke) within 10 years, which occurred in 894 (5.8%) women. Insulin resistance was associated with CVD risk after adjusting for age and race/ethnicity with hazard ratios (95% confidence interval [CI]) per doubling in insulin of 1.21 (CI, 1.12-1.31), in HOMA-IR of 1.19 (CI, 1.11-1.28), in TG/HDL-C of 1.35 (CI, 1.26-1.45), and for impaired fasting glucose of 1.31 (CI, 1.05-1.64). Although insulin, HOMA-IR, and TG/HDL-C remained associated with increased CVD risk after adjusting for most CVD risk factors, none remained significant after adjusting for HDL-C: hazard ratios for insulin, 1.06 (CI, 0.98-1.16); for HOMA-IR, 1.06 (CI, 0.98-1.15); for TG/HDL-C, 1.11 (CI, 0.99-1.25); and for glucose, 1.20 (CI, 0.96-1.50). Insulin resistance measures did not improve CVD risk discrimination and reclassification. Measures of insulin resistance were no longer associated with CVD risk after adjustment for high-density lipoprotein-cholesterol and did not provide independent prognostic information in postmenopausal women without diabetes mellitus. URL: Unique identifier: NCT00000611. © 2015 American Heart Association, Inc.
    Circulation Cardiovascular Quality and Outcomes 05/2015; 8(3). DOI:10.1161/CIRCOUTCOMES.114.001563 · 5.04 Impact Factor
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    ABSTRACT: This report evaluates incidence of cardiovascular disease (CVD) morbidity and mortality over 10 years among the >160,000 postmenopausal women in the Women's Health Initiative (WHI) in relation to self-reported RA, disease modifying anti-rheumatic drugs (DMARD) use, anti-CCP+, RF+, CVD risk factors, joint pain, and inflammation (white blood cell (WBC) count and IL-6.) Methods: Anti-CCP and RF were measured on a sample (n=9,988) of WHI participants with self-reported RA. RA was classified as self-reported RA plus anti-CCP+ positivity and/or use of DMARDs. Self-reported RA that was both anti-CCP- and DMARD- was classified as "unverified RA." Age-adjusted rates of coronary heart disease (CHD), stroke, CVD, fatal CVD and total mortality were higher for women with RA vs. no RA, with multivariable-adjusted HR(95%CI) of 1.46(1.17, 1.83) for CHD, and 2.55(1.86, 3.51) for fatal CVD. Within RA, anti-CCP+ and RF+ were not significantly associated with higher risk of any outcomes, despite slightly higher risk of fatal CVD and death for anti-CCP+ vs. anti-CCP- RA. Joint pain severity and CVD risk factors were strongly associated with CVD risk, even for women with no RA. CVD incidence was increased for RA vs. no RA at almost all risk factor levels, except low levels of joint pain or inflammation. Within RA, inflammation was more strongly associated with fatal CVD and total mortality than CHD or CVD. Among postmenopausal women, RA was associated with 1.5-2.5 higher CVD risk, strongly associated with CV risk factors, joint pain severity, and inflammation, but similar for anti-CCP+ and RF+. This article is protected by copyright. All rights reserved. © 2015, American College of Rheumatology.
    05/2015; DOI:10.1002/art.39198
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    ABSTRACT: It is unclear whether obesity unaccompanied by metabolic abnormalities is associated with increased cardiovascular disease risk across racial and ethnic subgroups. We identified 14 364 postmenopausal women from the Women's Health Initiative who had data on fasting serum lipids and serum glucose and no history of cardiovascular disease or diabetes at baseline. We categorized women by body mass index (in kg/m(2)) as normal weight (body mass index 18.5 to <25), overweight (body mass index 25 to <30), or obese (body mass index ≥30) and by metabolic health, defined first as the metabolic syndrome (metabolically unhealthy: ≥3 metabolic abnormalities) and second as the number of metabolic abnormalities. We used Cox proportional hazards regression to assess associations between baseline characteristics and cardiovascular risk. Over 13 years of follow-up, 1101 women had a first cardiovascular disease event (coronary heart disease or ischemic stroke). Among black women without metabolic syndrome, overweight women had higher adjusted cardiovascular risk than normal weight women (hazard ratio [HR] 1.49), whereas among white women without metabolic syndrome, overweight women had similar risk to normal weight women (HR 0.92, interaction P=0.05). Obese black women without metabolic syndrome had higher adjusted risk (HR 1.95) than obese white women (HR 1.07; interaction P=0.02). Among women with only 2 metabolic abnormalities, cardiovascular risk was increased in black women who were overweight (HR 1.77) or obese (HR 2.17) but not in white women who were overweight (HR 0.98) or obese (HR 1.06). Overweight and obese women with ≤1 metabolic abnormality did not have increased cardiovascular risk, regardless of race or ethnicity. Metabolic abnormalities appeared to convey more cardiovascular risk among black women. © 2015 The Authors. Published on behalf of the American Heart Association, Inc., by Wiley Blackwell.
    Journal of the American Heart Association 04/2015; 4(5). DOI:10.1161/JAHA.114.001695 · 2.88 Impact Factor
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    ABSTRACT: Background. To characterize the association of antiretroviral drug combinations on risk of cardiovascular events. Methods. Certain antiretroviral medications for HIV have been implicated in increasing risk of cardiovascular disease. However, antiretroviral drugs are typically prescribed in combination. We characterized the association of current exposure to antiretroviral drug combinations on risk of cardiovascular events including myocardial infarction, stroke, percutaneous coronary intervention, and coronary artery bypass surgery. We used the Veterans Health Administration Clinical Case Registry to analyze data from 24,510 patients infected with HIV from January 1996 through December 2009. We assessed the association of current exposure to 15 antiretroviral drugs and 23 pre-specified combinations of agents on the risk of cardiovascular event by using marginal structural models and Cox models extended to accommodate time-dependent variables. Results. Over 164,059 person-years of follow-up, 934 patients had a cardiovascular event. Current exposure to abacavir, efavirenz, lamivudine, and zidovudine was significantly associated with increased risk of cardiovascular event, with odds ratios ranging from 1.40 to 1.53. Five combinations were significantly associated with increased risk of cardiovascular event, all of which involved lamivudine. One of these - efavirenz, lamivudine and zidovudine -- was the second most commonly used combination and was associated with a risk of cardiovascular event that is 1.60 times that of patients not currently exposed to the combination (OR=1.60, 95% CI: 1.25-2.04). Conclusions. In the VA cohort, exposure to both individual drugs and drug combinations were associated with modestly increased risk of a cardiovascular event.
    Clinical Infectious Diseases 04/2015; 61(3). DOI:10.1093/cid/civ316 · 9.42 Impact Factor
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    ABSTRACT: Background Platelet inhibition after percutaneous coronary intervention (PCI) reduces the risk of myocardial infarction (MI) but increases the risk of bleeding. MIs and bleeds during the index hospitalization for PCI are known to negatively affect long-term outcomes. The impact of spontaneous bleeding occurring after discharge on long-term mortality is unknown. Objectives This study sought to examine, in a real-world cohort, the association between spontaneous major bleeding or MI after PCI and long-term mortality. Methods We conducted a retrospective cohort study of patients ≥30 years of age who underwent a PCI between 1996 and 2008 in an integrated healthcare delivery system. We used extended Cox regression to examine the associations of spontaneous bleeding and MI with all-cause mortality, after adjustment for time-updated demographics, comorbidities, periprocedural events, and longitudinal medication exposure. Results Among 32,906 patients who had a PCI and survived the index hospitalization, 530 had bleeds and 991 had MIs between 7 and 365 days post-discharge. There were 4,048 deaths over a mean follow-up of 4.42 years. The crude annual death rate after a spontaneous bleed (9.5%) or MI (7.6%) was higher than among patients who experienced neither event (2.6%). Bleeding was associated with an increased rate of death (adjusted hazard ratio [HR]: 1.61, 95% confidence interval [CI]: 1.30 to 2.00), similar to that after an MI (HR: 1.91; 95% CI: 1.62 to 2.25). The association of bleeding with death remained significant after additional adjustment for the longitudinal use of antiplatelet agents. Conclusions Spontaneous bleeding after a PCI was independently associated with higher long-term mortality, and conveyed a risk comparable to that of an MI during follow-up. This tradeoff between efficacy and safety bolsters the argument for personalizing antiplatelet therapy after PCI on the basis of the patient's long-term risk of both thrombotic and bleeding events.
    Journal of the American College of Cardiology 04/2015; 65(14):1411-20. DOI:10.1016/j.jacc.2015.01.047 · 15.34 Impact Factor
  • Mark A Hlatky
    Annals of internal medicine 03/2015; 162(6):JC8. DOI:10.7326/ACPJC-2015-162-6-008 · 16.10 Impact Factor
  • Dhruv S Kazi · Mark A Hlatky
    Journal of the American College of Cardiology 02/2015; 65(5):477-9. DOI:10.1016/j.jacc.2014.11.033 · 15.34 Impact Factor
  • Source
    Dhruv S Kazi · Mark A Hlatky
    JAMA Internal Medicine 02/2015; 175(2):314-5. DOI:10.1001/jamainternmed.2014.7023 · 13.25 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. DOI:10.1016/j.ahj.2014.10.004 · 4.56 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; 8(1). DOI:10.1161/CIRCOUTCOMES.114.001298 · 5.66 Impact Factor
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    ABSTRACT: ASCERT (American College of Cardiology Foundation and the Society of Thoracic Surgeons Collaboration on the Comparative Effectiveness of Revascularization Strategies) was a large observational study designed to compare the long-term effectiveness of coronary artery bypass graft (CABG) and percutaneous coronary intervention (PCI) to treat coronary artery disease (CAD) over 4 to 5 years. This study examined the cost-effectiveness of CABG versus PCI for stable ischemic heart disease. The Society of Thoracic Surgeons and American College of Cardiology Foundation databases were linked to the Centers for Medicare and Medicaid Services claims data. Costs for the index and observation period (2004 to 2008) hospitalizations were assessed by diagnosis-related group Medicare reimbursement rates; costs beyond the observation period were estimated from average Medicare participant per capita expenditure. Effectiveness was measured via mortality and life-expectancy data. Cost and effectiveness comparisons were adjusted using propensity score matching with the incremental cost-effectiveness ratio expressed as cost per quality-adjusted life-year gained. CABG patients (n = 86,244) and PCI patients (n = 103,549) were at least 65 years old with 2- or 3-vessel coronary artery disease. Adjusted costs were higher for CABG for the index hospitalization, study period, and lifetime by $10,670, $8,145, and $11,575, respectively. Patients undergoing CABG gained an adjusted average of 0.2525 and 0.3801 life-years relative to PCI over the observation period and lifetime, respectively. The life-time incremental cost-effectiveness ratio of CABG compared to PCI was $30,454/QALY gained. Over a period of 4 years or longer, patients undergoing CABG had better outcomes but at higher costs than those undergoing PCI. Copyright © 2015 American College of Cardiology Foundation. Published by Elsevier Inc. All rights reserved.
    Journal of the American College of Cardiology 01/2015; 65(1):1-11. DOI:10.1016/j.jacc.2014.09.078 · 15.34 Impact Factor
  • Journal of the American College of Cardiology 12/2014; 64(24):2712. DOI:10.1016/j.jacc.2014.10.003 · 15.34 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 12/2014; 16(12). DOI:10.1002/ejhf.182 · 6.58 Impact Factor
  • Mark A. Hlatky
    Journal of the American College of Cardiology 11/2014; 64(20). DOI:10.1016/j.jacc.2014.08.038 · 15.34 Impact Factor
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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; DOI:10.1038/ng.3097 · 29.65 Impact Factor
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    ABSTRACT: BACKGROUND 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. OBJECTIVES The aim of this study was to investigate whether multivessel CABG compared with PCI as an initial revascularization strategy is associated with a higher risk for AKI. METHODS A retrospective analysis of patients undergoing first documented coronary revascularization was conducted using 2 complementary cohorts: 1) Kaiser Permanente Northern California, a diverse, integrated health care delivery system; and 2) Medicare beneficiaries, a large, nationally representative older cohort. AKI was defined in the Kaiser Permanente Northern California cohort by an increase in serum creatinine of >= 0.3 mg/dl or >= 150% above baseline and in the Medicare cohort by discharge diagnosis codes and the use of dialysis. RESULTS The incidence of AKI was 20.4% in the Kaiser Permanente Northern California cohort and 6.2% in the Medicare cohort. The incidence of AKI requiring dialysis was <1%. CABG was associated with a 2- to3-fold significantly higher adjusted odds for developing AKI compared with PCI in both cohorts. CONCLUSIONS AKI is common after multivessel coronary revascularization and is more likely after CABG than after PCI. The risk for AKI should be considered when choosing a coronary revascularization strategy, and ways to prevent AKI after coronary revascularization are needed. (C) 2014 by the American College of Cardiology Foundation.
    Journal of the American College of Cardiology 09/2014; 64(10):985-94. DOI:10.1016/j.jacc.2014.04.077 · 15.34 Impact Factor
  • Dhruv S Kazi · Douglas K Owens · Mark A Hlatky
    Annals of internal medicine 09/2014; 161(5):378-9. DOI:10.7326/L14-5017-6 · 16.10 Impact Factor

Publication Stats

24k Citations
5,023.28 Total Impact Points


  • 1991–2015
    • Stanford Medicine
      • • Department of Health Research and Policy
      • • Stanford Center for Inherited Cardiovascular Disease
      • • Division of Cardiovascular Medicine
      • • Stanford School of Medicine
      • • Division of Health Services Research
      Stanford, California, United States
    • Stanford University
      • • Department of Medicine
      • • Department of Health Research and Policy
      • • Division of Cardiovascular Medicine
      Palo Alto, California, United States
    • University of Massachusetts Boston
      Boston, Massachusetts, United States
  • 2014
    • Lund University
      • Department of Cardiology
      Lund, Skåne, Sweden
  • 2011–2012
    • American College of Cardiology
      Washington, Washington, D.C., United States
  • 2010
    • Brigham and Women's Hospital
      Boston, Massachusetts, United States
    • The University of Arizona
      • College of Nursing
      Tucson, AZ, United States
  • 2007
    • Centers for Disease Control and Prevention
      • National Center for Chronic Disease Prevention and Health Promotion
      Druid Hills, GA, United States
  • 1999–2002
    • VA Palo Alto Health Care System
      Palo Alto, California, United States
  • 1984–2002
    • Duke University
      • Department of Medicine
      Durham, North Carolina, United States
  • 2000
    • Boston University
      Boston, Massachusetts, United States
  • 1996
    • University of Pittsburgh
      • Department of Epidemiology
      Pittsburgh, Pennsylvania, United States
  • 1995
    • Montreal Heart Institute
      Montréal, Quebec, Canada
  • 1994
    • University of California, San Francisco
      • School of Nursing
      San Francisco, California, United States
  • 1983–1993
    • Duke University Medical Center
      • • Department of Surgery
      • • Division of Cardiology
      • • Department of Medicine
      Durham, North Carolina, United States
    • Robert Wood Johnson University Hospital
      New Brunswick, New Jersey, United States
  • 1989
    • Tufts University
      • Department of Medicine
      Бостон, Georgia, United States
  • 1986
    • National Institute on Aging
      Baltimore, Maryland, United States