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ABSTRACT: OBJECTIVE: Obesity has been associated with superior outcomes in heart failure (HF) and acute coronary syndrome (ACS). Although patients with new-onset HF after ACS are at a high risk, they may receive less aggressive treatment. It is unknown whether treatment practices are biased by BMI. METHODS AND RESULTS: Consecutive patients without previous HF, who were hospitalized with ACS, and had left ventricular ejection fraction less than 40% or clinical HF were analyzed to assess the utilization of evidence-based treatment by BMI. BMI was categorized into normal (18.5 to <25 kg/m), overweight (25 to <30 kg/m), and obese (≥30 kg/m) groups. Multivariable logistic regression models were performed to examine the association of BMI with undergoing cardiac catheterization, and discharge on β-blocker or angiotensin converting enzyme (ACE) inhibitor or angiotensin receptor blocker (ARB). Analysis included 461 patients. There were no significant differences among BMI groups in performance of cardiac catheterization or discharge on ACE inhibitor/ARB or β-blocker. Compared with normal, neither overweight nor obese BMI was significantly associated with cardiac catheterization [overweight: odds ratio (OR) 1.49, 95% confidence interval (CI) 0.82-2.72, P=0.2; obese: OR 1.75, 95% CI 0.92-3.33, P=0.09], or discharge on ACE inhibitor/ARB (overweight: OR 0.70, 95% CI 0.40-1.21, P=0.7; obese: OR 0.69, 95% CI 0.39-1.23, P=0.2), or β-blocker (overweight: OR 1.24, 95% CI 0.69-2.21, P=0.5; obese: OR 1.13, 95% CI 0.62-2.07, P=0.7). CONCLUSION: Among patients with new-onset HF complicating ACS, there were no significant differences in evidence-based treatment practices by BMI.
Coronary artery disease 03/2013; · 1.56 Impact Factor
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ABSTRACT: The bilirubin level has been associated with worse outcomes, but it has not been studied as a predictor for the mode of death in patients with systolic heart failure. The Prospective Randomized Amlodipine Evaluation Study (PRAISE) cohort (including New York Heart Association class IIIB-IV patients with left ventricular ejection fraction <30%, n = 1,135) was analyzed, divided by bilirubin level: ≤0.6 mg/dl, group 1; >0.6 to 1.2 mg/dl, group 2; and >1.2 mg/dl, group 3. Multivariate Cox proportional hazards models were used to determine the association of bilirubin with the risk of sudden or pump failure death. Total bilirubin was entered as a base 2 log-transformed variable (log(2) bilirubin), indicating doubling of the bilirubin level corresponding to each increase in variable value. The higher bilirubin groups had a lower ejection fraction (range 19% to 21%), sodium (range 138 to 139 mmol/L), and systolic blood pressure (range 111 to 120 mm Hg), a greater heart rate (range 79 to 81 beats/min), and greater diuretic dosages (range 86 to 110 furosemide-equivalent total daily dose in mg). The overall survival rates declined with increasing bilirubin (24.3, 31.3, and 44.3 deaths per 100 person-years, respectively, for groups 1, 2, and 3). Although a positive relation was seen between log(2) bilirubin and both pump failure risk and sudden death risk, the relation in multivariate modeling was significant only for pump failure mortality (hazard ratio 1.47, 95% confidence interval 1.19 to 1.82, p = 0.0004), not for sudden death mortality (hazard ratio 1.21, 95% confidence interval 0.98 to 1.49, p = 0.08). In conclusion, an increasing bilirubin level was significantly associated with the risk of pump failure death but not for sudden death in patients with severe systolic heart failure.
The American journal of cardiology 01/2013; · 3.58 Impact Factor
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ABSTRACT: Despite positive associations with rejection, the clinical value of B-type natriuretic peptide (BNP) monitoring in heart transplant recipients has not been established. We sought to determine the predictive value of changes in serial BNP level for identifying patients with acute allograft rejection.
BNP, hemodynamics and biopsies were obtained for 205 transplant recipients who underwent a total of 4,007 endomyocardial biopsy procedures. Samples analyzed were collected ≥ 180 days post-transplant, without evidence of rejection on the immediately preceding biopsy. Using a repeated-measures multivariate model, we assessed the association of change in BNP with Grade ≥ 3A (2R) rejection. We also determined predictive values of various cut-off thresholds of change in serial BNP levels to predict Grade ≥ 3A rejection.
There were 47 episodes of Grade ≥ 3A rejection among the 1,350 samples analyzed. Median change in serial BNP (ΔBNP) for those with Grade ≥ 3A rejection was 20 pg/ml (IQR -26 to 169 pg/ml) and among those with Grade <3A rejection was -4 pg/ml (IQR -34 to 22 pg/ml, p = 0.003). On multivariate analysis, ΔBNP remained the most potent independent predictor of Grade ≥ 3A rejection (p = 0.001). ΔBNP >100 pg/ml predicted increased risk of Grade ≥ 3A rejection (OR = 5.3, p < 0.001) with high specificity (93.3%) and positive predictive value (13.0%) and excellent negative predictive value (97.3%).
Change in serial BNP level is an independent predictor of cardiac allograft rejection. With wide availability, rapid turnaround, low cost, favorable positive predictive value and excellent negative predictive value, serial BNP monitoring has several advantages for non-invasive monitoring of heart transplant recipients for acute cardiac allograft rejection.
The Journal of heart and lung transplantation: the official publication of the International Society for Heart Transplantation 04/2012; 31(7):708-14. · 3.54 Impact Factor
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ABSTRACT: Previous studies have not extensively examined the association of hyperuricemia and adverse outcomes in systolic heart failure (HF) in relation to xanthine oxidase inhibitor therapy.
The Prospective Randomized Amlodipine Survival Evaluation study included New York Heart Association class IIIB or IV patients with left ventricular ejection fraction <30%. For analysis, the population was divided into uric acid quartiles among nonallopurinol users (2.2-7.1, >7.1-8.6, >8.6-10.4, >10.4 mg/dL) and those using allopurinol. Multivariate Cox regression modeling was performed to identify predictors of mortality. Uric acid quartile and allopurinol groups were referenced to the lowest uric acid quartile.
A total of 1,152 patients were included. In general, patients in the allopurinol group and in the highest uric acid quartile had indicators of more severe HF, including worse renal function and greater proportion of New York Heart Association class IV patients, and greater diuretic use. The allopurinol group and highest uric acid quartile had the highest total mortality (41.7 and 42.4 per 100 person-years, respectively) and combined morbidity/mortality (45.6 and 51.0 per 100 person-years, respectively). Allopurinol use and highest uric acid quartile were independently associated with mortality (hazard ratio [HR] 1.65, 95% CI 1.22-2.23, P = .001 and HR 1.35, 95% CI 1.07-1.72, P = .01, respectively) and combined morbidity/mortality (uric acid quartile 4 vs 1: HR 1.32, 95% CI 1.06-1.66, P = .02; allopurinol use: HR 1.48, 95% CI 1.11-1.99, P = .008).
Elevated uric acid level was independently associated with mortality in patients with severe systolic HF, even when accounting for allopurinol use.
American heart journal 11/2010; 160(5):928-33. · 4.65 Impact Factor
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The Journal of heart and lung transplantation: the official publication of the International Society for Heart Transplantation 10/2010; 29(10):1200-2. · 3.54 Impact Factor
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ABSTRACT: To determine the association between obesity and outcomes in post-acute myocardial infarction (AMI) patients with systolic heart failure (HF).
Of the 6632 Eplerenone Post-Acute Myocardial Infarction Heart Failure Efficacy and Survival Study (EPHESUS) participants, 6611 had data on baseline body mass index (BMI) and 6561 had BMI > or = 18.5 kg/m(2). Of these, 1573 were obese (BMI > or = 30 kg/m(2)) and 4988 were non-obese (BMI 18.5-29.9 kg/m(2)). Propensity scores for obesity, estimated for each patient, were used to assemble a cohort of 1519 pairs of obese and non-obese patients who were balanced on 65 baseline characteristics. All-cause mortality occurred in 13.7 and 13.8% of matched obese and non-obese patients, respectively, during 16 months of median follow-up [matched hazard ratio (HR) for obesity 0.98; 95% confidence interval (CI) 0.79-1.21; P = 0.831]. Before matching, the obese group was younger (mean age, 62 vs. 64 years; P < 0.0001) and had more women (37 vs. 26%; P < 0.0001). The paradoxical pre-match association between obesity and reduced mortality (unadjusted HR 0.82; 95% CI 0.70-0.95; P = 0.008) disappeared when adjusted for age alone (age-adjusted HR 0.91; 95% CI 0.78-1.06; P = 0.206) but not for gender alone (gender-adjusted HR 0.79; 95% CI 0.68-0.92; P = 0.003). Obesity had no association with mortality in 1573 pairs of age-matched obese and non-obese patients (age-adjusted HR 0.94; 95% CI 0.77-1.13; P = 0.484).
In post-AMI patients with systolic HF, obesity provides no independent intrinsic survival benefit. The paradoxical unadjusted survival associated with obesity is largely explained by the younger age of obese patients.
European Journal of Heart Failure 03/2010; 12(6):566-73. · 4.90 Impact Factor
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ABSTRACT: Several studies have suggested that obesity may be associated with a survival advantage in heart failure (HF). The duration of HF likely influences disease severity and may introduce lead-time bias into analyses of outcomes. The aim of this study was to analyze a cohort in which the exact time of HF onset could be determined: patients in the University of Michigan subset of the acute coronary syndromes (ACS) database of the Global Registry of Acute Coronary Events (GRACE) who developed new-onset HF (no history of HF and left ventricular ejection fraction <or=40% or qualitatively diminished) with their index ACS events from January 1999 to March 2006 (n = 446). For analysis, body mass index (BMI) was categorized as normal (18.5 to <25 kg/m(2)), overweight (25 to <30 kg/m(2)), and obese (>or=30 kg/m(2)). Underweight patients (BMI <or=18.5 kg/m(2)) were excluded. Separate multivariate Cox regression models were performed to examine the effect of BMI group and other potential confounders on all-cause mortality and on the combined outcome of all-cause death, cardiac transplantation, or ventricular assist device implantation. BMI groups were not associated with different risks for the combined outcome, although overweight BMI approached statistical significance for lower risk for the combined outcome. Overweight BMI was significantly associated with lower risk for all-cause death (hazard ratio 0.63, 95% confidence interval 0.42 to 0.94, p = 0.02), although obese BMI was not (hazard ratio 1.06, 95% confidence interval 0.69 to 1.64, p = 0.8). In conclusion, these findings suggest a U-shaped relation between mortality and BMI in the setting of new-onset HF after ACS.
The American journal of cardiology 06/2009; 103(12):1736-40. · 3.58 Impact Factor
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Audrey H Wu
Heart (British Cardiac Society) 12/2008; 94(11):1503-9. · 4.22 Impact Factor
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Audrey H Wu
Heart (British Cardiac Society) 04/2007; 93(3):403-8. · 4.22 Impact Factor
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ABSTRACT: Preemptive cholecystectomy in cardiac transplant patients with radiographic biliary pathology reduces the morbidity and mortality of biliary tract disease following heart transplantation compared with expectant management.
Institutional survey at the University of Washington, Seattle.
Cardiac transplant recipients between January 1, 1992, and January 1, 2001. Main Outcome Measure Clinical course of patients who were diagnosed as having biliary tract disease following heart transplantation and were managed expectantly (observed) compared with the course of patients whose conditions were diagnosed and who underwent an operation.
Sixty (35.7%) of 168 cardiac transplant patients were evaluated for biliary tract pathologic condition. Of the 71.7% (43 of 60 patients) who had an abnormal radiographic evaluation, 46.5% (20 patients) had surgery on their biliary tract while the other patients were observed. Nine of the 23 patients who were followed up expectantly had cholelithiasis, 7 patients had gallbladder wall thickening, 5 patients had sludge in their gallbladder, and 2 had biliary dilatation. These patients were followed up for a mean +/- SD of 3.7 +/- 1.3 years; none developed biliary tract symptoms during this period. Cholecystectomies were completed for both emergent (7) and elective (14) indications. The mean +/- SD length of stay for patients who had emergent operations was 24.3 +/- 11.2 days, compared with 3.2 +/- 2.8 days for the patients who had elective operations. Seven (33%) of the 21 patients who had an operation had a significant complication and 1 patient died.
These data suggest that the morbidity of an elective cholecystectomy in cardiac transplant patients is significant and equivalent to the morbidity associated with emergent procedures. Expectant management of patients with radiographic evidence of biliary tract pathology discovered after transplantation was safe in this series.
Archives of Surgery 05/2005; 140(4):399-403; discussion 404. · 4.24 Impact Factor
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ABSTRACT: Calcium accumulation in the aortic valve is a hallmark of aortic sclerosis and aortic stenosis. Because lipoproteins, angiotensin-converting enzyme, and angiotensin II colocalize with calcium in aortic valve lesions, we hypothesized an association between angiotensin-converting enzyme inhibitor (ACEI) use and lowered aortic valve calcium (AVC) accumulation, as measured by electron beam computed tomography.
Rates of change in volumetric AVC scores were determined retrospectively for 123 patients who had undergone 2 serial electron beam computed tomographic scans. The mean (+/-SD) interscan interval was 2.5 (+/-1.7) years; 80 patients did not receive ACEIs and 43 received ACEIs. The relationship of ACEI use to median rates of AVC score change (both unadjusted and adjusted for baseline AVC scores and coronary heart disease risk factors) was determined. We also examined the relationship of ACEI use to the likelihood of and adjusted odds ratio for definite progression (AVC change >2 times the median interscan variability).
Unadjusted and adjusted median rates of AVC score change were significantly higher in the no-ACEI group than in the ACEI group (adjusted median AVC changes [95% confidence interval]: relative, 28.7%/y [18.9%-38.5%/y] vs 11.0%/y [-1.9% to 24.0%/y], P = .04; absolute: 25.1/y [19.7-30.5/y] vs 12.2/y [4.5-19.9/y], P = .02). The adjusted odds ratio (95% confidence interval) for definite AVC progression was significantly lower for patients who received ACEIs (0.29 [0.11-0.75], P = .01).
This retrospective study finds a significant association between ACEI use and a lower rate of AVC accumulation. The results support the need for prospective, randomized trials of ACEIs in calcific aortic valve disease.
Archives of Internal Medicine 05/2005; 165(8):858-62. · 11.46 Impact Factor
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ABSTRACT: This study was designed to assess effects of mitral valve annuloplasty (MVA) on mortality in patients with mitral regurgitation (MR) and left ventricular (LV) systolic dysfunction.
Mitral valve annuloplasty improves hemodynamics and symptoms in these patients, but effects on long-term mortality are not well established.
We retrospectively analyzed consecutive patients with significant MR and LV systolic dysfunction on echocardiography between 1995 and 2002. Cox regression analysis, including MVA as a time-dependent covariate and propensity scoring to adjust for differing probabilities of undergoing MVA, was used to identify predictors of death, LV assist device implantation, or United Network for Organ Sharing-1 heart transplantation.
Of 682 patients identified, 419 were deemed surgical candidates; 126 underwent MVA. Propensity score derivation identified age, ejection fraction, and LV dimension to be associated with undergoing MVA. End points were reached in 120 (41%) non-MVA and 62 (49%) MVA patients. Increased risk of end point was associated with coronary artery disease (hazard ratio [HR] 1.80, 95% confidence interval [CI] 1.30 to 2.49), blood urea nitrogen (HR 1.01, 95% CI 1.005 to 1.02), cancer (HR 2.77, 95% CI 1.45 to 5.30), and digoxin (HR 1.66, 95% CI 1.15 to 2.39). Reduced risk was associated with angiotensin-converting enzyme inhibitors (HR 0.65, 95% CI 0.44 to 0.95), beta-blockers (HR 0.59, 95% CI 0.42 to 0.83), mean arterial pressure (HR 0.98, 95% CI 0.97 to 0.99), and serum sodium (HR 0.93, 95% CI 0.90 to 0.96). Mitral valve annuloplasty did not predict clinical outcome.
In this analysis, there is no clearly demonstrable mortality benefit conferred by MVA for significant MR with severe LV dysfunction. A prospective randomized control trial is warranted for further study of mortality with MVA in this population.
Journal of the American College of Cardiology 03/2005; 45(3):381-7. · 14.16 Impact Factor
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Audrey H Wu,
Christie M Ballantyne,
Beth C Short,
Guillermo Torre-Amione,
James B Young,
Hector O Ventura,
Howard J Eisen,
Branislav Radovancevic,
Barry K Rayburn,
Kathleen D Lake,
Clyde W Yancy,
David O Taylor,
Mandeep R Mehra,
Spencer H Kubo,
Daniel P Fishbein,
Xue-Qiao Zhao,
Kevin D O'Brien
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ABSTRACT: Although small, randomized trials have shown that statin use is associated with decreased risks of mortality and severe rejection, no study has examined statin therapy as used in actual practice in large numbers of heart transplant recipients. We analyzed data from the Heart Transplant Lipid Registry (n = 12 centers). Patients were included if they underwent transplantation between 1995 and 1999, survived >/=30 days after transplantation, and had >/=30 days of Registry follow-up. Multivariable Cox regression models, with propensity scoring performed to adjust for nonrandom allocation of statin therapy, were performed to determine the association of statin therapy with death and fatal rejection. The study included 1,186 patients, with a mean follow-up of 580 +/- 469 days; 937 patients (79%) received statin therapy. Overall, 71 patients (6%) died and 40 (3.4%) had fatal rejection. The statin group had a lower frequency of death (4% vs 13.7%, p <0.0001) and fatal rejection (2.4% vs 7.2%, p = 0.0001). Using multivariable Cox regression, with propensity scoring included to adjust for likelihood of receiving statin therapy, statin use was the only factor associated with lower risk of death (hazard ratio 0.29, 95% confidence interval 0.13 to 0.67) and fatal rejection (hazard ratio 0.27, 95% confidence interval 0.09 to 0.78). This study represents the largest population of heart transplant recipients analyzed for the relation between statin therapy and clinical outcomes in actual practice. Statin therapy was significantly associated with lower risk of death and fatal rejection, benefits that were independent of lipid values.
The American Journal of Cardiology 03/2005; 95(3):367-72. · 3.37 Impact Factor
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ABSTRACT: Serum brain natriuretic peptide (BNP) has been reported to be elevated in heart transplant recipients with both cellular and vascular rejection. Whether BNP can be used to help predict the severity of rejection is not well established.
We analyzed serial BNP measurements obtained during endomyocardial biopsy procedures in consecutive heart transplant patients occurring >45 days after transplantation. To eliminate potential confounding from prior rejection episodes, we included only observations in which the previous biopsy grade was 0 or 1A. Multivariable linear regression was performed examining the outcome of increasing seriousness of rejection, defined as grade 0 < 1A < 2 < 1B < 3A < vascular rejection. A univariable logistic regression model was performed using log-transformed BNP as a predictor of vascular rejection.
There were 77 patients, with 161 separate observations. Median time between transplantation and first assessment was 6.0 months (interquartile range, 2.1, 31.6). Using multivariable linear regression, 3 factors were significantly associated with biopsy score: pulmonary capillary wedge pressure (p < 0.0001), BNP (p = 0.003), and heart rate (p = 0.01). Even after other significant univariable predictors (including pulmonary capillary wedge pressure) were forced into the model, BNP remained a significant predictor of biopsy score (p = 0.02). Log BNP was a significant univariable predictor of vascular rejection, with an odds ratio of 12.55 (per 1 unit increase, 95% confidence interval 3.43-45.84; p = 0.0001) and a model c-statistic of 0.91.
BNP predicts new episodes of serious cardiac allograft rejection, particularly vascular rejection, independent of hemodynamic measurements, and may be a useful part of rejection surveillance.
The Journal of Heart and Lung Transplantation 02/2005; 24(1):52-7. · 4.33 Impact Factor
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ABSTRACT: It is not well established to what degree advances have been adopted into contemporary percutaneous coronary intervention (PCI) practice in the community and what effect they have on the short-term outcomes of in-hospital mortality and length of stay.
We analyzed a prospectively-collected, statewide registry that includes consecutive patients undergoing isolated PCI to determine predictors of in-hospital outcomes after the first PCI performed in the community. Multivariable logistic regression analysis was used to determine factors associated with in-hospital mortality after first PCI.
Between January 1, 1999 and December 31, 2000 there were a total of 12,920 cases of first PCI performed, 4535 (35.1%) of which were for acute myocardial infarction (MI). Stents and glycoprotein (GP) IIb/IIIa inhibitors were used in 89.6% and 70.0%, respectively, of all cases. In-hospital mortality was 1.8%. Length of hospital stay was 1 (1, 3) days [median (interquartile range)] in the absence of acute MI, and 3 (2, 4) days after acute MI. After acute MI, peri-procedure GP IIb/IIIa inhibitor use [adjusted OR 0.41 (95% CI 0.26, 0.63)] and stenting [adjusted OR 0.61 (95% CI 0.37, 0.996)] were the only factors positively associated with freedom from hospital death.
Intracoronary stenting and use of GP IIb/IIIa inhibitors have been well integrated into community practice. The observed in-hospital mortality rate is slightly higher than published in other series, but likely reflects the significant proportion of acute MI cases being treated aggressively with PCI as the primary therapy.
Journal of Interventional Cardiology 07/2004; 17(3):151-8. · 1.18 Impact Factor
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ABSTRACT: We sought to determine the incidence of and risk factors for repeat revascularization after nonemergent, first percutaneous coronary intervention (PCI) performed in contemporary community practice.
We analyzed a prospective registry of consecutive patients undergoing isolated PCI in the state of Washington. Multivariate Cox regression analysis was used to determine predictors of repeat revascularization (by PCI or bypass surgery) within 1 year after first PCI.
Between January 1, 1999, and December 31, 1999, there were 3571 nonemergent first PCIs, 87.7% of which involved stent placement. Repeat revascularization occurred in 577 (16.2%) patients. Repeat revascularization was predicted by multivessel disease (hazard ratio [HR] 1.36, 95% CI 1.12-1.66), stable versus no angina (HR 1.27, 95% CI 1.03-1.57), and maximum stent length used (per 1 mm longer: HR 1.01, 95% CI 1.002-1.02), while prior myocardial infarction (HR 0.77, 95% CI 0.62-0.96) and creatinine >1.2 mg/dL (HR 0.74, 95% CI 0.56-0.98) were associated with lower risk of repeat revascularization. Diabetes was a significant predictor only when the outcome was limited to revascularization by coronary artery bypass surgery (HR 1.52, 95% CI 1.03-2.23). Although glycoprotein IIb/IIIa inhibitor use was a significant univariate predictor of freedom from early repeat revascularization (within 60 days after first PCI), after controlling for potential confounders, it was no longer significant.
In this contemporary, community-based registry of patients undergoing nonemergent first PCI, clinical practice and outcomes are consistent with evidence from clinical trials and previous controlled studies. Results from controlled studies may reasonably be extrapolated to such a community setting.
American heart journal 02/2004; 147(1):146-50. · 4.65 Impact Factor
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ABSTRACT: This study was undertaken to determine whether aortic valve calcium (AVC) scores measured by electron beam tomography can identify patients with echocardiographically defined aortic stenosis. Electron beam tomography is increasingly being used to detect coronary artery calcium. AVC can also be measured on electron beam tomographic (EBT) scans obtained to screen for coronary calcium. Whether EBT AVC scores correlate with the presence of aortic stenosis, as assessed by echocardiography, is unknown. Results of this study suggest that AVC scores should be calculated routinely for coronary calcium screening EBT scans, and that patients with Agatston AVC scores above a certain level (e.g., >150) should be referred for echocardiography.
The American Journal of Cardiology 08/2003; 92(3):349-53. · 3.37 Impact Factor
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Current Problems in Cardiology 04/2003; 28(3):229-60. · 2.58 Impact Factor
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ABSTRACT: The purpose of this study was to document the prevalence and clinical features of aortic aneurysms in heart and abdominal transplant patients.
We undertook a retrospective review of 1557 patients who had heart, liver, or kidney transplantation between January 1, 1987, and December 31, 2000. Aortic aneurysms were identified by computed tomographic scan, ultrasound scan, or at the time of surgery for rupture. An aortic diameter of 3.5 cm was used as the threshold for the definition of aneurysmal disease. We compared dichotomous variables with Fisher's exact test and continuous variables with the Wilcoxon rank-sum test.
There were 296 heart, 450 liver, and 811 kidney transplants performed on adult patients during the study period. We identified 18 transplant patients who had an aortic aneurysm (13 heart, three liver, two kidney). Seven patients (41%) had rupture of the aortic aneurysm, and five of these patients died. There were no deaths from causes other than aortic aneurysm rupture. The rate of aneurysm rupture was 22.5% per year. Eight patients had the aortic aneurysm repaired electively with no deaths and no hospital stay greater than 15 days. The mean aortic aneurysm size at rupture was 6.02 +/- 0.86 cm, and the smallest aneurysm that ruptured was 5.1 cm. The pretransplant rate of aortic aneurysm expansion was 0.46 cm/y, but this increased to 1.00 cm/y after transplantation (P =.08). The rate of aortic aneurysm expansion among heart transplant patients and abdominal transplant patients was the same (P =.51). The prevalence of aortic aneurysm was 4.1% in cardiac transplant patients and 0.4% in abdominal transplant patients. Earlier in our series (1987 to 1996), 11% of the cardiac transplant patients were screened for aortic aneurysms, and the prevalence rate of diagnosis was 3.0%. Screening of cardiac transplant candidates became more frequent in 1997 (87% screened), with an associated increase in the aortic aneurysm prevalence rate to 5.8% in the patients who were screened.
Aortic aneurysms in cardiac and abdominal transplant patients have an aggressive natural history with high expansion and rupture rates. Screening transplant patients for aortic aneurysms will increase detection and facilitate elective repair, which is generally well tolerated. These findings support programs for early detection and elective treatment of aortic aneurysms in organ transplant patients, particularly those having heart transplants.
Journal of Vascular Surgery 02/2003; 37(1):27-31. · 3.21 Impact Factor
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ABSTRACT: The purpose of this study was to examine treatment and outcomes in patients admitted to the hospital with acute myocardial infarction (AMI) complicated by congestive heart failure (CHF).
Although cardiogenic shock complicating AMI has been studied extensively, the hospital course of patients presenting with CHF is less well established.
The Second National Registry of Myocardial Infarction (NRMI-2) was analyzed to determine hospital outcomes for patients with ST-elevation AMI admitted with CHF (Killip classes II or III).
Of 190,518 patients with AMI, 36,303 (19.1%) had CHF on admission. Patients presenting with CHF were older (72.6 +/- 12.5 vs. 63.2 +/- 13.5 years), more often female (46.8% vs. 32.1%), had longer time to hospital presentation (2.80 +/- 2.6 vs. 2.50 +/- 2.4 h), and had higher prevalence of anterior/septal AMI (38.8% vs. 33.3%), diabetes (33.1% vs. 19.5%), and hypertension (54.6% vs. 46.1%) (all p < 0.0005). Also, they had longer lengths of stay (8.1 +/- 7.1 vs. 6.8 +/- 5.3 days, p < 0.00005) and greater risk for in-hospital death (21.4% vs. 7.2%; p < 0.0005). Patients with CHF were less likely to receive aspirin (75.7% vs. 89.0%), heparin (74.6% vs. 91.1%), oral beta-blockers (27.0% vs. 41.7%), fibrinolytics (33.4% vs. 58.0%), or primary angioplasty (8.6% vs. 14.6%), and more likely to receive angiotensin-converting enzyme inhibitors (25.4% vs. 13.0%). Congestive heart failure on admission was one of the strongest predictors of in-hospital death (adjusted odds ratio 1.68; 95% confidence interval 1.62, 1.75).
Patients with AMI presenting with CHF are at higher risk for adverse in-hospital outcomes. Despite this, they are less likely to be treated with reperfusion therapy and medications with proven mortality benefit.
Journal of the American College of Cardiology 10/2002; 40(8):1389-94. · 14.16 Impact Factor
