Jerome L Fleg

National Heart, Lung, and Blood Institute, 베서스다, Maryland, United States

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Publications (292)2206.21 Total impact

  • [Show abstract] [Hide abstract]
    ABSTRACT: Aims: While mineralocorticoid receptor antagonists (MRAs) have been shown to benefit patients with reduced left ventricular ejection fraction (LVEF), spironolactone did not reduce the primary endpoint of cardiovascular death, heart failure hospitalization, or aborted cardiac arrest in patients with heart failure with preserved ejection fraction (HFpEF) in the TOPCAT trial, which enrolled patients with LVEF of 45% or greater. We utilized data from TOPCAT to assess the relationship between LVEF as well as outcomes and efficacy of spironolactone. Methods and results: We assessed differences in baseline characteristics and outcomes across LVEF categories in 3444 patients with HFpEF, and determined whether LVEF modified the treatment effect of spironolactone. Ejection fraction ranged from 44 to 85%. Patients with higher ejection fraction were older, more likely to be female, less likely to have a history of myocardial infarction, and more likely to have a history of hypertension and diabetes. The incidence of the primary endpoint and cardiovascular death was highest in patients at the lower end of the ejection fraction spectrum. Ejection fraction modified the spironolactone treatment effect, particularly in the patients enrolled in the Americas, for the primary outcome (P = 0.046) and for heart failure hospitalization (P = 0.039), with stronger estimated benefits of spironolactone at the lower end of the ejection fraction spectrum with respect to the primary endpoint (LVEF <50%: HR 0.72, 95% CI 0.50, 1.05; LVEF ≥60%: HR 0.97, 95% CI 0.76, 1.23) and heart failure hospitalization (LVEF <50%: HR 0.76, 95% CI 0.46, 1.27; LVEF ≥60%: HR 0.98, 95% CI 0.74, 1.30). Conclusion: In patients with HFpEF enrolled in TOPCAT, patient characteristics and outcomes varied substantially by LVEF. The potential efficacy of spironolactone was greatest at the lower end of the LVEF spectrum. Clinicaltrialsgov number: NCT00094302.
    European Heart Journal 09/2015; DOI:10.1093/eurheartj/ehv464 · 15.20 Impact Factor
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    ABSTRACT: Aerobic exercise training in sedentary individuals improves physical fitness and various cardiovascular (CV) biomarkers. Nevertheless, there has been controversy as to whether exercise training may adversely affect some biomarkers in a small segment of the population. The purpose of this study was to investigate whether clinically significant worsening of CV biomarkers was more prevalent among individuals randomized to a supervised endurance training program as compared to those randomized to a control condition. Baseline and end of study measurements of fasting insulin (FI), triglycerides (TG), resting systolic blood pressure (SBP), and HDL-cholesterol (HDL-C) were obtained on 1188 healthy sedentary subjects from four clinical studies. Each study randomized subjects to 4- to 6-month supervised aerobic exercise programs or to a control group of no supervised exercise training. For each of the 4 CV biomarkers, we calculated the respective proportions of control and exercise group subjects whose baseline-to-followup changes were greater than or equal to previously reported adverse change (AC) thresholds. Those thresholds were increases of ≥ 24 pmol[BULLET OPERATOR]Lfor FI, ≥ 0.42 mmol[BULLET OPERATOR]L for TG, ≥ 10 mm Hg for SBP, and a decrease of ≥ 0.12 mmol[BULLET OPERATOR]L for HDL-C. The respective proportions of subjects meeting the AC threshold in the control and exercise groups were 15.2% vs. 9.6% (p=0.02) for FI, 14.9% vs. 13.1% (p=0.37) for TG, 16.9% vs. 15.8% (p=0.52) for SBP, and 28.6% vs. 22.5% (p=0.03) for HDL-C. All were nonsignificant at the 0.0125 Bonferroni threshold adjusting for multiple comparisons. These findings do not support the concept that aerobic exercise training increases the risk of adverse changes in the CV biomarkers we studied.
    Medicine and science in sports and exercise 08/2015; DOI:10.1249/MSS.0000000000000752 · 3.98 Impact Factor
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    ABSTRACT: The beneficial effects of physical activity (PA) are well documented, yet the mechanisms by which PA prevents disease and improves health outcomes are poorly understood. To identify major gaps in knowledge and potential strategies for catalyzing progress in the field, the NIH convened a workshop in late October 2014 entitled "Understanding the Cellular and Molecular Mechanisms of Physical Activity-Induced Health Benefits." Presentations and discussions emphasized the challenges imposed by the integrative and intermittent nature of PA, the tremendous discovery potential of applying "-omics" technologies to understand interorgan crosstalk and biological networking systems during PA, and the need to establish an infrastructure of clinical trial sites with sufficient expertise to incorporate mechanistic outcome measures into adequately sized human PA trials. Identification of the mechanisms that underlie the link between PA and improved health holds extraordinary promise for discovery of novel therapeutic targets and development of personalized exercise medicine. Copyright © 2015 Elsevier Inc. All rights reserved.
    Cell metabolism 06/2015; 22(1). DOI:10.1016/j.cmet.2015.05.011 · 17.57 Impact Factor
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    ABSTRACT: -Although studies have shown that depression is associated with worse outcomes in heart failure (HF) patients, most studies have been in White patients. The impact of depression on outcomes in African Americans (AAs) with HF has not been studied. -We analyzed 747 AAs and 1,420 Whites enrolled in HF-ACTION, which randomized 2,331 patients with ejection fraction ≤35% to usual care with or without exercise training. We examined the association between depressive symptoms assessed by the Beck Depression Inventory II (BDI-II) at baseline and after 3 months with all-cause mortality/hospitalization. A race by baseline BDI-II interaction was observed (P=.003) in which elevated baseline scores were associated with worse outcomes in AAs versus Whites. In AAs, the association was non-linear with a hazard ratio of 1.44 (95% CI: 1.24-1.68) when comparing the 75(th) and 25(th) percentile of BDI-II (score of 15 and 5, respectively). Among Whites, the association was linear and not significant (HR 1.08, 95% CI: 0.96-1.21). No race interaction was observed for mortality (P=.34). There was no differential association between BDI-II change and outcomes in AAs vs. Whites. In AAs, an increase in BDI-II score from baseline to 3 months was associated with increased mortality/hospitalization (HR 1.33, 95% CI: 1.12-1.57 per 10 point increase), while a decrease was not related to outcomes. -In AAs with HF, baseline symptoms of depression and worsening of symptoms over time are associated with increased all-cause mortality/hospitalization. Routine assessment of depressive symptoms in AAs with HF may help guide management. Clinical Trial Registration-URL: Unique identifier: NCT00047437.
    Circulation Heart Failure 04/2015; DOI:10.1161/CIRCHEARTFAILURE.114.001995 · 5.89 Impact Factor
  • Circulation Heart Failure 04/2015; 8(3). DOI:10.1161/HHF.0000000000000005 · 5.89 Impact Factor
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    ABSTRACT: Heart failure (HF) is a complex syndrome in which structural or functional cardiac abnormalities impair the filling of ventricles or left ventricular ejection of blood. HF disproportionately occurs in those ≥65 years of age. 1 Among the estimated 1.5 to 2 million residents in skilled nursing facilities (SNFs) in the United States, cardiovascular disease is the largest diagnostic category, and HF is common. 2,3 Despite the high prevalence of HF in SNF residents, none of the large randomized clinical trials of HF therapy included SNF residents, and very few included patients >80 years of age with complex comorbidities. Several issues make it important to address HF care in SNFs. The healthcare environment and characteristics of SNF residents are distinct from those of communitydwelling adults. Comorbid illness unrelated to HF (eg, dementia, hip fracture) increases with age >75 years, and these conditions may complicate both the initial HF diagnosis and ongoing management. 4-6 Morbidity and mortality rates are significantly increased for hospitalized older adults with HF discharged to SNFs compared with those discharged to other sites. 7Transitions between hospitals and SNFs may be problematic. 8 SNF 30-day rehospitalization rates for HF range from 27% to 43%, 7,9,10 and long-term care residents sent to the emergency department are at increased risk for hospital admission and death. 11 The purpose of this scientific statement is to provide guidance for management of HF in SNFs to improve patient-centered outcomes and reduce hospitalizations. This statement addresses unique issues of SNF care and adapts HF guidelines and other recommendations to this setting. © 2015 Elsevier, Inc. All Rights Reserved, and by the American Heart Association, Inc.
    Journal of cardiac failure 04/2015; 21(4):263-299. DOI:10.1016/j.cardfail.2015.02.007 · 3.05 Impact Factor
  • Journal of the American College of Cardiology 03/2015; 65(10):A874. DOI:10.1016/S0735-1097(15)60874-9 · 16.50 Impact Factor
  • Journal of the American College of Cardiology 03/2015; 65(10):A229. DOI:10.1016/S0735-1097(15)60229-7 · 16.50 Impact Factor
  • Journal of the American College of Cardiology 03/2015; 65(10):A1175. DOI:10.1016/S0735-1097(15)61175-5 · 16.50 Impact Factor
  • Journal of the American College of Cardiology 03/2015; 65(10):A1034. DOI:10.1016/S0735-1097(15)61034-8 · 16.50 Impact Factor
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    ABSTRACT: Whether a coronary artery calcium (CAC) scan provides added value to coronary computed tomographic angiography (CCTA) in emergency department patients with acute chest pain remains unsettled. We sought to determine the value of CAC scan in patients with acute chest pain undergoing CCTA. In the multicenter Rule Out Myocardial Infarction using Computer-Assisted Tomography (ROMICAT) II trial, we enrolled low-intermediate risk emergency department patients with symptoms suggesting acute coronary syndrome (ACS). In this prespecified subanalysis of 473 patients (54±8 years, 53% men) who underwent both CAC scanning and CCTA, the ACS rate was 8%. Overall, 53% of patients had CAC=0 of whom 2 (0.8%) developed ACS, whereas 7% had CAC>400 with 49% whom developed ACS. C-statistic of CAC>0 was 0.76, whereas that using the optimal cut point of CAC≥22 was 0.81. Continuous CAC score had lower discriminatory capacity than CCTA (c-statistic, 0.86 versus 0.92; P=0.03). Compared with CCTA alone, there was no benefit combining CAC score with CCTA (c-statistic, 0.93; P=0.88) or with selective CCTA strategies after initial CAC>0 or optimal cut point CAC≥22 (P≥0.09). Mean radiation dose from CAC acquisition was 1.4±0.7 mSv. Higher CAC scores resulted in more nondiagnostic CCTA studies although the majority remained interpretable. In emergency department patients with acute chest pain, CAC score does not provide incremental value beyond CCTA for ACS diagnosis. CAC=0 does not exclude ACS, nor a high CAC score preclude interpretation of CCTA in most patients. Thus, CAC results should not influence the decision to proceed with CCTA, and the decision to perform a CAC scan should be balanced with the additional radiation exposure required. Unique identifier: NCT01084239. © 2015 American Heart Association, Inc.
    Circulation Cardiovascular Imaging 03/2015; 8(3). DOI:10.1161/CIRCIMAGING.114.002225 · 5.32 Impact Factor
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    ABSTRACT: To the Editor:In our study showing no increase in the rate of falls with intensive blood pressure (BP) control in the ACCORD trial, Dr. Jolobe inquires whether the prevalence of orthostatic hypotension differed between the intensive and standard BP control groups. He further notes that orthostatic hypotension may not be accompanied by symptoms. The ACCORD BP trial did gather data on orthostatic BP change and dizziness on standing in a subgroup of participants. Of the 3,099 participants included in our analysis, orthostatic BP measurements and reports of dizziness or lightheadedness on standing during the measurement are available on 905 participants at baseline. We also have data on a subgroup of 607 participants who were assessed for health-related quality of life at baseline and 12 months. This included a question about dizziness on standing within the previous month.Seated and standing brachial artery BP was measured using an Omron model HEM-907 automatic sphygmomanometer. After 7 m ...
    Journal of General Internal Medicine 02/2015; 30(5). DOI:10.1007/s11606-015-3191-z · 3.45 Impact Factor
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    ABSTRACT: -Previous studies have demonstrated the psychosocial impact of Heart Failure in patients with reduced ejection fraction (EF). However, the effects on patients with preserved EF have not yet been elucidated. The present study aimed to determine the baseline characteristics of participants with Heart Failure with preserved ejection fraction (HFpEF) as it relates to impaired quality of life (QOL) and depression, identify predictors of poor QOL and depression, and determine the correlation between QOL and depression. -Among patients enrolled in the TOPCAT trial, 3400 patients completed the Kansas City Cardiomyopathy Questionnaire (KCCQ), 3395 patients completed EuroQOL 5D Visual Analog Scale (EQ-5D VAS), and 1431 patients in US and Canada completed the Patient Health Questionnaire-9. The mean summary score on the KCCQ was 54.8; and on EQ-5D VAS was 60.3; 27% of patients had moderate to severe depression. Factors associated with better KCCQ and EQ-5D VAS via multiple logistic regression analysis (MLRA) were American region, older age; no history of angina pectoris or asthma, no use of hypoglycemic agent; more activity level; and lower NYHA class. Factors associated with depression via MLRA included younger age, female gender, comorbid angina, COPD, use of a hypoglycemic agent, lower activity level, higher NYHA class, and SSRI use. There were significant correlations between each of the QOL scores and depression. -Patients with HFpEF who were younger, had higher NYHA class or comorbid angina pectoris, had lower activity levels, lived in Eastern Europe or were taking hypoglycemic agents, were more likely to have impaired QOL and depression. Clinical Trial Registration-URL: Unique identifier: NCT00094302.
    Circulation Heart Failure 02/2015; 8(2). DOI:10.1161/CIRCHEARTFAILURE.114.001838 · 5.89 Impact Factor
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    Circulation Heart Failure 01/2015; 8(1):209-20. DOI:10.1161/CIRCHEARTFAILURE.113.001420 · 5.89 Impact Factor
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    ABSTRACT: -Treatment of Preserved Cardiac Function Heart Failure With an Aldosterone Antagonist (TOPCAT) patients with heart failure and preserved left ventricular ejection fraction assigned to spironolactone did not achieve a significant reduction in the primary composite outcome (time to cardiovascular death, aborted cardiac arrest, or hospitalization for management of heart failure) compared with patients receiving placebo. In a post hoc analysis, an ≈4-fold difference was identified in this composite event rate between the 1678 patients randomized from Russia and Georgia compared with the 1767 enrolled from the United States, Canada, Brazil, and Argentina (the Americas). -To better understand this regional difference in clinical outcomes, demographic characteristics of these populations and their responses to spironolactone were explored. Patients from Russia/Georgia were younger, had less atrial fibrillation and diabetes mellitus, but were more likely to have had prior myocardial infarction or a hospitalization for heart failure. Russia/Georgia patients also had lower left ventricular ejection fraction and creatinine but higher diastolic blood pressure (all P<0.001). Hyperkalemia and doubling of creatinine were more likely and hypokalemia was less likely in patients receiving spironolactone in the Americas with no significant treatment effects in Russia/Georgia. All clinical event rates were markedly lower in Russia/Georgia, and there was no detectable impact of spironolactone on any outcomes. In contrast, in the Americas, the rates of the primary outcome, cardiovascular death, and hospitalization for heart failure were significantly reduced by spironolactone. -This post hoc analysis demonstrated greater potassium and creatinine changes and possible clinical benefits with spironolactone in patients with heart failure and preserved ejection fraction from the Americas. Clinical Trial Registration-URL: Unique identifier: NCT00094302.
    Circulation 11/2014; 131(1). DOI:10.1161/CIRCULATIONAHA.114.013255 · 14.43 Impact Factor
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    ABSTRACT: Purpose: To determine the association between nonalcoholic fatty liver disease (NAFLD) and the presence of high-risk coronary atherosclerotic plaque as assessed with coronary computed tomographic (CT) angiography. Materials and methods: This study was approved by the local ethics committees; informed consent was obtained. Patients randomized to the coronary CT angiography arm of the Rule Out Myocardial Infarction using Computer Assisted Tomography, or ROMICAT, II trial who underwent both nonenhanced CT to assess calcium score and contrast material-enhanced coronary CT angiography were included. Readers assessed coronary CT angiography images for the presence of coronary plaque, significant stenosis (≥50%), and high-risk plaque features (positive remodeling, CT attenuation < 30 HU, napkin-ring sign, spotty calcium). NAFLD was defined as hepatic steatosis at nonenhanced CT (liver minus spleen CT attenuation < 1 HU) without evidence of clinical liver disease, liver cirrhosis, or alcohol abuse. To determine the association between high-risk plaque and NAFLD, univariable and multivariable logistic regression analyses were performed, with high-risk plaque as a dependent variable and NAFLD, traditional risk factors, and extent of coronary atherosclerosis as independent variables. Results: Overall, 182 (40.9%) of 445 patients had CT evidence of NAFLD. High-risk plaque was more frequent in patients with NAFLD than in patients without NAFLD (59.3% vs 19.0%, respectively; P < .001). The association between NAFLD and high-risk plaque (odds ratio, 2.13; 95% confidence interval: 1.18, 3.85) persisted after adjusting for the extent and severity of coronary atherosclerosis and traditional risk factors. Conclusion: NAFLD is associated with advanced high-risk coronary plaque, independent of traditional cardiovascular risk factors and the extent and severity of coronary artery disease.
    Radiology 11/2014; 274(3):140933. DOI:10.1148/radiol.14140933 · 6.87 Impact Factor
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    ABSTRACT: We sought to determine if outcomes with exercise training in heart failure (HF) vary according to ventricular pacing type. Heart Failure: A Controlled Trial Investigating Outcomes of Exercise TraiNing (HF-ACTION) randomized 2331 outpatients with HF and LVEF ≤35% to usual care plus exercise training or usual care alone. We examined the relation between outcomes and randomized treatment by ventricular pacing status using Cox proportional hazards modeling. In HF-ACTION 1118 patients (48%) had an implanted cardiac rhythm device; 683 with right ventricular and 435 with biventricular pacemakers. Patients with pacing devices were older, more frequently white, and had lower peak VO2 (p<.001 for all). Peak VO2 improved similarly with training in groups with and without pacing devices. The primary composite endpoint, all-cause death or hospitalization, was reduced only in patients randomized to exercise training without a device (HR 0.79 [95% CI 0.67-.93], p=0.004; RV pacing HR 1.04 [95% CI 0.84-1.28], p=0.74; BiV pacing HR 1.05 [95% CI 0.82-1.34], p=0.72; interaction p=0.058). Exercise training may improve exercise capacity in patients with implanted cardiac devices. However, the apparent beneficial effects of exercise on hospitalization or death may be attenuated in patients with implanted cardiac devices and requires further study. Copyright © 2014 Elsevier Inc. All rights reserved.
    Journal of Cardiac Failure 10/2014; 21(1). DOI:10.1016/j.cardfail.2014.10.004 · 3.05 Impact Factor
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    ABSTRACT: This study sought to determine the multicenter reproducibility of magnetic resonance imaging (MRI) and the compatibility of different scanner platforms in assessing carotid plaque morphology and composition. A standardized multi-contrast MRI protocol was implemented at 16 imaging sites (GE: 8; Philips: 8). Sixty-eight subjects (61 ± 8 years; 52 males) were dispersedly recruited and scanned twice within 2 weeks on the same magnet. Images were reviewed centrally using a streamlined semiautomatic approach. Quantitative volumetric measurements on plaque morphology (lumen, wall, and outer wall) and plaque tissue composition [lipid-rich necrotic core (LRNC), calcification, and fibrous tissue] were obtained. Inter-scan reproducibility was summarized using the within-subject standard deviation, coefficient of variation (CV) and intraclass correlation coefficient (ICC). Good to excellent reproducibility was observed for both morphological (ICC range 0.98-0.99) and compositional (ICC range 0.88-0.96) measurements. Measurement precision was related to the size of structures (CV range 2.5-4.9 % for morphology, 36-44 % for LRNC and calcification). Comparable measurement variability was found between the two platforms on both plaque morphology and tissue composition. In conclusion, good to excellent inter-scan reproducibility of carotid MRI can be achieved in multicenter settings with comparable measurement precision between platforms, which may facilitate future multicenter endeavors that use serial MRI to monitor atherosclerotic plaque progression.
    The International Journal of Cardiovascular Imaging 09/2014; 31(1). DOI:10.1007/s10554-014-0532-7 · 1.81 Impact Factor
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    ABSTRACT: Background It is not known whether high-risk plaque, as detected by coronary computed tomography angiography (CTA), permits improved early diagnosis of acute coronary syndromes (ACS) independently to the presence of significant coronary artery disease (CAD) in patients with acute chest pain. Objectives The primary aim of this study was to determine whether high-risk plaque features, as detected by CTA in the emergency department (ED), may improve diagnostic certainty of ACS independently and incrementally to the presence of significant CAD and clinical risk assessment in patients with acute chest pain but without objective evidence of myocardial ischemia or myocardial infarction (MI). Methods We included patients randomized to the coronary CTA arm of the ROMICAT-II (Rule Out Myocardial Infarction/Ischemia Using Computer-Assisted Tomography II) trial. Readers assessed coronary CTA qualitatively for the presence of nonobstructive CAD (1% to 49% stenosis), significant CAD (≥50% or ≥70% stenosis), and the presence of at least 1 of the high-risk plaque features (positive remodeling, low <30 Hounsfield units plaque, napkin-ring sign, spotty calcium). In logistic regression analysis, we determined the association of high-risk plaque with ACS (MI or unstable angina pectoris) during the index hospitalization and whether this was independent of significant CAD and clinical risk assessment. Results Overall, 37 of 472 patients who underwent coronary CTA with diagnostic image quality (mean age 53.9 ± 8.0 years; 52.8% men) had ACS (7.8%; MI n = 5; unstable angina pectoris n = 32). CAD was present in 262 patients (55.5%; nonobstructive CAD in 217 patients [46.0%] and significant CAD with ≥50% stenosis in 45 patients [9.5%]). High-risk plaques were more frequent in patients with ACS and remained a significant predictor of ACS (odds ratio [OR]: 8.9; 95% CI: 1.8 to 43.3; p = 0.006) after adjustment for ≥50% stenosis (OR: 38.6; 95% CI: 14.2 to 104.7; p < 0.001) and clinical risk assessment (age, sex, number of cardiovascular risk factors). Similar results were observed after adjustment for ≥70% stenosis. Conclusions In patients presenting to the ED with acute chest pain but negative initial electrocardiogram and troponin, presence of high-risk plaques on coronary CTA increased the likelihood of ACS independent of significant CAD and clinical risk assessment (age, sex, and number of cardiovascular risk factors). (Multicenter Study to Rule Out Myocardial Infarction by Cardiac Computed Tomography [ROMICAT-II]; NCT01084239)
    Journal of the American College of Cardiology 08/2014; 64(7):684–692. DOI:10.1016/j.jacc.2014.05.039 · 16.50 Impact Factor
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    ABSTRACT: To the Editor: The results of the Atherothrombosis Intervention in Metabolic Syndrome with Low HDL/High Triglycerides: Impact on Global Health Outcomes (AIM-HIGH) trial were published in the Journal in 2011.(1) This study showed no incremental clinical benefit from the addition of high-dose extended-release niacin (Niaspan, AbbVie) to statin therapy during a 36-month mean follow-up period in 3414 patients who had stable atherosclerotic disease, low baseline levels of high-density lipoprotein (HDL) cholesterol, and elevated triglyceride levels. In that article, we provided data on adverse events resulting in a reduction in the dose or discontinuation of the study drug. These results were . . .
    New England Journal of Medicine 07/2014; 371(3):288-90. DOI:10.1056/NEJMc1311039 · 55.87 Impact Factor

Publication Stats

13k Citations
2,206.21 Total Impact Points


  • 2005–2015
    • National Heart, Lung, and Blood Institute
      • Division of Cardiovascular Sciences (DCVS)
      베서스다, Maryland, United States
    • Tufts University
      • Jean Mayer USDA Human Nutrition Research Center on Aging
      Georgia, United States
  • 1982–2014
    • National Institute on Aging
      • • Laboratory of Cardiovascular Science (LCS)
      • • Clinical Research Branch (CRB)
      • • Laboratory of Clinical Investigation (LCI)
      • • Human Cardiovascular Studies Unit
      • • Laboratory of Behavioral Neuroscience
      Baltimore, MD, United States
  • 2013
    • Durham University
      Durham, England, United Kingdom
    • Brigham and Women's Hospital
      • Division of Cardiovascular Medicine
      Boston, Massachusetts, United States
  • 2011
    • American College of Cardiology
      Washington, Washington, D.C., United States
  • 2009–2011
    • University of North Carolina at Charlotte
      • School of Nursing
      Charlotte, NC, United States
  • 2010
    • Henry Ford Hospital
      Detroit, Michigan, United States
  • 2001–2009
    • Duke University
      • Department of Medicine
      Durham, North Carolina, United States
  • 2008
    • National Institutes of Health
      Maryland, United States
  • 1986–2008
    • Johns Hopkins Medicine
      • Department of Medicine
      Baltimore, Maryland, United States
  • 2006
    • Cornell University
      Итак, New York, United States
  • 1987–2004
    • Johns Hopkins University
      • • Division of Cardiology
      • • Department of Environmental Health Sciences
      • • Department of Medicine
      Baltimore, MD, United States
  • 2001–2003
    • University of Maryland, College Park
      • Department of Kinesiology
      College Park, MD, United States
  • 2002
    • University of Pittsburgh
      • Department of Human Genetics
      Pittsburgh, Pennsylvania, United States
  • 1982–2001
    • University of Maryland, Baltimore
      • Department of Medicine
      Baltimore, Maryland, United States
  • 2000
    • University of Maryland Eastern Shore
      • Department of Physical Therapy
      Maryland, United States
    • Baylor University
      Waco, Texas, United States
  • 1996
    • National Institute of Aerospace
      Hampton, Virginia, United States