Peter A McCullough

Baylor Hamilton Heart and Vascular Hospital, Dallas, Texas, United States

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Publications (476)1898.69 Total impact

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    ABSTRACT: Contrast-induced acute kidney injury (CI-AKI) is associated with increased morbidity and mortality after percutaneous coronary interventions and is a patient safety objective of the National Quality Forum. However, no formal quality improvement program to prevent CI-AKI has been conducted. Therefore, we sought to determine whether a 6-year regional multicenter quality improvement intervention could reduce CI-AKI after percutaneous coronary interventions.
    Circulation Cardiovascular Quality and Outcomes 07/2014; · 5.66 Impact Factor
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    ABSTRACT: Intravenous loop diuretics are a cornerstone of therapy in acutely decompensated heart failure (ADHF). We sought to determine if there are any differences in clinical outcomes between intravenous bolus and continuous infusion of loop diuretics.
    Critical care (London, England) 06/2014; 18(3):R134. · 4.72 Impact Factor
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    ABSTRACT: Background: Bardoxolone methyl, an Nrf2-activating and nuclear factor-κB-inhibiting semisynthetic oleanane triterpenoid compound, was evaluated in a phase 3 trial (BEACON) in patients with type 2 diabetes mellitus (T2DM) and stage 4 chronic kidney disease (CKD). The trial was terminated because of an increase in heart failure events in the bardoxolone methyl group, many of which appeared related to fluid retention. Thus, additional analyses were conducted to explain these serious adverse events. Methods: Patients (n = 2,185) were randomized to receive once-daily bardoxolone methyl (20 mg) or placebo. Twenty-four-hour urine collections were analyzed in a subset of the BEACON population and from a separate, open-label pharmacology study in patients with stage 3b/4 CKD and T2DM administered 20 mg bardoxolone methyl once daily for 56 consecutive days. Results: Bardoxolone-methyl-treated patients in the BEACON substudy had a clinically meaningful reduction in urine volume and sodium excretion at week 4 relative to baseline (p < 0.05), and a separate study revealed that decreased sodium excretion and urine output occurred in some patients with stage 4 CKD but not those with stage 3b CKD. The clinical phenotype of fluid overload and heart failure in BEACON was similar to that observed with endothelin receptor antagonists in advanced CKD patients, and preclinical data demonstrate that bardoxolone methyl modifies endothelin signaling. Conclusions: The totality of the evidence suggests that through modulation of the endothelin pathway, bardoxolone methyl may pharmacologically promote acute sodium and volume retention and increase blood pressure in patients with more advanced CKD. © 2014 S. Karger AG, Basel.
    American journal of nephrology. 06/2014; 39(6):499-508.
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    ABSTRACT: Dabigatran etexilate, was found to be effective for stroke prevention in patients with non-valvular atrial fibrillation. Given its predictable pharmacodynamics, laboratory monitoring is not required. Moreover, the risks of overall bleeding, intracranial bleeding, and life-threatening hemorrhage from dabigatran were found to be lower than warfarin. However, a higher risk of gastrointestinal (GI) bleeding caused by dabigatran from the randomized evaluation of long-term anticoagulant therapy (RE-LY) trial has raised the concern regarding clinical outcomes of patients with GI bleeding caused by dabigatran compared with warfarin.
    Cardiovascular diagnosis and therapy. 06/2014; 4(3):224-31.
  • Peter A McCullough
    American Journal of Kidney Diseases 04/2014; · 5.29 Impact Factor
  • Nephrology news & issues 04/2014; 28(4):41-2.
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    ABSTRACT: Biomarker testing for efficacy of therapy is an accepted way for clinicians to individualize dosing to genetic and/or environmental factors that may be influencing a treatment regimen. Aspirin is used by nearly 43 million Americans on a regular basis to reduce risks associated with various atherothrombotic diseases. Despite its widespread use, many clinicians are unaware of the link between suboptimal response to aspirin therapy and increased risk for inferior clinical outcomes in several disease states, and biomarker testing for efficacy of aspirin therapy is not performed as routinely as efficacy testing in other therapeutic areas. This article reviews the clinical and laboratory aspects of determining whole-body thromboxane production, particularly as it pertains to efficacy assessment of aspirin responsiveness.
    Reviews in cardiovascular medicine 01/2014; 15(2):119-130. · 0.58 Impact Factor
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    ABSTRACT: Objectives The aim of this study was to evaluate the relationship between pre-procedural fluid status assessed by bioimpedance vector analysis (BIVA) and development of contrast-induced acute kidney injury (CI-AKI). Background Accurate fluid management in patients undergoing angiographic procedures is of critical importance in limiting the risk of CI-AKI. Therefore, establishing peri-procedural fluid volume related to increased risk of CI-AKI development is essential. Methods We evaluated fluid status of 900 consecutive patients with stable coronary artery disease (CAD) immediately before coronary angiography, by BIVA, measuring the resistance/height (R/H) ratio and impedance/height (Z/H) vector. CI-AKI was defined as an increase in serum creatinine ≥0.5 mg/dl above baseline within 3 days after contrast administration (Iodixanol). Results CI-AKI occurred in 54 (6.0%) patients. Pre-procedural R/H ratios were significantly higher in CI-AKI than non CI-AKI patients (395±71 versus 352±58 Ohm/m, p=0.001 for females; 303±59 versus 279±45 Ohm/m, p=0.009 for males) indicating lower fluid volume in these subjects. When patients were stratified according to R/H ratio there was an almost 3-fold higher risk in patients with higher values (OR 2.9, 95% CI 1.5-5.5; p=0.002). The optimal receiver operating curve analysis threshold values of R/H ratio for predicting CI-AKI were 380 for females and 315 Ohm/m for males. R/H ratio above these thresholds was found to be a significant and independent predictor of CI-AKI (OR 3.1, 95% CI 1.8-5.5; p=0.001). Conclusions Lower fluid status evaluated by BIVA immediately before contrast medium administration resulted a significant and independent predictor of CI-AKI in stable CAD patients. This simple non-invasive analysis should be tested in guiding tailored volume repletion.
    Journal of the American College of Cardiology 01/2014; · 14.09 Impact Factor
  • Peter A. McCullough
    American Journal of Kidney Diseases 01/2014; · 5.29 Impact Factor
  • Peter A. McCullough
    Interventional Cardiology Clinics. 01/2014; 3(3):357–362.
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    ABSTRACT: Homozygous familial hypercholesterolemia (HoFH) is associated with severe hypercholesterolemia and premature cardiovascular morbidity and mortality. The most frequent cause of HoFH is loss of function mutations in the gene for the low-density lipoprotein receptor, resulting in reduced clearance of low-density lipoprotein (LDL) cholesterol from the circulation. Patients with HoFH have attenuated responsiveness to lipidlowering therapies such as statins, cholesterol absorption inhibition, and bile acid binding resins because of impaired LDL receptor expression. Lomitapide is a novel microsomal triglyceride transfer protein inhibitor that does not depend on the ability to upregulate LDL receptors on the surface of hepatocytes. Lomitapide reduces production of apolipoprotein B-containing lipoproteins, significantly reduces serum levels of LDL cholesterol, and is approved for use in patients with HoFH in the United States and the European Union.
    Reviews in cardiovascular medicine 01/2014; 15(1):1-10. · 0.58 Impact Factor
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    ABSTRACT: The plasma pool of potassium is a partial reflection of the overall body, transient cellular shifts, and potassium elimination regulated by the kidneys. Potassium concentrations elevating above the upper limit of normal (> 5.0 mEq/L) have become more common in cardiovascular practice due to the growing population of patients with chronic kidney disease and the broad applications of drugs that modulate potassium excretion by either reducing production of angiotensin II (angiotensin-converting enzyme inhibitors, direct renin inhibitors, beta-adrenergic receptor antagonists), blocking angiotensin II receptors (angiotensin receptor blockers), or antagonizing the action of aldosterone on mineralocorticoid receptors (mineralocorticoid receptor antagonists). In addition, acute kidney injury, critical illness, crush injuries, and massive red blood cell transfusions can result in hyperkalemia. Progressively more severe elevations in potassium are responsible for abnormalities in cardiac depolarization and repolarization and contractility. Untreated severe hyperkalemia results in sudden cardiac death. Traditional management steps have included reducing dietary potassium and discontinuing potassium supplements; withdrawal of exacerbating drugs; acute treatment with intravenous calcium gluconate, insulin, and glucose; nebulized albuterol; correction of acidosis with sodium bicarbonate for short-term shifts out of the plasma pool; and, finally, gastrointestinal ion exchange with oral sodium polystyrene sulfonate in sorbitol, which is mainly used in the hospital and is poorly tolerated due to gastrointestinal adverse effects. This review explores hyperkalemia as a complication in cardiovascular patients and highlights new acute, chronic, and preventative oral therapies (patiromer calcium, cross-linked polyelectrolyte, ZS-9) that could potentially create a greater margin of safety for vulnerable patients with combined heart and kidney disease.
    Reviews in cardiovascular medicine 01/2014; 15(1):11-23. · 0.58 Impact Factor
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    ABSTRACT: Structural heart disease is highly prevalent in patients with chronic kidney disease requiring dialysis. More than 80% of end-stage renal disease (ESRD) patients are reported to have cardiovascular disease (CVD). This observation has enormous clinical relevance, as the leading causes of death for ESRD patients are of CVD etiology, including heart failure, myocardial infarction, and sudden cardiac death. The two systems most commonly used to classify the severity of heart failure are the New York Heart Association (NYHA) functional classification and the American Heart Association/American College of Cardiology (AHA/ACC) staging system. With rare exceptions, ESRD patients who do not receive renal replacement therapy (RRT) develop signs and symptoms of heart failure, including dyspnea and edema due to inability of the severely diseased kidneys to excrete sodium and water. Thus, by definition, nearly all ESRD patients develop a symptomatology consistent with heart failure if fluid removal by RRT is delayed. Neither the AHA/ACC heart failure staging nor the NYHA functional classification system identifies the variable symptomatology that ESRD patients experience depending upon whether evaluation occurs before or after fluid removal by RRT. Consequently, the incidence, severity, and outcomes of heart failure in ESRD patients are poorly characterized. The 11th Acute Dialysis Quality Initiative has identified this issue as a critical unmet need for the proper evaluation and treatment of heart failure in patients with ESRD. We propose a classification schema based on patient-reported dyspnea assessed both pre- and post-ultrafiltration, in conjunction with echocardiography.
    Journal of the American College of Cardiology 01/2014; · 14.09 Impact Factor
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    ABSTRACT: Background Combination therapy with angiotensin-converting-enzyme (ACE) inhibitors and angiotensin-receptor blockers (ARBs) decreases proteinuria; however, its safety and effect on the progression of kidney disease are uncertain. Methods We provided losartan (at a dose of 100 mg per day) to patients with type 2 diabetes, a urinary albumin-to-creatinine ratio (with albumin measured in milligrams and creatinine measured in grams) of at least 300, and an estimated glomerular filtration rate (GFR) of 30.0 to 89.9 ml per minute per 1.73 m(2) of body-surface area and then randomly assigned them to receive lisinopril (at a dose of 10 to 40 mg per day) or placebo. The primary end point was the first occurrence of a change in the estimated GFR (a decline of ≥30 ml per minute per 1.73 m(2) if the initial estimated GFR was ≥60 ml per minute per 1.73 m(2) or a decline of ≥50% if the initial estimated GFR was <60 ml per minute per 1.73 m(2)), end-stage renal disease (ESRD), or death. The secondary renal end point was the first occurrence of a decline in the estimated GFR or ESRD. Safety outcomes included mortality, hyperkalemia, and acute kidney injury. Results The study was stopped early owing to safety concerns. Among 1448 randomly assigned patients with a median follow-up of 2.2 years, there were 152 primary end-point events in the monotherapy group and 132 in the combination-therapy group (hazard ratio with combination therapy, 0.88; 95% confidence interval [CI], 0.70 to 1.12; P=0.30). A trend toward a benefit from combination therapy with respect to the secondary end point (hazard ratio, 0.78; 95% CI, 0.58 to 1.05; P=0.10) decreased with time (P=0.02 for nonproportionality). There was no benefit with respect to mortality (hazard ratio for death, 1.04; 95% CI, 0.73 to 1.49; P=0.75) or cardiovascular events. Combination therapy increased the risk of hyperkalemia (6.3 events per 100 person-years, vs. 2.6 events per 100 person-years with monotherapy; P<0.001) and acute kidney injury (12.2 vs. 6.7 events per 100 person-years, P<0.001). Conclusions Combination therapy with an ACE inhibitor and an ARB was associated with an increased risk of adverse events among patients with diabetic nephropathy. (Funded by the Cooperative Studies Program of the Department of Veterans Affairs Office of Research and Development; VA NEPHRON-D ClinicalTrials.gov number, NCT00555217 .).
    New England Journal of Medicine 11/2013; · 51.66 Impact Factor
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    ABSTRACT: Interactions between the heart and kidneys have been labeled as the cardiorenal syndrome (CRS). Type-5 CRS describes a disease that simultaneously damages both organs. With severe infection, systemic inflammatory mediators (TNF-α and IL-1β) cause wide-spread endothelial dysfunction, cellular apoptosis, and depressed organ function. Impaired myocardial function promotes worsening renal function and vice versa, leading to a dangerous positive feedback loop. Influenza viruses cause both myocardial and kidney injury, presumably through an immune-mediated mechanism. Herein we present a lethal case of influenza, resulting in acute type V cardiorenal syndrome. © 2013 S. Karger AG, Basel.
    Blood Purification 11/2013; 36(2):112-115. · 2.06 Impact Factor
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    ABSTRACT: Background Anemia is associated with decreased functional capacity, reduced quality of life, and worsened outcomes among patients with heart failure (HF) due to reduced left ventricular ejection fraction (HFREF). We sought to evaluate the independent effect of anemia on clinical outcomes among those with HFREF. HypothesisAnemia is associated with cardiovascular events in patients with heart failure. Methods The HF-ACTION trial was a prospective, randomized trial of exercise therapy vs usual care in 2331 patients with HFREF. Patients with New York Heart Association class II to IV HF and left ventricular ejection fractions of ≤35% were recruited. Hemoglobin (Hb) was measured up to 1 year prior to entry and was stratified by quintile. Anemia was defined as baseline Hb <13 g/dL and <12 g/dL in men and women, respectively. Hemoglobin was assessed in 2 models: a global prediction model that had been previously developed, and a modified model including variables associated with anemia and the studied outcomes. ResultsHemoglobin was available at baseline in 1763 subjects (76% of total study population); their median age was 59.0 years, 73% were male, and 62% were Caucasian. The prevalence of anemia was 515/1763 (29%). Older age, female sex, African American race, diabetes, hypertension, and lower estimated glomerular filtration rates were all more frequent in lower Hb quintiles. Over a median follow-up of 30 months, the primary outcome of all-cause mortality or all-cause hospitalization occurred in 78% of those with anemia and 64% in those without (P < 0.001). The secondary outcomes of all-cause mortality alone,cardiovascular (CV) mortality or CV hospitalization, and CV mortality or HF hospitalization occurred in 23% vs 15%, 67% vs 54%, and 44 vs 29%, respectively (P < 0.001). Heart failure hospitalizations occurred in 36% vs 22%, and urgent outpatient visits for HF exacerbations occurred in 67% and 55%, respectively (P < 0.001). For the global model, there was an association observed for anemia and all-cause mortality or hospitalization (adjusted hazard ratio [HR]: 1.15, 95% confidence interval [CI]: 1.01-1.32, P = 0.04), but other outcomes were not significant at P < 0.05. In the modified model, the adjusted HR for anemia and the primary outcome of all-cause mortality or all-cause hospitalization was 1.25 (95% CI: 1.10-1.42, P < 0.001). There were independent associations between anemia and all-cause death (HR: 1.11, 95% CI: 0.87-1.42, P = 0.38), CV death or CV hospitalization (HR: 1.16, 95% CI: 1.01-1.33, P = 0.035), and CV death and HF hospitalization (HR: 1.27, 95% CI: 1.06-1.51, P = 0.008). Conclusions Anemia modestly is associated with increased rates of death, hospitalization, and HF exacerbation in patients with chronic HFREF. After adjusting for other important covariates, anemia is independently associated with an excess hazard for all-cause mortality and all-cause hospitalization. Anemia is also associated with combinations of CV death and CV/HF hospitalizations as composite endpoints.
    Clinical Cardiology 10/2013; 36(10). · 1.83 Impact Factor
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    ABSTRACT: Preparation for end-stage renal disease (ESRD) is widely acknowledged to be suboptimal in the United States. We sought to determine whether participation in a kidney disease screening and education program resulted in improved ESRD preparation and survival in 595 adults who developed ESRD after participating in the National Kidney Foundation Kidney Early Evaluation Program (KEEP), a community-based screening and education program. Non-KEEP patients were selected from a national ESRD registry and matched to KEEP participants based on demographic and clinical characteristics. The main outcomes were pre-ESRD nephrologist care, placement of permanent vascular access, use of peritoneal dialysis, pre-emptive transplant wait listing, transplantation, and mortality after ESRD. Participation in KEEP was associated with significantly higher rates of pre-ESRD nephrologist care (76.0% vs. 69.3%), peritoneal dialysis (10.3% vs. 6.4%), pre-emptive transplant wait listing (24.2% vs. 17.1%), and transplantation (9.7% vs. 6.4%) but not with higher rates of permanent vascular access (23.4% vs. 20.1%). Participation in KEEP was associated with a lower risk for mortality (hazard ratio 0.80), but this was not statistically significant after adjusting for ESRD preparation. Thus, participation in a voluntary community kidney disease screening and education program was associated with higher rates of ESRD preparation and survival.Kidney International advance online publication, 25 September 2013; doi:10.1038/ki.2013.369.
    Kidney International 09/2013; · 8.52 Impact Factor
  • Claudio Ronco, Peter A McCullough, Lakhmir S Chawla
    The Lancet 09/2013; 382(9896):939-40. · 39.06 Impact Factor
  • Peter A McCullough, Krittapoom Akrawinthawong
    Journal of the American College of Cardiology 08/2013; · 14.09 Impact Factor
  • Source
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    ABSTRACT: Background: Recombinant erythropoietin has become a routine component of care of patients with chronic kidney disease reducing the need for blood transfusions but raising the risks for cardiovascular events. We undertook this secondary analysis of subjects enrolled in the Correction of Hemoglobin and Outcomes in Renal Insufficiency (CHOIR) trial to examine the interrelationships between epoetin-alfa maintenance doses utilized and achieved hemoglobin (Hb) irrespective of treatment target and randomized allocation. Methods: We performed a post hoc analysis from the CHOIR trial. Inclusion criteria were Hb <11.0 g/dl and estimated glomerular filtration rates of 15-50 ml/min/1.73 m(2). To be included in the present analysis, subjects needed to be free of the composite event at 4 months, receive epoetin-alfa, and have ≥1 postbaseline Hb measurement. The mean weekly dose of epoetin-alfa received up to the time of first event or censure was the main exposure variable, while the achieved Hb at month 4 was the confounder representing the subject's underlying response to treatment. The primary outcome was the composite of death, heart failure hospitalization, stroke, or myocardial infarction. A Cox proportional hazard regression model was used in time-to-event analysis. Results: Among 1,244 subjects with complete data, the average weekly dose of epoetin-alfa ranged 143.3-fold from 133 to 19,106 units/week at the time of first event or censure. Cox proportional hazard analysis found that those in the middle tertile of Hb achieved (>11.5 to <12.7 g/dl) and the lowest tertile of epoetin-alfa dose exposure level (<5,164 units/week) had the lowest risk. Irrespective of Hb achieved, the relative risk in the highest tertile (>10,095 units/week) of epoetin-alfa dose exposure level was significantly escalated (hazard ratios ranged from 2.536 to 3.572, p < 0.05, when compared to the group of middle Hb tertile and lowered dose tertile). In a multivariable model that adjusted for achieved Hb, albumin, cholesterol, age, prior heart failure, prior stroke, prior deep venous thrombosis, atrial fibrillation or malignancy, the average weekly dose had a significant (p = 0.005) relative risk of 1.067 per 1,000 units of epoetin-alfa for the primary end point. Conclusions: In the CHOIR trial, average epoetin-alfa doses >10,095 units/week were associated with increased risks for cardiovascular events irrespective of the Hb achieved within the first 4 months of treatment. These data suggest the weekly epoetin-alfa dose and not the Hb achieved was a principal determinant in the primary outcome observed implicating a cardiovascular toxicity of this erythrocyte-stimulating agent.
    American Journal of Nephrology 05/2013; 37(6):549-558. · 2.62 Impact Factor

Publication Stats

12k Citations
1,898.69 Total Impact Points

Institutions

  • 2014
    • Baylor Hamilton Heart and Vascular Hospital
      Dallas, Texas, United States
  • 2013
    • Otto-von-Guericke-Universität Magdeburg
      Magdeburg, Saxony-Anhalt, Germany
    • Ghent University
      Gand, Flanders, Belgium
    • University of Tennessee
      Knoxville, Tennessee, United States
  • 2011–2013
    • St. John's Medical Center
      Jackson, Wyoming, United States
    • State University of New York Downstate Medical Center
      Brooklyn, New York, United States
    • Northern New England Cardiovascular Research Study Group
      Lebanon, New Hampshire, United States
    • Oakland University
      • William Beaumont School of Medicine
      Rochester, MI, United States
  • 2010–2013
    • Cedars-Sinai Medical Center
      • • Division of Cardiology
      • • Cedars Sinai Medical Center
      Los Angeles, California, United States
    • St. John Providence Health System
      Detroit, Michigan, United States
    • University of Alberta
      • Division of Critical Care Medicine
      Edmonton, Alberta, Canada
    • Mount Sinai School of Medicine
      • Department of Medicine
      Manhattan, NY, United States
    • London Health Sciences Centre
      • Division of Nephrology
      London, Ontario, Canada
    • Beaumont Health System
      Detroit, Michigan, United States
    • National University (California)
      San Diego, California, United States
    • Columbia University
      • Division of Nephrology
      New York City, NY, United States
  • 2009–2013
    • University of Washington Seattle
      • Division of General Internal Medicine
      Seattle, Washington, United States
    • Baystate Medical Center
      Springfield, Massachusetts, United States
    • University of Chicago
      • Department of Medicine
      Chicago, IL, United States
    • Akershus universitetssykehus
      Kristiania (historical), Oslo County, Norway
  • 2002–2013
    • University of California, San Diego
      • • Department of Medicine
      • • Division of Cardiology
      San Diego, CA, United States
  • 2012
    • St. Luke's Hospital (MO, USA)
      Saint Louis, Michigan, United States
    • Saint Luke's Hospital (NY, USA)
      New York City, New York, United States
    • Temple University
      Philadelphia, Pennsylvania, United States
    • San Bortolo Hospital
      Vicenza, Veneto, Italy
    • Christiana Care Health System
      Wilmington, Delaware, United States
  • 2011–2012
    • Washington University in St. Louis
      San Luis, Missouri, United States
  • 2002–2012
    • University of Missouri
      • Department of Internal Medicine
      Columbia, MO, United States
  • 1997–2012
    • William Beaumont Army Medical Center
      El Paso, Texas, United States
  • 2010–2011
    • Tufts Medical Center
      • Division of Nephrology
      Boston, Massachusetts, United States
  • 2008–2011
    • University of California, Los Angeles
      • Division of General Internal Medicine and Health Services Research
      Los Angeles, California, United States
    • Eastern Virginia Medical School
      • School of Medicine
      Norfolk, VA, United States
  • 2003–2010
    • University of Texas Southwestern Medical Center
      • Department of Internal Medicine
      Dallas, Texas, United States
  • 2006
    • CSU Mentor
      Long Beach, California, United States
    • Air Force Research Laboratory
      Washington, Washington, D.C., United States
    • Southeast Renal Research Institute
      Chattanooga, Tennessee, United States
    • University of Oslo
      • Division of Medicine
      Oslo, Oslo, Norway
    • Università degli Studi di Trieste
      Trst, Friuli Venezia Giulia, Italy
    • Hennepin County Medical Center
      Minneapolis, Minnesota, United States
    • Universitair Ziekenhuis Ghent
      Gand, Flanders, Belgium
  • 2001–2006
    • Truman Medical Center
      Kansas City, Kansas, United States
    • Lenox Hill Hospital
      New York City, New York, United States
  • 2005
    • Hôpital Bichat - Claude-Bernard (Hôpitaux Universitaires Paris Nord Val de Seine)
      Lutetia Parisorum, Île-de-France, France
    • Rush University Medical Center
      • Department of Preventive Medicine
      Chicago, IL, United States
    • San Francisco VA Medical Center
      San Francisco, California, United States
  • 2004–2005
    • Oslo University Hospital
      • Department of Cardiology
      Kristiania (historical), Oslo County, Norway
    • St. Luke's Hospital
      Cedar Rapids, Iowa, United States
    • Good Samaritan Hospital
      Suffern, New York, United States
    • Hartford Hospital
      • Department of Pathology and Laboratory Medicine
      Hartford, CT, United States
    • Mayo Clinic - Rochester
      • Department of Cardiovascular Diseases
      Rochester, Minnesota, United States
  • 2001–2005
    • University of Missouri - Kansas City
      • • School of Medicine
      • • Department of Internal Medicine
      Kansas City, MO, United States
  • 1998–2005
    • Henry Ford Health System
      • • Department of Emergency Medicine
      • • Department of Internal Medicine
      Detroit, Michigan, United States
  • 1999–2003
    • Henry Ford Hospital
      • • Department of Emergency Medicine
      • • Department of Internal Medicine
      Detroit, Michigan, United States
  • 2000–2001
    • Albany Medical College
      • Division of Cardiology
      Albany, NY, United States