Mark A Hlatky

Stanford University, Palo Alto, California, United States

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Publications (388)4140.59 Total impact

  • [Show abstract] [Hide abstract]
    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. · 14.09 Impact Factor
  • Dhruv S Kazi, Douglas K Owens, Mark A Hlatky
    Annals of internal medicine 09/2014; 161(5):378-9. · 13.98 Impact Factor
  • Mark Hlatky
    Journal of the American College of Cardiology 08/2014; 64(7):741. · 14.09 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. · 14.09 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; · 5.66 Impact Factor
  • David J Maron, Mark A Hlatky
    American heart journal. 07/2014; 168(1):4-5.
  • Dhruv S Kazi, Mark A Hlatky
    JAMA Internal Medicine 06/2014; · 10.58 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. · 13.98 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; · 15.20 Impact Factor
  • Journal of the American College of Cardiology 03/2014; · 14.09 Impact Factor
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    ABSTRACT: Capturing long-term outcomes from large clinical databases by use of claims data is a potential strategy for improving efficiency while reducing study costs. We sought to compare the use of Medicare data with data from the Women's Health Initiative (WHI) to determine peripheral vascular events, as defined by the WHI study design. We studied participants from the WHI with both adjudicated outcomes and links to Medicare enrollment and utilization data through 2007. Outcomes of interest included hospitalizations for treatment of abdominal aortic aneurysm (AAA), lower extremity peripheral artery disease (LE PAD), and carotid artery stenosis (CAS). Events determined by WHI adjudication were compared with events defined by coding algorithms using diagnosis and procedure codes from Medicare data with a pilot data set and then validated with a test data set. We assessed agreement by a κ statistic and evaluated reasons for disagreement. In the pilot set, records from 50,511 participants were analyzed. Agreement between the Centers for Medicare and Medicaid Services and WHI for admissions with a diagnosis but no treatment procedures for vascular conditions was poor (κ, 0.02-0.18). On the basis of WHI outcome data collection, vascular treatment procedures occurred in 29 participants for AAA, 204 for LE PAD events, and 281 for CAS. Medicare hospital claims recorded 41 treatments for AAA, 255 for LE PAD, and 317 for CAS. For participants with a Centers for Medicare and Medicaid Services-captured vascular procedure and a record adjudicated by WHI, κ values for treatment procedures were 0.81 for AAA, 0.77 for PAD, and 0.93 for CAS. For vascular procedures identified by WHI but not by Medicare hospital data (n = 82), 55% were captured by Medicare physician claims. Conversely, for treatments identified by Medicare hospital data but not captured by WHI adjudication (n = 57), 74% had physician claims consistent with the procedure. Fifteen participants with AAA or LE PAD procedures in hospital claims had medical records available for review, and nine of these had definitive documentation of procedures that were not captured by the WHI adjudication process. Estimated positive predictive value of Medicare data was 91% to 94% for AAA, 92% to 95% for LE PAD, and 94% to 99% for CAS. Available test set data (n = 50,253) yielded generally similar results with κ of 0.77 for AAA, 0.79 for LE PAD, and 0.94 for CAS. Medicare data appear useful for identifying vascular treatment procedures for WHI participants. Medicare hospital claims identify more procedures than WHI does, with high positive predictive value, but also may not capture some procedures identified in WHI.
    Journal of vascular surgery: official publication, the Society for Vascular Surgery [and] International Society for Cardiovascular Surgery, North American Chapter 03/2014; · 3.52 Impact Factor
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    Journal of the American College of Cardiology 02/2014; 63(7):698-721. · 14.09 Impact Factor
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    ABSTRACT: The choice of antiplatelet therapy after acute coronary syndrome (ACS) is complicated: Ticagrelor and prasugrel are novel alternatives to clopidogrel, patients with some genotypes may not respond to clopidogrel, and low-cost generic formulations of clopidogrel are available. To determine the most cost-effective strategy for dual antiplatelet therapy after percutaneous coronary intervention for ACS. Decision-analytic model. Published literature, Medicare claims, and life tables. Patients having percutaneous coronary intervention for ACS. Lifetime. Societal. Five strategies were examined: generic clopidogrel, prasugrel, ticagrelor, and genotyping for polymorphisms of CYP2C19 with carriers of loss-of-function alleles receiving either ticagrelor (genotyping with ticagrelor) or prasugrel (genotyping with prasugrel) and noncarriers receiving clopidogrel. Direct medical costs, quality-adjusted life-years (QALYs), and incremental cost-effectiveness ratios (ICERs). The clopidogrel strategy produced $179 301 in costs and 9.428 QALYs. Genotyping with prasugrel was superior to prasugrel alone, with an ICER of $35 800 per QALY relative to clopidogrel. Genotyping with ticagrelor was more effective than genotyping with prasugrel ($30 200 per QALY relative to clopidogrel). Ticagrelor was the most effective strategy ($52 600 per QALY relative to genotyping with ticagrelor). Stronger associations between genotype and thrombotic outcomes rendered ticagrelor substantially less cost-effective ($104 800 per QALY). Genotyping with prasugrel was the preferred therapy among patients who could not tolerate ticagrelor. No randomized trials have directly compared genotyping strategies or prasugrel with ticagrelor. Genotype-guided personalization may improve the cost-effectiveness of prasugrel and ticagrelor after percutaneous coronary intervention for ACS, but ticagrelor for all patients may be an economically reasonable alternative in some settings. American Heart Association, U.S. Department of Veterans Affairs, Stanford University, and University of California San Francisco.
    Annals of internal medicine 02/2014; 160(4). · 13.98 Impact Factor
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    ABSTRACT: Background: The Duke Activity Status Index (DASI) assesses the functional capacity of patients with cardiovascular disease (CVD), but there is no Portuguese version validated for CVD. Objectives: To translate and adapt cross-culturally the DASI for the Portuguese-Brazil language, and to verify its psychometric properties in the assessment of functional capacity of patients with CVD. Methods: The DASI was translated into Portuguese, then checked by back-translation into English and evaluated by an expert committee. The pre-test version was first evaluated in 30 subjects. The psychometric properties and correlation with exercise testing was performed in a second group of 67 subjects. An exploratory factor analyses was performed in all 97 subjects to verify the construct validity of the DASI. Results: The intraclass correlation coefficient for test-retest reliability was 0.87 and for the inter-rater reliability was 0.84. Cronbach's α for internal consistency was 0.93. The concurrent validity was verified by significant positive correlations of DASI scores with the VO2max (r = 0.51, p < 0.001). The factor analysis yielded two factors, which explained 54% of the total variance, with factor 1 accounting for 40% of the variance. Application of the DASI required between one and three and a half minutes per patient. Conclusions: The Brazilian version of the DASI appears to be a valid, reliable, fast and easy to administer tool to assess functional capacity among patients with CVD.
    Arquivos brasileiros de cardiologia 02/2014; · 1.32 Impact Factor
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    ABSTRACT: Correctable weaknesses in the design, conduct, and analysis of biomedical and public health research studies can produce misleading results and waste valuable resources. Small effects can be difficult to distinguish from bias introduced by study design and analyses. An absence of detailed written protocols and poor documentation of research is common. Information obtained might not be useful or important, and statistical precision or power is often too low or used in a misleading way. Insufficient consideration might be given to both previous and continuing studies. Arbitrary choice of analyses and an overemphasis on random extremes might affect the reported findings. Several problems relate to the research workforce, including failure to involve experienced statisticians and methodologists, failure to train clinical researchers and laboratory scientists in research methods and design, and the involvement of stakeholders with conflicts of interest. Inadequate emphasis is placed on recording of research decisions and on reproducibility of research. Finally, reward systems incentivise quantity more than quality, and novelty more than reliability. We propose potential solutions for these problems, including improvements in protocols and documentation, consideration of evidence from studies in progress, standardisation of research efforts, optimisation and training of an experienced and non-conflicted scientific workforce, and reconsideration of scientific reward systems.
    The Lancet 01/2014; 383(9912):166-75. · 39.06 Impact Factor
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    ABSTRACT: . Unique identifier: NCT00000611.
    Circulation Cardiovascular Quality and Outcomes 01/2014; · 5.66 Impact Factor
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    ABSTRACT: Prognostic factors are usually evaluated by their statistical significance rather than by their clinical utility. Risk reclassification measures the extent to which a novel marker adds useful information to a prognostic model. The extent to which estimated glomerular filtration rate (eGFR) adds information about prognosis among patients with coronary heart disease is uncertain. We studied patients in an integrated health care delivery system with newly diagnosed coronary heart disease. We developed a model of the risk of death over 2 years of follow-up and then added eGFR to the model and measured changes in C-index, net reclassification improvement, and integrated discrimination improvement. Almost half of the 31,533 study patients had reduced eGFR (<60 mL/min per 1.73 m(2)). Mortality was significantly higher among patients who had lower levels of eGFR, even after adjustment for baseline characteristics (P < .0001). The addition of eGFR to the prognostic model increased the C-index from 0.837 to 0.843, the net reclassification improvement by 3.2% (P < .0001), and integrated discrimination improvement by 1.3% (P = .007). Estimated glomerular filtration rate is an informative prognostic factor among patients with incident coronary heart disease, independent of other clinical characteristics.
    American heart journal 01/2014; 167(1):86-92. · 4.65 Impact Factor
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    ABSTRACT: Objectives The goal of this study was to compare the economic outcomes of patients undergoing different noninvasive tests to evaluate suspected coronary artery disease (CAD). Background Evaluation of noninvasive tests is shifting to an assessment of their effect on clinical outcomes rather than on their diagnostic accuracy. Economic outcomes of testing are particularly important in light of rising medical care costs. Methods We used an observational registry of 1,703 patients who underwent coronary computed tomography angiography (CTA) (n = 590), positron emission tomography (PET) (n = 548), or single-photon emission computed tomography (SPECT) (n = 565) for diagnosis of suspected CAD at 1 of 41 centers. We followed patients for 2 years, and documented resource use, medical costs for CAD, and clinical outcomes. We used multivariable analysis and propensity score matching to control for differences in baseline characteristics. Results Two-year costs were highest after PET ($6,647, 95% confidence interval [CI]: $5,896 to $7,397), intermediate after CTA ($4,909, 95% CI: $4,378 to $5,440), and lowest after SPECT ($3,965, 95% CI: $3,520 to $4,411). After multivariable adjustment, CTA costs were 15% higher than SPECT (p < 0.01), and PET costs were 22% higher than SPECT (p < 0.0001). Two-year mortality was 0.7% after CTA, 1.6% after SPECT, and 5.5% after PET. The incremental cost-effectiveness ratio for CTA compared with SPECT was $11,700 per life-year added, but was uncertain, with higher costs and higher mortality in 13% of bootstrap replications. Patients undergoing PET had higher costs and higher mortality than patients undergoing SPECT in 98% of bootstrap replications. Conclusions Costs were significantly lower after using SPECT rather than CTA or PET in the evaluation of suspected coronary disease. SPECT was economically attractive compared with PET, whereas CTA was associated with higher costs and no significant difference in mortality compared with SPECT.
    Journal of the American College of Cardiology 01/2014; 63(10):1002–1008. · 14.09 Impact Factor

Publication Stats

15k Citations
4,140.59 Total Impact Points

Institutions

  • 1994–2014
    • Stanford University
      • • Division of Cardiovascular Medicine
      • • Department of Health Research and Policy
      • • Department of Radiology
      • • Stanford Prevention Research Center
      • • Department of Medicine
      Palo Alto, California, United States
  • 1991–2014
    • Stanford Medicine
      • • Stanford Center for Inherited Cardiovascular Disease
      • • Department of Health Research and Policy
      • • Division of Cardiovascular Medicine
      • • Division of Health Services Research
      Stanford, California, United States
  • 2010–2013
    • Naval Medical Center San Diego
      • Division of Cardiology
      San Diego, California, United States
    • University of Pittsburgh
      • Department of Epidemiology
      Pittsburgh, PA, 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
    • University of California, San Diego
      • Division of Cardiology
      San Diego, CA, United States
    • American College of Cardiology
      Washington, Washington, D.C., United States
  • 2010–2011
    • The University of Arizona
      • College of Nursing
      Tucson, AZ, United States
  • 2002–2011
    • University of California, San Francisco
      • Division of Hospital Medicine
      San Francisco, CA, United States
    • University of Washington Seattle
      • Department of Biostatistics
      Seattle, WA, United States
  • 2007
    • Centers for Disease Control and Prevention
      • National Center for Chronic Disease Prevention and Health Promotion
      Druid Hills, GA, United States
  • 1983–2005
    • Duke University Medical Center
      • • Duke Clinical Research Institute
      • • Department of Medicine
      • • Division of Cardiology
      Durham, NC, United States
    • Robert Wood Johnson University Hospital
      New Brunswick, New Jersey, United States
  • 1999–2002
    • VA Palo Alto Health Care System
      Palo Alto, California, United States
  • 1991–2002
    • Duke University
      • Department of Medicine
      Durham, North Carolina, United States
  • 2000
    • Montreal Heart Institute
      Montréal, Quebec, Canada