Publications (12)118.58 Total impact
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Article: Percutaneous intervention of an acute left main coronary occlusion due to dissection of the aortic root.
06/2011; 4(6):713-5. · 1.07 Impact Factor -
Article: The efficacy and safety of prasugrel with and without a glycoprotein IIb/IIIa inhibitor in patients with acute coronary syndromes undergoing percutaneous intervention: a TRITON-TIMI 38 (Trial to Assess Improvement in Therapeutic Outcomes by Optimizing Platelet Inhibition With Prasugrel-Thrombolysis In Myocardial Infarction 38) analysis.
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ABSTRACT: We evaluated the efficacy and safety of prasugrel and clopidogrel in the setting of a glycoprotein (GP) IIb/IIIa inhibitor. Prasugrel reduced cardiovascular events as compared with clopidogrel in TRITON-TIMI 38 (Trial to Assess Improvement in Therapeutic Outcomes by Optimizing Platelet Inhibition with Prasugrel-Thrombolysis in Myocardial Infarction 38) but with increased bleeding. Researchers in the TRITON-TIMI 38 randomized 13,608 subjects with acute coronary syndrome undergoing percutaneous coronary intervention to prasugrel versus clopidogrel. The use of a GP IIb/IIIa inhibitor was at the physician's discretion. For the current analysis, end points were examined at 30 days and were stratified by use of a GP IIb/IIIa inhibitor. A total of 7,414 subjects (54.5%) received a GP IIb/IIIa inhibitor during their index hospitalization. There was a consistent benefit of prasugrel over clopidogrel for reducing cardiovascular death, myocardial infarction, or stroke in patients who did (hazard ratio: 0.76; 95% confidence interval: 0.64 to 0.90) or did not receive a GP IIb/IIIa inhibitor (hazard ratio: 0.78; 95% confidence interval: 0.63 to 0.97, p(interaction) = 0.83). Prasugrel significantly reduced myocardial infarction, urgent revascularization, and stent thrombosis irrespective of GP IIb/IIIa inhibitor use. Although subjects treated with a GP IIb/IIIa inhibitor had greater rates of bleeding, the risk of Thrombolysis in Myocardial Infarction major or minor bleeding with prasugrel versus clopidogrel was not significantly different in patients who were or were not treated with GP IIb/IIIa inhibitor (p(interaction) = 0.19). Prasugrel significantly reduces the risk of cardiovascular events in patients with acute coronary syndromes after percutaneous coronary intervention regardless of whether or not a GP IIb/IIIa inhibitor is used. The use of a GP IIb/IIIa inhibitor does not accentuate the relative risk of bleeding with prasugrel as compared with clopidogrel.Journal of the American College of Cardiology 09/2009; 54(8):678-85. · 14.16 Impact Factor -
Article: Elevated plasma fibrinogen level predicts suboptimal response to therapy with both single- and double-bolus eptifibatide during percutaneous coronary intervention.
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ABSTRACT: This study sought to determine the factors associated with suboptimal platelet inhibition (PI) with single- and double-bolus eptifibatide during percutaneous coronary intervention (PCI). Although PI > or = 95% measured 10 min after glycoprotein IIb/IIIa inhibitor therapy is associated with improved outcomes following PCI, this level of PI often is not achieved. We prospectively studied 150 patients undergoing PCI with single-bolus eptifibatide (180 microg/kg) (n = 100) and double-bolus eptifibatide (180 microg/kg administered 10 min apart) (n = 50) followed by standard infusion (2 microg/kg/min). Measuring platelet aggregation at baseline and at 10 min and 30 to 45 min after eptifibatide bolus, patients were classified as optimal responders (OPT) (> or =95% PI) or suboptimal responders (sub-OPT) (<95% PI) based on 10-min PI after final bolus. Suboptimal PI was achieved in 61% of patients with single-bolus eptifibatide and in 36% with double-bolus eptifibatide. In the single-bolus group, sub-OPT had higher fibrinogen levels (324 +/- 85 mg/dl vs. 259 +/- 49 mg/dl, p = 0.0002), platelet counts (221 +/- 70 vs. 186 +/- 47, p = 0.008), and white blood cell counts (7.7 +/- 2.3 vs. 6.6 +/- 1.9, p = 0.02). In the double-bolus group, sub-OPT also had higher fibrinogen levels (324 +/- 68 mg/dl vs. 278 +/- 53 mg/dl, p = 0.01) and were more likely to be smokers (38.9% vs. 9.4%, p = 0.01). Multivariable analysis showed that fibrinogen level was the only independent predictor of suboptimal PI, with fibrinogen cutoffs at 375 and 325 mg/dl predicting suboptimal PI (single-bolus: 100% and 90.0%, respectively; double-bolus: 100% and 60%, respectively) with both doses. During PCI, both single- and double-bolus eptifibatide provide suboptimal PI in a substantial proportion of patients. A fibrinogen level >375 mg/dl is a strong predictor of suboptimal PI.Journal of the American College of Cardiology 07/2007; 49(22):2163-71. · 14.16 Impact Factor -
Article: Geographical differences in the rates of angiographic restenosis and ischemia-driven target vessel revascularization after percutaneous coronary interventions: results from the Prevention of Restenosis With Tranilast and its Outcomes (PRESTO) Trial.
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ABSTRACT: Many cardiologists consider it reasonable to assume in clinical practice that percutaneous coronary intervention using drug-eluting stents ought to be considered equivalent, if not superior, to bypass surgery. In the absence of a definitive clinical trial to support this view, how should the prudent, cutting-edge cardiologist proceed? This study assessed the geographical differences in target vessel revascularization (TVR) after percutaneous coronary intervention (PCI) in the Prevention of Restenosis With Tranilast and its Outcomes (PRESTO) trial. An aggressive approach to PCI is more common in the U.S. than in other countries. The impact of this approach on restenosis outcomes has not been studied. Using the PRESTO trial, we compared nine-month ischemic TVR after PCI in U.S.-treated patients (n = 5,026) with rates in other countries (n = 6,458). We defined TVR as repeat intervention for chest pain/positive stress test. Additionally, angiographic restenosis (> or =50% narrowing or > or =50% loss of gain at nine-month follow-up) was compared between U.S. and non-U.S. patients within the prespecified angiographic subset (n = 2,823). Regression models were developed to adjust for clinical and lesion-related characteristics. Higher rates of TVR (18% vs. 11%), and angiographic restenosis (65% vs. 48%) were observed in patients treated in the U.S. as compared with the other patients (p < 0.01 for both comparisons). Patients treated in the U.S. were more likely to be female, diabetic, not currently smoking, to have unstable angina, and to have a prior PCI. In U.S. patients, lesions tended to be longer, but less likely to be American College of Cardiology/American Heart Association class C. After adjusting for clinical and angiographic variables, PCI in the U.S. was still associated with increased angiographic restenosis and ischemic TVR. Angiographic restenosis and ischemia-driven TVR rates were higher in patients treated in the U.S. The difference could only partially be explained by the higher prevalence of measured adverse clinical and angiographic features.Journal of the American College of Cardiology 01/2006; 47(1):34-9. · 14.16 Impact Factor -
Article: Endothelial dysfunction after sirolimus-eluting stent placement.
Journal of the American College of Cardiology 08/2005; 46(2):237-8. · 14.16 Impact Factor -
Article: Predictive factors for ischemic target vessel revascularization in the Prevention of Restenosis with Tranilast and its Outcomes (PRESTO) trial.
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ABSTRACT: The aim of the present study was to determine the rates of target vessel revascularization (TVR) and to determine predictors of TVR from clinical and angiographic variables available in the Prevention of Restenosis With Tranilast and its Outcomes (PRESTO) database. The rates of TVR after percutaneous revascularization procedures, and its prediction with available clinical and angiographic variables, is less well known. We studied nine-month TVR in 11,484 patients enrolled in the PRESTO trial. Clinical, lesion-related, and procedural characteristics were analyzed in a logistic regression model. Study data were divided at random into an 80% training set on which the models were developed and a 20% hold-out set on which the model properties were evaluated. A total of 14% (n = 1,609) had ischemic TVR. Clinical variables with increased risk for TVR included younger age; hypertension; diabetes mellitus; nonsmokers; unstable angina; previous coronary artery bypass grafting; peripheral vascular disease; procedure- and lesion-related such as ostial location, multilesion angioplasty, location in the left anterior descending artery, length > or =20 mm, in-stent restenosis at baseline, and use of rotablator. There was significant increase in the risk of ischemic TVR at U.S. treatment sites. Smoking and stent placement were associated with lower risk of ischemic TVR. The mean area (+/- SD) under the receiver-operating characteristic curve of the bootstrap samples was 0.66, indicating a modest ability of the model to discriminate patients who needed TVR on follow-up. Despite being the largest prospective trial designed to test restenosis, the discriminatory ability of the clinical and angiographic variables to predict TVR is modest.Journal of the American College of Cardiology 02/2005; 45(2):198-203. · 14.16 Impact Factor -
Article: Clinical and angiographic predictors of restenosis after percutaneous coronary intervention: insights from the Prevention of Restenosis With Tranilast and Its Outcomes (PRESTO) trial.
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ABSTRACT: Restenosis prediction from published studies is hampered by inadequate sample size and incomplete angiographic follow-up. The prediction of restenosis with the existing variables is poor. The aim of the present study was to include the clinical and angiographic variables commonly associated with angiographic restenosis and develop a prediction model for restenosis from the PRESTO database. This study included 1312 patients with a single lesion enrolled in the angiographic substudy of the PRESTO trial. We constructed 2 risk scores. The first used preprocedural variables (female gender, vessel size [< or =2.5 mm, 2.5 to 3 mm, 3 to 3.5 mm, 3.5 to 4 mm, >4 mm], lesion length >20 mm, diabetes, smoking status, type C lesion, any previous percutaneous coronary intervention [PCI], and unstable angina) derived from previous studies. Estimated restenosis rates and corresponding variability for each possible level of the resultant risk score were obtained via bootstrapping techniques. The area under the receiver-operator characteristic (ROC) curve was 0.63, indicating modest discriminatory ability to predict restenosis. The second approach constructed a multiple logistic regression model considering significant univariate clinical and angiographic predictors of restenosis identified from the PRESTO database (treated diabetes mellitus, nonsmoker, vessel size, lesion length, American College of Cardiology/American Heart Association type C lesion, ostial location, and previous PCI). The area under the ROC curve for this risk score was also 0.63. The preprocedural clinical and angiographic variables from available studies and from the PRESTO trial have only modest predictive ability for restenosis after PCI.Circulation 06/2004; 109(22):2727-31. · 14.74 Impact Factor -
Article: Severe ostial saphenous vein graft disease leading to acute coronary syndromes following proximal aorto-saphenous anastomoses with the symmetry bypass connector device: is it a suture device or a "stent"?
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ABSTRACT: The Symmetry Bypass Connector (St. Jude Medical, St. Paul, Minnesota) is a nitinol, star-shaped device that was designed to facilitate placement of sutureless aorto-saphenous anastomoses during off-pump coronary artery bypass graft surgery (CABG). Although the device is approved for clinical use in Europe and the U.S., its short- and long-term safety and efficacy are not established. We report on 5 of 121 patients undergoing CABG who presented with an acute coronary syndrome two to five months following placement of this device. In each patient, all saphenous vein grafts (SVGs) placed (n = 11) with the device were totally occluded (n = 6) or compromised by ostial stenoses (n = 5). Treatment consisted of repeat CABG in one patient and percutaneous coronary intervention (PCI) in four patients with cutting balloon atherotomy and stenting. Following PCI, two of four patients presented again within two months with near-occlusive ostial restenosis in all stents placed. Intracoronary ultrasound showed severe neointimal hyperplasia, but only at the proximal interface of the device and stent. One patient was treated with brachytherapy in two SVGs but had a recurrence four months later and was treated with drug-eluting stents in both restenotic segments. Recalcitrant neointimal hyperplasia is postulated to be involved in the pathogenesis of anastomotic device stenosis, possibly similar to in-stent restenosis. Prospective randomized clinical trials are needed to assess the clinical safety and efficacy of this device. Pending such studies, consideration should be given in limiting its use to cases of unacceptably high risk of stroke during aortic cross-clamping. Dual antiplatelet agents, evaluation for ischemia, and close follow-up are warranted in patients that have already received the device.Journal of the American College of Cardiology 02/2004; 43(1):133-9. · 14.16 Impact Factor -
Article: Patients at low risk for periprocedural myocardial infarction can be identified by assessment immediately following percutaneous coronary intervention.
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ABSTRACT: Despite utilizing optimal anticoagulant therapy during percutaneous coronary intervention (PCI), the incidence of periprocedural myocardial infarction (PPMI) remains 5 7% and evaluation of preprocedural clinical/angiographic characteristics has failed to reliably predict the likelihood of a PPMI. We hypothesized that immediate post-PCI assessment could identify a group of patients at very low risk for PPMI. A consecutive series of 258 PCI patients was stratified into 3 groups based on immediate post-PCI assessment. Group I (PPMI not expected) included those with an acceptable angiographic result of treated vessel (residual stenosis < 50%), TIMI 3 flow and absence of any intraprocedural complications. Group II (PPMI not unexpected) included those with an acceptable angiographic result, TIMI 3 flow but with any/all of the following: saphenous vein graft (SVG) PCI, transient closure of culprit vessel or major sidebranch, intracoronary thrombus, prolonged chest pain, electrocardiographic (ECG) changes, hypotension, resolved slow flow/no reflow, bailout glycoprotein IIb/IIIa inhibitor use, loss of a minor sidebranch or any angiographic residual stenosis > 50% with TIMI 3 flow. Group III (PPMI expected) included those with any angiographic result of native coronary artery or SVG with < TIMI 3 flow, unresolved chest pain, hypotension or ECG changes at the end of the PCI, loss of a major sidebranch or vessel, or persistent no-reflow. Group stratification was analyzed in relation to the incidence of PPMI (CK-MB > 3 times the upper limit of normal; 18 24 hours post-PCI). Rate of PPMI: Group I (1/141; 0.7%), Group II (7/71; 9.9%), Group III (5/11; 45.5%) (p < 0.001). The 3 groups did not differ in age, clinical presentation or stent use (p = NS). Sixty out of 105 patients (57.1%) with unstable angina, seventy-seven out of 146 patients (52.7%) with B2/C lesions, and 105/180 patients (58.3%) with unstable angina or B2/C lesions were stratified to Group I. This study demonstrates that immediate post-PCI evaluation of the clinical/angiographic characteristics can predict the likelihood of PPMI and a group of patients at a very low risk for a PPMI can be identified, in whom implications exist for limited hospitalization and post-procedural antithrombotic therapy.The Journal of invasive cardiology 06/2003; 15(6):343-7. · 1.84 Impact Factor -
Article: Cardiac catheterization tip: Rapid cannulation of the superior vena cava via femoral approach.
The Journal of invasive cardiology 04/2003; 15(3):178. · 1.84 Impact Factor -
Article: Improvement of coronary artery endothelial dysfunction with lipid-lowering therapy: heterogeneity of segmental response and correlation with plasma-oxidized low density lipoprotein
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ABSTRACT: OBJECTIVESThis study assessed coronary artery endothelial function in patients with hypercholesterolemia before and after lipid lowering, using quantitative angiography to examine the acetylcholine (Ach) response along the entire analyzable vessel.BACKGROUNDLipid lowering reverses endothelial dysfunction, but whether improvement occurs only in some segments and not others has not been established. Statistical correlation of improvement with specific lipid moieties remains undefined.METHODSQuantitative angiography was performed after Ach (10−6, 10−5, 10−4M) in 29 patients with coronary atherosclerosis before and 18 ± 5.2 months after lipid-lowering treatment (statins, bile sequestrant resins). Standard lipid moieties and markers of oxidized low density lipoprotein (LDL) (immunoglobulin G and M autoantibody titers to malondialdehyde-LDL, E06 epitope) were measured serially.RESULTSPre-treatment of the vessel diameters at control and with 10−6M, 10−5M and 10−4M Ach were 2.108 ± 0.085, 2.086 ± 0.087, 2.069 ± 0.084 and 1.963 ± 0.097 mm (M ± SE), respectively, and increased at follow-up to 2.139 ± 0.094, 2.119 ± 0.086, 2.127 ± 0.084 and 2.080 ± 0.085 mm (p < 0.0001). Improvement in the most constricted and modest declination in the more dilated segments were observed. Change in the E06 and Apolipoprotein A-1 titers correlated with improved vasomotion (p = 0.027 and 0.005, respectively). The pre- and post-treatment levels of the E06 epitope, as well as the post-treatment IgM autoantibody titer to MDA-low density lipoprotein, also correlated (p < 0.028, < 0.001 and p < 0.004, respectively).CONCLUSIONSDrug treatment reverses endothelial dysfunction, but the effect is heterogeneous. Most coronary segments show enhancement, while others show declination of dilation, underscoring the importance of assessing the entire analyzable artery. Improvement in vasomotion correlates most significantly with markers of plasma-oxidized low-density lipoprotein.Journal of the American College of Cardiology 03/2001; · 14.16 Impact Factor -
Article: Editorial comment
International Journal of Cardiac Imaging 11/1996; 12(4):231-232.
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2011
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CSU Mentor
Long Beach, CA, USA
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2003
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University of California, San Diego
- Division of Cardiology
San Diego, CA, USA
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