Marc Cohen

Beth Israel Medical Center, New York, New York, United States

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Publications (201)2048.09 Total impact

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    ABSTRACT: Aims: The aims of the study are to compare the outcome with and without major bleeding and to identify the independent correlates of major bleeding complications and mortality in patients described in the ATOLL study. Methods: The ATOLL study included 910 patients randomly assigned to either 0.5 mg/kg intravenous enoxaparin or unfractionated heparin before primary percutaneous coronary intervention. Incidence of major bleeding and ischemic end points was assessed at 1 month, and mortality, at 1 and 6 months. Patients with and without major bleeding complication were compared. A multivariate model of bleeding complications at 1 month and mortality at 6 months was realized. Intention-to-treat and per-protocol analyses were performed. Results: The most frequent bleeding site appears to be the gastrointestinal tract. Age >75 years, cardiac arrest, and the use of insulin or >1 heparin emerged as independent correlates of major bleeding at 1 month. Patients presenting with major bleeding had significantly higher rates of adverse ischemic complications. Mortality at 6 months was higher in bleeders. Major bleeding was found to be one of the independent correlates of 6-month mortality. The addition or mixing of several anticoagulant drugs was an independent factor of major bleeding despite the predominant use of radial access. Conclusions: This study shows that major bleeding is independently associated with poor outcome, increasing ischemic events, and mortality in primary percutaneous coronary intervention performed mostly with radial access.
    American heart journal 09/2015; 170(4):778-86. DOI:10.1016/j.ahj.2015.05.021 · 4.46 Impact Factor
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    ABSTRACT: Paravalvular aortic root abscess with intracardiac fistula formation is an exceedingly rare complication of infective endocarditis. This condition is even more rarely encountered in patients with bioprosthetic valve endocarditis. We report an unusual case of a 68-year-old Bosnian female with a bioprosthetic aortic valve, who developed an extensive aortic root abscess, complicated by an aortico-left atrial intracardiac fistula. This case illustrates that a high index of suspicion, prompt diagnosis by echocardiography, proper antibiotic therapy, and early surgical intervention are crucial to improving treatment outcomes for this rare condition.
    08/2015; 2015(2):473246. DOI:10.1155/2015/473246
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    ABSTRACT: Acute thrombosis is the most common mode of stent-graft failure. Thrombectomy and thrombolysis have inadequate medium-term and long-term results. We propose a new technique for treating acute stent-graft thrombosis by "relining" the thrombosed graft with a second stent-graft. Ten patients were treated with this technique and have been free of any repeat intervention for up to 1 year, showing its feasibility. The Viabahn-in-Viabahn technique needs a larger study to confirm its efficacy and safety.
    The Journal of invasive cardiology 05/2015; 27(5):E65-7. · 0.95 Impact Factor
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    ABSTRACT: Background: Right ventricular (RV) dysfunction after left ventricular assist device (LVAD) implantation significantly complicates post-device management and has been shown to be associated with increased mortality. Pre-operative identification of patients who may develop post-LVAD RV dysfunction is challenging. This study was designed to evaluate pre-operative echocardiographic speckle tracking imaging as a predictor of post operative RV dysfunction. Methods: Thirty-nine patients who underwent Heartmate II LVAD placement in a single center were studied. Pre- and post-operative clinical, hemodynamic, laboratory, and echocardiographic data were prospectively collected as part of an ongoing institutional LVAD database. RV strain parameters were measured retrospectively using off-line speckletracking analysis software. Results: Twenty five of 39 LVAD recipients developed acute RV failure during the early post-operative period. RV function in 14 of these recipients improved with inotropes and judicious adjustment of LVAD parameters. Eleven patients, however, expired despite aggressive medical therapy including 7 patients who underwent placement of an RVAD. These 11 individuals were identified as having significantly lower global RV strain prior to device placement (p<0.05). Seventy two percent of the patients with a peak longitudinal systolic RV strain higher than -3%, expired. Twenty-four of 27 (88%) patients with a global RV strain of -3% or lower survived without need for an RVAD (p<0.001). Hemodynamic, laboratory and traditional echocardiographic data were not predictive of post-LVAD RV dysfunction or survival. Multivariate analysis showed RV longitudinal strain, especially global strain, to be the only significant predictor of severe RV dysfunction. Conclusion: Poor intrinsic RV myocardial function is associated with a higher mortality in LVAD patients. Speckle-tracking echocardiography imaging, particularly, peak systolic global RV strain appears to be promising in predicting LVAD patients who require RVAD.
    Journal of cardiovascular disease research 03/2015; 6(1):1-11. DOI:10.5530/jcdr.2015.1.1
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    ABSTRACT: Background: The potential benefit of dual antiplatelet therapy beyond 1 year after a myocardial infarction has not been established. We investigated the efficacy and safety of ticagrelor, a P2Y12 receptor antagonist with established efficacy after an acute coronary syndrome, in this context. Methods: We randomly assigned, in a double-blind 1:1:1 fashion, 21,162 patients who had had a myocardial infarction 1 to 3 years earlier to ticagrelor at a dose of 90 mg twice daily, ticagrelor at a dose of 60 mg twice daily, or placebo. All the patients were to receive low-dose aspirin and were followed for a median of 33 months. The primary efficacy end point was the composite of cardiovascular death, myocardial infarction, or stroke. The primary safety end point was Thrombolysis in Myocardial Infarction (TIMI) major bleeding. Results: The two ticagrelor doses each reduced, as compared with placebo, the rate of the primary efficacy end point, with Kaplan-Meier rates at 3 years of 7.85% in the group that received 90 mg of ticagrelor twice daily, 7.77% in the group that received 60 mg of ticagrelor twice daily, and 9.04% in the placebo group (hazard ratio for 90 mg of ticagrelor vs. placebo, 0.85; 95% confidence interval [CI], 0.75 to 0.96; P=0.008; hazard ratio for 60 mg of ticagrelor vs. placebo, 0.84; 95% CI, 0.74 to 0.95; P=0.004). Rates of TIMI major bleeding were higher with ticagrelor (2.60% with 90 mg and 2.30% with 60 mg) than with placebo (1.06%) (P<0.001 for each dose vs. placebo); the rates of intracranial hemorrhage or fatal bleeding in the three groups were 0.63%, 0.71%, and 0.60%, respectively. Conclusions: In patients with a myocardial infarction more than 1 year previously, treatment with ticagrelor significantly reduced the risk of cardiovascular death, myocardial infarction, or stroke and increased the risk of major bleeding. (Funded by AstraZeneca; PEGASUS-TIMI 54 number, NCT01225562.).
    New England Journal of Medicine 03/2015; 372(19). DOI:10.1056/NEJMoa1500857 · 55.87 Impact Factor
  • Journal of the American College of Cardiology 03/2015; 65(10):A601. DOI:10.1016/S0735-1097(15)60601-5 · 16.50 Impact Factor
  • Journal of the American College of Cardiology 03/2015; 65(10):A1902. DOI:10.1016/S0735-1097(15)61902-7 · 16.50 Impact Factor
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    ABSTRACT: Guidelines recommendations regarding anticoagulant therapy after percutaneous coronary intervention (PCI) among patients with atrial fibrillation (AF) rely on retrospective, nonrandomized observational data. Currently, patients are treated with triple-therapy (dual antiplatelet therapy [DAPT] + oral anticoagulation therapy), but neither the duration of DAPT nor the level of anticoagulation has been studied in a randomized fashion. Recent studies also suggest dual pathway therapy with clopidogrel plus oral anticoagulation therapy may be superior, and other studies suggest that novel oral anticoagulants such as rivaroxaban may further improve patient outcomes. PIONEER AF-PCI ( NCT01830543) is an exploratory, open-label, randomized, multicenter clinical study assessing the safety of 2 rivaroxaban treatment strategies and 1 vitamin K antagonist (VKA) treatment strategy in subjects who have paroxysmal, persistent, or permanent nonvalvular AF and have undergone PCI with stent placement. Approximately 2,100 subjects will be randomized in a 1:1:1 ratio to receive either rivaroxaban 15 mg once daily plus clopidogrel 75 mg daily for 12 months (a WOEST trial-like strategy), or rivaroxaban 2.5 mg twice daily (with stratification to a prespecified duration of DAPT 1, 6, or 12 months, an ATLAS trial-like strategy), or dose-adjusted VKA once daily (with stratification to a prespecified duration of DAPT 1, 6, or 12 months, traditional triple therapy). All patients will be followed up for 12 months for the primary composite end point of Thrombolysis in Myocardial Infarction major bleeding, bleeding requiring medical attention, and minor bleeding (collectively, clinically significant bleeding). The PIONEER AF-PCI study is the first randomized comparison of VKA vs novel oral anticoagulant therapy in patients with NVAF receiving antiplatelet therapy after PCI to assess the relative risks of bleeding complications. Copyright © 2014 Elsevier Inc. All rights reserved.
    American heart journal 12/2014; 169(4). DOI:10.1016/j.ahj.2014.12.006 · 4.46 Impact Factor
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    ABSTRACT: Carotid Duplex Ultrasonography (CDUS) is one of the non-invasive imaging modalities used to evaluate for carotid artery stenosis. However, it is often used in patients with coronary artery disease (CAD), peripheral artery disease (PAD), before heart surgery, syncope and non-specific neurological symptoms although its value is unclear. Our study aimed to further investigate the yield of CDUS in these conditions. A retrospective analysis was conducted on 827 consecutive carotid ultrasounds ordered between March 2013 and August 2013 at Newark Beth Israel Medical Center. Clinical characteristics such as age, sex, smoking status, systemic hypertension, diabetes mellitus, CAD, PAD, carotid bruit and indications for carotid ultrasound were included. Significant cerebrovascular disease (sCBVD) was defined as greater than or equal to 50% diameter reduction in internal carotid arteries (ICA) or any degree of occlusion in vertebrobasilar system. Only 88 out of 827 (10.6%) patients had sCBVD. Using logistic regression analysis we identified age greater than 65 years (OR 2.1, 95% CI 1.2 to 3.7; P = 0.006), carotid bruit (OR 7.8, 95% CI 3.6 to 16.6; P <0.001) and history of prior carotid endarterectomy or carotid artery stenting (OR 5.8, 95% CI 2.3 to 14.8; P <0.001) as significant predictors of sCBVD. Significant carotid artery stenosis is more likely in patients 65 years and older, presence of carotid bruit and prior CEA. On the other hand, it has low diagnostic yield in less than 65-year-old individuals, syncope and non-focal neurological symptoms. This highlights the need for better risk prediction models in order to promote optimal utilization.
    Cardiovascular Ultrasound 11/2014; 12(1):48. DOI:10.1186/1476-7120-12-48 · 1.34 Impact Factor
  • Journal of the American College of Cardiology 09/2014; 64(11):B215. DOI:10.1016/j.jacc.2014.07.806 · 16.50 Impact Factor
  • Journal of the American College of Cardiology 09/2014; 64(11):B229. DOI:10.1016/j.jacc.2014.07.856 · 16.50 Impact Factor
  • Joint Annual Meeting of the New-England-Society-for-Vascular-Surgery; 09/2014
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    Marc Cohen · Deepa Iyer
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    ABSTRACT: Acute coronary syndrome (ACS) is a medical emergency often associated with an occlusive coronary event with consequent myocardial underperfusion. Patients require immediate antiplatelet therapy and long-term antithrombotic prophylaxis to reduce the risk of recurrence. Acetylsalicylic acid alone or in combination with a platelet P2Y12 inhibitor (dual antiplatelet therapy) has become the clinically accepted antithrombotic prophylaxis for patients post ACS. Historically, studies assessing the utility of adding oral anticoagulants have not demonstrated a clinical benefit with regard to acceptable bleeding risk. Studies with vitamin K antagonists such as warfarin demonstrated a potential to reduce the risk for subsequent death by reinfarction but this benefit was offset by increases in bleeding. Results from studies of two targeted non-vitamin K antagonist oral anticoagulants also proved disappointing, with little or no apparent reduction in the rate of ischemic events seen. However, the recent ATLAS studies assessing rivaroxaban (an oral Factor Xa inhibitor) in patients with ACS demonstrated a reduction in the composite endpoint of deaths from cardiovascular causes, myocardial infarction, or stroke, and a reduction in the rate of stent thrombosis. This review provides an overview of the pivotal studies in which the addition of oral anticoagulants to antiplatelet therapy (the so-called 'dual-pathway' approach) has been investigated for the management of patients post ACS, and considers the results of the ATLAS studies and their potential impact on the management of patients after an acute event. This article is protected by copyright. All rights reserved.
    Cardiovascular Therapeutics 06/2014; 32(5). DOI:10.1111/1755-5922.12083 · 2.36 Impact Factor
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    ABSTRACT: P2Y12 receptor antagonist therapy is recommended in addition to ASA for up to 1 year after acute coronary syndrome to reduce ischemic events. In contrast, the benefit of long-term dual antiplatelet therapy beyond 1 year remains unclear. Ticagrelor is a potent, reversibly binding P2Y12 receptor-antagonist that has been shown to be superior to clopidogrel in patients with acute coronary syndromes for up to 1 year. PEGASUS-TIMI 54 is a randomized, double-blind, placebo-controlled, multinational clinical trial designed to evaluate the efficacy and safety of ticagrelor in addition to aspirin (75-150 mg) for the prevention of major adverse cardiovascular events in patients with a history of myocardial infarction and risk factors. Patients with a history of spontaneous myocardial infarction within 1 to 3 years are randomized in a 1:1:1 fashion to ticagrelor 90 mg twice daily, ticagrelor 60 mg twice daily, or matching placebo, all with low dose ASA, until the end of the study. The primary endpoint is a composite of cardiovascular death, myocardial infarction, or stroke. Recruitment began in October 2010 and completed in April 2013 with a sample size of over 21,000 patients. The trial is planned to continue until the latest of either 1,360 adjudicated primary end points are accrued or the last patient randomized has been followed for at least 12 months. PEGASUS-TIMI 54 is investigating whether the addition of intensive antiplatelet therapy with ticagrelor to low-dose aspirin reduces major adverse cardiovascular events in high-risk patients with a history of myocardial infarction.
    American heart journal 04/2014; 167(4):437-444.e5. DOI:10.1016/j.ahj.2013.12.020 · 4.46 Impact Factor
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    Journal of the American College of Cardiology 10/2013; 62(18). DOI:10.1016/j.jacc.2013.08.1484 · 16.50 Impact Factor
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    ABSTRACT: Intravenous enoxaparin did not reduce significantly the primary end point (p = 0.06) compared with unfractionated heparin (UFH) in the randomized Acute Myocardial Infarction Treated with primary angioplasty and intravenous enoxaparin Or unfractionated heparin to Lower ischemic and bleeding events at short- and Long-term follow-up (ATOLL) trial. We present the results of the prespecified per-protocol analysis excluding patients who did not receive the treatment allocated by randomization or received both enoxaparin and UFH. We evaluated all-cause mortality, complication of myocardial infarction, procedural failure, or major bleeding (primary end point) and all-cause mortality, recurrent acute coronary syndrome, or urgent revascularization (main secondary end point). Baseline and procedural characteristics were well balanced between the 2 treatment groups. Of 910 randomized patients, 795 patients (87.4%) were treated according to the protocol with consistent anticoagulation using intravenous enoxaparin (n = 400) or UFH (n = 395). Enoxaparin reduced significantly the rates of the primary end point (relative risk [RR] 0.76, 95% confidence interval [CI] 0.62 to 0.94, p = 0.012) and the main secondary end point (RR 0.37, 95% CI 0.22 to 0.63, p <0.0001). There was less major bleeding with enoxaparin (RR 0.46, 95% CI 0.21 to 1.01, p = 0.050) contributing to the significant improvement of the net clinical benefit (RR 0.46, 95% CI 0.3 to 0.74, p = 0.0002). All-cause mortality was also reduced with enoxaparin (RR 0.36, 95% CI 0.18 to 0.74, p = 0.003). In conclusion, in the per-protocol analysis of the ATOLL trial, pertinent to >87% of the study population, enoxaparin was superior to UFH in reducing ischemic end points and mortality.
    The American journal of cardiology 09/2013; 112(9). DOI:10.1016/j.amjcard.2013.07.003 · 3.28 Impact Factor
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    ABSTRACT: IMPORTANCE: The optimal anticoagulant for patients with non-ST-segment elevation acute coronary syndromes (NSTE-ACS) managed with an invasive strategy remains controversial. OBJECTIVE: To compare the clinical efficacy and safety of otamixaban, a novel intravenous direct factor Xa inhibitor, with that of unfractionated heparin plus downstream eptifibatide in patients with NSTE-ACS undergoing a planned early invasive strategy. DESIGN, SETTING, AND PARTICIPANTS: Randomized, double-blind, active-controlled superiority trial that enrolled 13,229 patients with NSTE-ACS and a planned early invasive strategy, at 568 active sites in 55 countries and conducted between April 2010 and February 2013. A planned interim analysis was conducted for otamixaban dose selection. INTERVENTIONS: Eligible participants were randomized to otamixaban (bolus and infusion, at 1 of 2 doses) or unfractionated heparin plus, at the time of percutaneous coronary intervention, eptifibatide. The otamixaban dose selected at interim analysis was an intravenous bolus of 0.080 mg/kg followed by an infusion of 0.140 mg/kg per hour. MAIN OUTCOMES AND MEASURES: The primary efficacy outcome was the composite of all-cause death or new myocardial infarction through day 7. RESULTS: Rates of the primary efficacy outcome were 5.5% (279 of 5105 patients) randomized to receive otamixaban and 5.7% (310 of 5466 patients) randomized to receive unfractionated heparin plus eptifibatide (adjusted relative risk, 0.99 [95% CI, 0.85-1.16]; P = .93). There were no differences for the secondary end points, including procedural thrombotic complications. The primary safety outcome of Thrombosis in Myocardial Infarction major or minor bleeding through day 7 was increased by otamixaban (3.1% vs 1.5%; relative risk, 2.13 [95% CI, 1.63-2.78]; P < .001). Results were consistent across prespecified subgroups. CONCLUSIONS AND RELEVANCE: Otamixaban did not reduce the rate of ischemic events relative to unfractionated heparin plus eptifibatide but did increase bleeding. These findings do not support the use of otamixaban for patients with NSTE-ACS undergoing planned early percutaneous coronary intervention. TRIAL REGISTRATION: Identifier: NCT01076764.
    JAMA The Journal of the American Medical Association 09/2013; 310(11). DOI:10.1001/jama.2013.277165 · 35.29 Impact Factor
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    ABSTRACT: OBJECTIVES: To determine if rivaroxaban is associated with a reduction in stent thrombosis among ACS subjects in the ATLAS ACS 2-TIMI 51 trial. BACKGROUND: Dual antiplatelet therapy has been the mainstay of efforts to prevent stent thrombosis. Since thrombin is a potent stimulant of platelet activation, we hypothesized that inhibition of thrombin generation via factor Xa inhibition may further reduce the risk of stent thrombosis. METHODS: ATLAS ACS 2-TIMI 51 was a placebo-controlled trial that randomly assigned 15,526 patients with a recent acute coronary syndrome to receive twice-daily doses of either 2.5 mg or 5 mg of rivaroxaban or placebo for a mean of 13 months and up to 31 months. RESULTS: Among subjects who had a stent placed prior to or at the time of the index event, rivaroxaban significantly reduced independently adjudicated Academic Research Consortium (ARC) definite and probable stent thrombosis in the pooled (1.9% vs. 1.5%, HR 0.65, p=0.017) and the 2.5 mg BID (1.9% vs. 1.5%, HR 0.61, p=0.023) treatment groups when compared to placebo, with a trend toward a reduction in the 5 mg BID treatment group (1.9% vs. 1.5%, HR 0.70, p=0.089). Among subjects who received both aspirin and a thienopyridine (Stratum 2), the benefit of rivaroxaban emerged during the period of active treatment with dual antiplatelet therapy (HR 0.68, 95% CI 0.50-0.92, combined rivaroxaban group vs. placebo). Among stented subjects who were treated with dual antiplatelet therapy, there was a mortality reduction among those treated with 2.5 mg BID of rivaroxaban (HR 0.56, 95% CI 0.35-0.89, p=0.014). CONCLUSIONS: Among stented ACS patients treated with dual antiplatelet therapy, the administration of 2.5 mg BID of rivaroxaban is associated with a reduction in stent thrombosis and mortality. CLINICAL TRIAL ID: NCT00809965.
    Journal of the American College of Cardiology 04/2013; 62(4). DOI:10.1016/j.jacc.2013.03.041 · 16.50 Impact Factor
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    ABSTRACT: The use of glycoprotein IIb/IIIa receptor inhibitors (GPIs) in high-risk patients with acute coronary syndromes has been associated with reductions in ischemic events but increases in bleeding complications. The role of GPIs in patients who undergo primary percutaneous coronary intervention (PCI) by the transradial approach (TRA) is not well studied. The aim of this post hoc analysis from the randomized prospective Acute Myocardial Infarction Treated With Primary Angioplasty and Intravenous Enoxaparin or Unfractionated Heparin to Lower Ischemic and Bleeding Events at Short- and Long-Term Follow-Up (ATOLL) trial was to assess the safety and efficacy of GPIs in primary PCI performed using the TRA. A total of 910 patients were enrolled in ATOLL; 522 patients (67%) underwent PCI using the TRA. Two comparative analyses were performed. First, patients who underwent PCI using the TRA who received GPIs were compared with those who did not receive GPIs. Second, patients who underwent PCI using the TRA who received GPIs were compared with those who underwent PCI using a nonradial route and received GPIs. Composite end points of net clinical benefit, ischemic outcomes, and safety consisting of bleeding and transfusion at 1 month were analyzed. A propensity score was constructed, and weight adjustment were made for variables, including but not limited to age, weight, gender, renal function, concomitant use of other medications, Killip class, and medical history, when analyzing the end points. There was no significant difference in net clinical benefit or ischemic outcomes between either TRA patients with versus without GPIs or TRA patients with GPIs versus non-TRA patients with GPIs. Additionally, there were significantly fewer major bleeding events and blood transfusions in TRA patients with GPIs compared with non-TRA patients with GPIs. In conclusion, the addition of GPIs in the setting of primary PCI using the TRA was not associated with bleeding liability. The use of GPIs with TRA was associated with safer outcomes than using GPIs with a nontransradial approach. This study was limited in that it was a nonrandomized retrospective analysis.
    The American journal of cardiology 03/2013; 111(12). DOI:10.1016/j.amjcard.2013.02.020 · 3.28 Impact Factor
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    Journal of the American College of Cardiology 03/2013; 61(10). DOI:10.1016/S0735-1097(13)61813-6 · 16.50 Impact Factor

Publication Stats

8k Citations
2,048.09 Total Impact Points


  • 2003–2014
    • Beth Israel Medical Center
      • • Department of Medicine
      • • Cardiac Catheterization Lab
      New York, New York, United States
  • 1984–2014
    • Icahn School of Medicine at Mount Sinai
      • • Division of Cardiology
      • • Department of Medicine
      Borough of Manhattan, New York, United States
  • 2009
    • Beth Israel Deaconess Medical Center
      Boston, Massachusetts, United States
  • 1992–2003
    • Philadelphia University
      Philadelphia, Pennsylvania, United States
  • 2002
    • Hospital of the University of Pennsylvania
      Philadelphia, Pennsylvania, United States
    • University of Geneva
      Genève, Geneva, Switzerland
    • The Philadelphia Center
      Filadelfia, Pennsylvania, United States
  • 2000–2002
    • Tenet HealthSystem Medical, Inc.
      Dallas, Texas, United States
    • Harvard Medical School
      • Department of Medicine
      Boston, Massachusetts, United States
  • 2001
    • Danbury Hospital
      DXR, Connecticut, United States
  • 1997–2000
    • Allegheny University
      Worcester, Massachusetts, United States
  • 1983–1996
    • Mount Sinai Medical Center
      New York, New York, United States
  • 1994
    • Miramar Polyclinic
      Palma, Balearic Islands, Spain
  • 1986–1992
    • Mount Sinai Hospital
      New York City, New York, United States
  • 1987–1991
    • CUNY Graduate Center
      New York City, New York, United States
  • 1990
    • Gracie Square Hospital, New York, NY
      New York, New York, United States