Ravi V Shah

Beth Israel Deaconess Medical Center, Boston, Massachusetts, United States

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Publications (101)692.1 Total impact

  • Ravi V Shah · Michael Jerosch-Herold
    Circulation Cardiovascular Imaging 08/2015; 8(8). DOI:10.1161/CIRCIMAGING.115.003901 · 6.75 Impact Factor
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    ABSTRACT: To balance competing cardiovascular benefits and metabolic risks of statins, markers of type 2 diabetes (T2D) susceptibility are needed. We sought to define a competing risk/benefit of statin therapy on T2D and cardiovascular disease (CVD) events using liver attenuation and coronary artery calcification (CAC). 3153 individuals from the Multi-Ethnic Study of Atherosclerosis (MESA) without CVD, T2D/impaired fasting glucose, or baseline statin therapy had CT imaging for CAC and hepatic attenuation (hepatic steatosis). Cox models and rates of CVD and T2D were calculated to assess the role of liver attenuation in T2D and the relative risks/benefits of statins on CVD and T2D. 216 T2D cases were diagnosed at median 9.1 years follow-up. High liver fat and statin therapy were associated with diabetes (HR 2.06 [95%CI 1.52-2.79, P < 0.0001] and 2.01 [95%CI 1.46-2.77, P < 0.0001], respectively), after multivariable adjustment. With low liver fat and CAC = 0, the number needed to treat (NNT) for statin to prevent one CVD event (NNT 218) was higher than the number needed to harm (NNH) with an incident case of T2D (NNH 68). Conversely, those with CAC >100 and low liver fat were more likely to benefit from statins for CVD reduction (NNT 29) relative to T2D risk (NNH 67). Among those with CAC >100 and fatty liver, incremental reduction in CVD with statins (NNT 40) was less than incremental risk increase for T2D (NNH 24). Liver fat is associated with incident T2D and stratifies competing metabolic/CVD risks with statin therapy. Hepatic fat may inform T2D surveillance and lipid therapeutic strategies. Copyright © 2015 Elsevier Ireland Ltd. All rights reserved.
    Atherosclerosis 07/2015; 242(1):211-217. DOI:10.1016/j.atherosclerosis.2015.07.018 · 3.97 Impact Factor
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    ABSTRACT: Visceral fat (VF) is a source of pro-inflammatory adipokines implicated in cardiac remodeling. We sought to determine the impact of visceral fat and subcutaneous fat (SQ) depots on left ventricular (LV) structure, function, and geometry in the Multi-Ethnic Study of Atherosclerosis (MESA). We performed a post-hoc analysis on 1151 participants from MESA with cardiac magnetic resonance quantification of LV mass and LV mass-to-volume ratio (LVMV, an index of concentricity) and computed tomographic-derived SQ and VF area. Multivariable regression models to estimate association between height-indexed SQ and VF area (per cm(2)/m) with height-indexed LV mass (per height(2.7)) and LVMV were constructed, adjusted for clinical, biochemical, and demographic covariates. We found that both VF and SQ area were associated with height-indexed LV mass (ρ = 0.36 and 0.12, P < 0.0001, respectively), while only VF area was associated with LVMV (ρ = 0.28, P < 0.0001). Individuals with above-median VF had lower LV ejection fraction, greater indexed LV volumes and mass, and higher LVMV (all P < 0.001). In multivariable models adjusted for weight, VF (but not SQ) area was associated with LV concentricity and LV mass index, across both sexes. Visceral adiposity is independently associated with LV concentricity, a precursor to heart failure. Further study into the role of VF in LV remodeling as a potential therapeutic target is warranted. Copyright © 2015 Elsevier B.V. All rights reserved.
    Nutrition Metabolism and Cardiovascular Diseases 04/2015; 25(7). DOI:10.1016/j.numecd.2015.03.016 · 3.88 Impact Factor
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    ABSTRACT: Objectives The aim of this study was to describe the role of contrast-enhanced cardiac magnetic resonance (CMR) in the workup of patients with aborted sudden cardiac arrest (SCA) and in the prediction of long-term outcomes. Background Myocardial fibrosis is a key substrate for SCA, and late gadolinium enhancement (LGE) on a CMR study is a robust technique for imaging of myocardial fibrosis. Methods We performed a retrospective review of all survivors of SCA who were referred for CMR studies and performed follow-up for the subsequent occurrence of an adverse event (death and appropriate defibrillator therapy). Results After a workup that included a clinical history, electrocardiogram, echocardiography, and coronary angiogram, 137 patients underwent CMR for workup of aborted SCA (66% male; mean age 56 ± 11 years; left ventricular ejection fraction 43 ± 12%). The presenting arrhythmias were ventricular fibrillation (n = 105 [77%]) and ventricular tachycardia (n = 32 [23%]). Overall, LGE was found in 98 patients (71%), with an average extent of 9.9 ± 5% of the left ventricular myocardium. CMR imaging provided a diagnosis or an arrhythmic substrate in 104 patients (76%), including the presence of an infarct-pattern LGE in 60 patients (44%), noninfarct LGE in 21 (15%), active myocarditis in 14 (10%), hypertrophic cardiomyopathy in 3 (2%), sarcoidosis in 3, and arrhythmogenic cardiomyopathy in 3. In a median follow-up of 29 months (range 18 to 43 months), there were 63 events. In a multivariable analysis, the strongest predictors of recurrent events were the presence of LGE (adjusted hazard ratio: 6.7; 95% CI: 2.38 to 18.85; p < 0.001) and the extent of LGE (hazard ratio: 1.15; 95% CI: 1.11 to 1.19; p < 0.001). Conclusions Among patients with SCA, CMR with contrast identified LGE in 71% and provided a potential arrhythmic substrate in 76%. In follow-up, both the presence and extent of LGE identified a group at markedly increased risk of future adverse events.
    JACC. Cardiovascular imaging 03/2015; 8(4). DOI:10.1016/j.jcmg.2014.11.017 · 6.99 Impact Factor
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    ABSTRACT: To measure association between hepatic fat and albuminuria (an early marker of renal injury) in individuals without diabetes or hypertension. 2,281 individuals in the Multi-Ethnic Study of Atherosclerosis without diabetes or hypertension, renal disease, or excess alcohol consumption underwent computed tomography (CT) for assessment of liver attenuation (marker of hepatic lipid content) and urinalysis (for albuminuria) at initial study visit, with assessment of incident and prevalent albuminuria by logistic regression in follow-up. After adjustment for age, gender, race, smoking, blood pressure, insulin resistance, and body mass index, individuals with less liver fat (higher liver CT attenuation) had a lower probability of having albuminuria at Exam 1 (OR per 10 unit increase in attenuation 0.77, 95 % CI 0.61-0.97, P = 0.02). At median 9.3 years follow-up, albuminuria was identified in 129 individuals were (5.8 %). In fully adjusted models (with age, smoking, body mass index, blood pressure, diabetes and hypertension as time-dependent covariates), lower liver attenuation (greater liver fat) was associated with higher risk of incident albuminuria (OR 0.79, 95 % CI 0.66-0.94, P = 0.008). Hepatic attenuation is associated with prevalent and incident albuminuria, an early, potent risk factor for renal risk in a population not clearly at risk for future renal failure.
    Journal of nephrology 02/2015; DOI:10.1007/s40620-015-0177-1 · 2.00 Impact Factor
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    ABSTRACT: Patients with left ventricular systolic dysfunction frequently show abnormal coronary vascular function, even in the absence of overt coronary artery disease. Moreover, the severity of vascular dysfunction might be related to the aetiology of cardiomyopathy. We sought to determine the incremental value of assessing coronary vascular dysfunction among patients with ischaemic (ICM) and non-ischaemic (NICM) cardiomyopathy at risk for adverse cardiovascular outcomes. Coronary flow reserve (CFR, stress/rest myocardial blood flow) was quantified in 510 consecutive patients with rest left ventricular ejection fraction (LVEF) ≤45% referred for rest/stress myocardial perfusion PET imaging. The primary end point was a composite of major adverse cardiovascular events (MACE) including cardiac death, heart failure hospitalization, late revascularization, and aborted sudden cardiac death. Median follow-up was 8.2 months. Cox proportional hazards model was used to adjust for clinical variables. The annualized MACE rate was 26.3%. Patients in the lowest two tertiles of CFR (CFR ≤ 1.65) experienced higher MACE rates than those in the highest tertile (32.6 vs. 15.5% per year, respectively, P = 0.004), irrespective of aetiology of cardiomyopathy. Impaired coronary vascular function, as assessed by reduced CFR by PET imaging, is common in patients with both ischaemic and non-ischaemic cardiomyopathy and is associated with MACE. © The Author 2015. Published by Oxford University Press on behalf of the European Society of Cardiology.
    European Heart Journal – Cardiovascular Imaging 02/2015; DOI:10.1093/ehjci/jev012 · 2.65 Impact Factor
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    ABSTRACT: We aimed to assess whether chronic obstructive pulmonary disease (COPD) is associated with expansion of the myocardial extracellular volume (ECV) using T1 measurements. Adult COPD patients Global Initiative for Chronic Obstructive Lung Disease [GOLD] stage 2 or higher and free of known cardiovascular disease were recruited. All study patients underwent measures of pulmonary function, 6-minute walk test, serum measures of inflammation, overnight polysomnography, and a contrast cardiac magnetic resonance study. Eight patients with COPD were compared with 8 healthy control subjects. The mean predicted forced expiratory volume at 1 second of COPD subjects was 68%. Compared with control subjects, patients had normal left ventricular (LV) and right ventricular size, mass, and function. However, compared with control subjects, the LV remodelling index (median, 0.87; interquartile range [IQR], 0.71-1.14; vs median, 0.62; IQR, 0.60-0.77; P ¼ 0.03) and active left atrial emptying fraction was increased (median, 46; IQR, 41-49; vs median, 38; IQR, 33-43; P ¼ 0.005), and passive left atrial emptying fraction was reduced (median, 24; IQR, 20-30; vs median, 44; IQR, 31-51; P ¼ 0.007). The ECV was increased in patients with COPD (median, 0.32; IQR, 0.05; vs median, 0.27; IQR, 0.05; P = 0.001). The ECV showed a strong positive association with LV remodelling (r = 0.72; P = 0.04) and an inverse association with the 6-minute walk duration (r = -0.79; P = 0.02) and passive left atrial emptying fraction (r = -0.68; P = 0.003). Expansion of the ECV, suggestive of diffuse myocardial fibrosis, is present in COPD and is associated with LV remodelling, and reduced left atrial function and exercise capacity. Copyright © 2014 Canadian Cardiovascular Society. Published by Elsevier Inc. All rights reserved.
    The Canadian journal of cardiology 12/2014; 30(12):1668-75. DOI:10.1016/j.cjca.2014.08.006 · 3.94 Impact Factor
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    ABSTRACT: This study sought to evaluate differential effects of visceral fat (VF) and subcutaneous fat and their effects on metabolic syndrome (MetS) risk across body mass index (BMI) categories. The regional distribution of adipose tissue is an emerging risk factor for cardiometabolic disease, although serial changes in fat distribution have not been extensively investigated. VF and its alterations over time may be a better marker for risk than BMI in normal weight and overweight or obese individuals. We studied 1,511 individuals in the MESA (Multi-Ethnic Study of Atherosclerosis) with adiposity assessment by computed tomography (CT). A total of 253 participants without MetS at initial scan underwent repeat CT (median interval 3.3 years). We used discrete Cox regression with net reclassification to investigate whether baseline and changes in VF area are associated with MetS. Higher VF was associated with cardiometabolic risk and coronary artery calcification, regardless of BMI. After adjustment, VF was more strongly associated with incident MetS than subcutaneous fat regardless of weight, with a 28% greater MetS hazard per 100 cm(2)/m VF area and significant net reclassification (net reclassification index: 0.44, 95% confidence interval [CI]: 0.29 to 0.60) over clinical risk. In individuals with serial imaging, initial VF (hazard ratio: 1.24 per 100 cm(2)/m, 95% CI: 1.08 to 1.44 per 100 cm(2)/m, p = 0.003) and change in VF (hazard ratio: 1.05 per 5% change, 95% CI: 1.01 to 1.08 per 5% change, p = 0.02) were associated with MetS after adjustment. Changes in subcutaneous fat were not associated with incident MetS after adjustment for clinical risk and VF area. VF is modestly associated with BMI. However, across BMI, a single measure of and longitudinal change in VF predict MetS, even accounting for weight changes. Visceral adiposity is essential to assessing cardiometabolic risk, regardless of age, race, or BMI, and may serve as a marker and target of therapy in cardiometabolic disease. Copyright © 2014 American College of Cardiology Foundation. Published by Elsevier Inc. All rights reserved.
    JACC Cardiovascular Imaging 11/2014; 7(12). DOI:10.1016/j.jcmg.2014.07.017 · 6.99 Impact Factor
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    ABSTRACT: A standard ("core") implementation of American College of Cardiology/American Heart Association 2013 lipid guidelines (based on 10-year risk) dramatically increases the statin-eligible population in older Americans, raising controversy in the cardiovascular community. The guidelines also endorse a more "comprehensive" risk approach based in part on lifetime risk. The impact of this broader approach on statin eligibility remains unclear. We studied the impact of 2 different implementations of the new guidelines ("core" and "comprehensive") using the National Health and Nutrition Examination Survey. Although "core" guidelines led to 72.0 million subjects qualifying for statin therapy, the broader "comprehensive" application led to nearly a twofold greater estimate for statin-eligible subjects (121.2 million), with the greatest impact among those aged 21 to 45 years. Subjects indicated for statin therapy under comprehensive guidelines had a greater burden of cardiovascular risk factors and a higher lifetime risk of cardiovascular disease than those not indicated for statins. In particular, men aged 21 to 45 years had a 3.13-fold increased odds of being eligible for statin therapy only under the "comprehensive" guidelines (vs standard "core" guidelines; 95% confidence interval 2.82 to 3.47, p <0.0001). There were no racial differences. In conclusion, the "comprehensive" approach to statin eligibility espoused by the American College of Cardiology/American Heart Association 2013 guidelines would increase the statin-eligible population to over 120 million Americans, particularly targeting younger men with high-risk factor burden. Copyright © 2014 Elsevier Inc. All rights reserved.
    The American Journal of Cardiology 10/2014; 115(1). DOI:10.1016/j.amjcard.2014.09.045 · 3.43 Impact Factor
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    ABSTRACT: We investigated the association between major adverse cardiovascular events (MACE) and inducible ischemia on regadenoson cardiac magnetic resonance myocardial perfusion imaging (CMRMPI) performed at 3.0-Tesla. Regadenoson stress CMRMPI is increasingly used to assess patients with suspected ischemia; however, its values in patient prognostication and risk reclassification are only emerging. We studied 346 patients with suspected ischemia who were referred for regadenoson CMR. We determined the prognostic association of presence of inducible ischemia by CMR with major adverse cardiac events (MACE). In addition, we assessed the extent of net reclassification improvement (NRI) by CMR beyond a clinical risk model. There were 52 MACE during a median follow-up of 1.9 years. Patients with inducible ischemia were four-fold more likely to experience MACE (HR=4.14, 95% CI 2.37-7.24, P<0.0001). In the best overall model, presence of inducible ischemia conferred a 2.6-fold increased hazard to MACE adjusted to known clinical risk markers (adjusted HR 2.59, 95% CI 1.30-5.18, P=0.0069). Individuals with no inducible ischemia experienced a low rate of cardiac death and MI (0.6% per patient year), while individuals with inducible ischemia had an annual event rate of 3.2%. NRI across risk categories (low <5%, intermediate 5-10%, and high >10%) by CMR was 0.29 [95%CI 0.15-0.44] and continuous NRI was 0.58. In conclusion, patients with a clinical suspicion of myocardial ischemia, regadenoson stress CMRMPI provides robust risk stratification. A CMRMPI negative for ischemia was associated with very low annual rate of hard cardiac events. In addition, CMRMPI provides effective risk reclassification in a substantial proportion of patients.
    Journal of Cardiovascular Magnetic Resonance 10/2014; 114(8). DOI:10.1016/j.amjcard.2014.07.041 · 5.11 Impact Factor
  • Ravi V Shah · Michael M Givertz
    Journal of Cardiac Failure 09/2014; 20(12). DOI:10.1016/j.cardfail.2014.09.009 · 3.07 Impact Factor
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    ABSTRACT: Reduced coronary flow reserve (CFR), an indicator of coronary microvascular dysfunction, is seen in type 2 diabetes mellitus (T2DM) and predicts cardiac mortality. Since aldosterone plays a key role in vascular injury, the aim of this study was to determine whether mineralocorticoid receptor (MR) blockade improves CFR in individuals with T2DM. Sixty-four men and women with well-controlled diabetes on chronic angiotensin converting enzyme inhibition (enalapril 20 mg/day) were randomized to add-on therapy of spironolactone 25mg, hydrochlorothiazide (HCTZ) 12.5mg, or placebo for 6 months. CFR was assessed by cardiac positron emission tomography (PET) at baseline and at the end of treatment. There were significant and similar decreases in systolic blood pressure with spironolactone and HCTZ but not with placebo. CFR improved with treatment in the spironolactone group as compared with the HCTZ group and with the combined HCTZ and placebo groups. The increase in CFR with spironolactone remained significant after controlling for baseline CFR, change in BMI, race and statin use. Treatment with spironolactone improved coronary microvascular function raising the possibility that MR blockade could have beneficial effects in preventing cardiovascular disease in patients with T2DM.
    Diabetes 08/2014; 64(1). DOI:10.2337/db14-0670 · 8.47 Impact Factor
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    ABSTRACT: Impact of weight loss on cardiac structure has not been extensively investigated in large, multi-ethnic, community-based populations. We investigated the longitudinal impact of weight loss on cardiac structure by cardiac magnetic resonance (CMR).
    European Journal of Preventive Cardiology 07/2014; 16(Suppl 1). DOI:10.1177/2047487314541731 · 2.68 Impact Factor
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    ABSTRACT: Background-Although pulmonary vein isolation has become a mainstream therapy for selected patients with atrial fibrillation (AF), late recurrent AF is common and its risk factors remain poorly defined. The purpose of our study was to test the hypothesis that reduced left atrial passive emptying function (LAPEF) as determined by cardiac magnetic resonance has a strong association with late recurrent AF after pulmonary vein isolation. Methods and Results-Three hundred forty-six patients with AF referred for cardiac magnetic resonance pulmonary vein mapping before pulmonary vein isolation were included. Maximum LA volumes (VOLmax) and volumes before atrial contraction (VOLbac) were measured; LAPEF was calculated as (VOLmax-VOLbac)/VOLmax x100. Kaplan-Meier curves were constructed to determine late recurrent AF stratified by LAPEF quintile. Cox proportional hazards regression was used to adjust for known markers of recurrence. During a median follow-up of 27 months, 124 patients (35.8%) experienced late recurrent AF. Patients with recurrence were more likely to have nonparoxysmal AF (75.8% versus 51.4%; P<0.01), higher mean VOLmax (60.2 versus 52.8 mL/m(2); P<0.01), and lower mean LAPEF (19.1% versus 26.0%; P<0.01). Patients in the lowest LAPEF quintile were at highest risk of developing recurrent AF (2-year recurrence for lowest versus highest: 60.5% versus 17.3%; P<0.01). After adjusting for known predictors of recurrence, patients with low LAPEF remained significantly more likely to recur (hazard ratio for lowest versus highest quintile, 3.92; 95% confidence interval, 2.01-7.65). Conclusions-We found a strong association between LAPEF and recurrent AF after pulmonary vein isolation that persisted after multivariable adjustment.
    Circulation Cardiovascular Imaging 06/2014; 7(4). DOI:10.1161/CIRCIMAGING.113.001472 · 6.75 Impact Factor
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    ABSTRACT: Multiple guidelines and statements related to hypertension have recently been published. Much discord has arisen from discrepant treatment and target systolic blood pressure thresholds for individuals aged 60 to 79 years of <150 mm Hg in the guideline published by members assigned to the Eighth Joint National Committee and <140 mm Hg in a statement by the American Society of Hypertension and International Society of Hypertension 2013. We sought to evaluate the public health implications of these differences using data from the 2005 to 2010 National Health and Nutrition Examination Survey (NHANES) cycles. NHANES is an ongoing survey designed to allow characterization of the US population and subpopulations. We found that only ≈2.4% (95% confidence interval, 1.5-3.2%) of adults aged 60 to 79 years had indications for antihypertensive treatment under the more stringent American Society of Hypertension and International Society of Hypertension 2013 guideline but not under Eighth Joint National Committee. About 65.7% (95% confidence interval, 62.4-69.0%) of adults aged 60 to 79 years had indications for treatment under both guidelines. Furthermore, those with indications for treatment under American Society of Hypertension and International Society of Hypertension 2013 but not under Eighth Joint National Committee generally had higher systolic blood pressure and less favorable lipid profiles compared with those with indications for treatment under both guidelines. Importantly, a larger group, comprising 21.0% (95% confidence interval, 18.7-23.2%) of adults aged 60 to 79 years, had either untreated or inadequately treated hypertension and represents an important group for continued efforts.
    Hypertension 05/2014; 64(2). DOI:10.1161/HYPERTENSIONAHA.114.03703 · 7.63 Impact Factor
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    ABSTRACT: Background Nearly 50% of patients with heart failure (HF) have preserved LV ejection fraction, with interstitial fibrosis and cardiomyocyte hypertrophy as early manifestations of pressure overload. However, methods to assess both tissue characteristics dynamically and noninvasively with therapy are lacking. We measured the effects of mineralocorticoid receptor blockade on tissue phenotypes in LV pressure overload using cardiac magnetic resonance (CMR). Methods and Results Mice were randomized to l‐nitro‐ω‐methyl ester (l‐NAME, 3 mg/mL in water; n=22), or l‐NAME with spironolactone (50 mg/kg/day in subcutaneous pellets; n=21). Myocardial extracellular volume (ECV; marker of diffuse interstitial fibrosis) and the intracellular lifetime of water (τic; marker of cardiomyocyte hypertrophy) were determined by CMR T1 imaging at baseline and after 7 weeks of therapy alongside histological assessments. Administration of l‐NAME induced hypertensive heart disease in mice, with increases in mean arterial pressure, LV mass, ECV, and τic compared with placebo‐treated controls, while LV ejection fraction was preserved (>50%). In comparison, animals receiving both spironolactone and l‐NAME (“l‐NAME+S”) showed less concentric remodeling, and a lower myocardial ECV and τic, indicating decreased interstitial fibrosis and cardiomyocyte hypertrophy (ECV: 0.43±0.09 for l‐NAME versus 0.25±0.03 for l‐NAME+S, P<0.001; τic: 0.42±0.11 for l‐NAME groups versus 0.12±0.05 for l‐NAME+S group). Mice treated with a combination of l‐NAME and spironolactone were similar to placebo‐treated controls at 7 weeks. Conclusions Spironolactone attenuates interstitial fibrosis and cardiomyocyte hypertrophy in hypertensive heart disease. CMR can phenotype myocardial tissue remodeling in pressure‐overload, furthering our understanding of HF progression.
    Journal of the American Heart Association 04/2014; 3(3). DOI:10.1161/JAHA.114.000790 · 2.88 Impact Factor
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    ABSTRACT: This study sought to determine feasibility and prognostic performance of stress cardiac magnetic resonance (CMR) in obese patients (body mass index [BMI] ≥30 kg/m(2)). Current stress imaging methods remain limited in obese patients. Given the impact of the obesity epidemic on cardiovascular disease, alternative methods to effectively risk stratify obese patients are needed. Consecutive patients with a BMI ≥30 kg/m(2) referred for vasodilating stress CMR were followed for major adverse cardiovascular events (MACE), defined as cardiac death or nonfatal myocardial infarction. Univariable and multivariable Cox regressions for MACE were performed to determine the prognostic association of inducible ischemia or late gadolinium enhancement (LGE) by CMR beyond traditional clinical risk indices. Of 285 obese patients, 272 (95%) completed the CMR protocol, and among these, 255 (94%) achieved diagnostic imaging quality. Mean BMI was 35.4 ± 4.8 kg/m(2), with a maximum weight of 200 kg. Reasons for failure to complete CMR included claustrophobia (n = 4), intolerance to stress agent (n = 4), poor gating (n = 4), and declining participation (n = 1). Sedation was required in 19 patients (7%; 2 patients with intravenous sedation). Sixteen patients required scanning by a 70-cm-bore system (6%). Patients without inducible ischemia or LGE experienced a substantially lower annual rate of MACE (0.3% vs. 6.3% for those with ischemia and 6.7% for those with ischemia and LGE). Median follow-up of the cohort was 2.1 years. In a multivariable stepwise Cox regression including clinical characteristics and CMR indices, inducible ischemia (hazard ratio 7.5; 95% confidence interval: 2.0 to 28.0; p = 0.002) remained independently associated with MACE. When patients with early coronary revascularization (within 90 days of CMR) were censored on the day of revascularization, both presence of inducible ischemia and ischemia extent per segment maintained a strong association with MACE. Stress CMR is feasible and effective in prognosticating obese patients, with a very low negative event rate in patients without ischemia or infarction.
    JACC. Cardiovascular imaging 04/2014; 7(5). DOI:10.1016/j.jcmg.2013.11.011 · 6.99 Impact Factor
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    ABSTRACT: Obesity is associated with the development of atrial fibrillation (AF), and both obesity and AF are independently associated with the development of heart failure with preserved ejection fraction. We tested the hypothesis that sleep apnea (SA) would have a body mass index (BMI) independent association with adverse left ventricular (LV) remodeling and clinical outcomes in patients with AF and preserved LV function. From 720 consecutive patients with AF, 403 patients without myocardial disease (preserved LV function) were identified and followed up for 3.3 ± 1.5 years. The primary outcome was a combination of all-cause mortality/heart failure hospitalization. Left ventricular mass and LV mass-to-volume ratio were higher in patients with SA and obesity (P < .0001 for all). Body mass index (β per log = .47; P < .0001) and SA (β = .05; P = .045) were independently associated with LV mass index. Patients with treated SA had a lower LV mass index (but not LV mass-to-volume ratio) compared with untreated (P = .002). In a best overall multivariable model, SA therapy (β = -.129; P = .001) and BMI (β per log = .373; P = .0007) had opposing associations with LV mass index. Sleep apnea (hazard ratio [HR] = 2.94; P = .0004) and BMI (HR per 1 kg/m(2) = 1.08; P = .004) were associated with clinical outcome in unadjusted analysis. Only SA was associated with clinical outcome in a best overall multivariable model (HR = 2.14; P = .02). Sleep apnea and obesity are independently associated with adverse LV remodeling and clinical outcomes in patients with preserved LV function, whereas continuous positive airway pressure therapy is associated with a beneficial effect on LV remodeling. Research investigating SA therapies in patients at high risk for LV remodeling and heart failure is warranted.
    American heart journal 04/2014; 167(4):620-6. DOI:10.1016/j.ahj.2014.01.002 · 4.56 Impact Factor
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    ABSTRACT: Emerging literature suggests that obesity may be “protective” against mortality and cardiovascular outcomes, while dysglycemia may worsen outcomes regardless of obesity. The authors measured the association of weight, smoking, and glycemia with mortality in the Antihypertensive and Lipid-Lowering Treatment to Prevent Heart Attack Trial (ALLHAT). Among 5423 ALLHAT participants without established diabetes or cardiovascular disease, 3980 (73%) had normal fasting glucose and 1443 (27%) had impaired fasting glucose (IFG) levels at study entry. After a median of 4.9 years follow-up, 554 (10%) had died (37% cardiovascular). IFG was associated with higher all-cause mortality (adjusted hazard ratio [HR], 1.23; 95% confidence interval [CI], 1.02–1.50), while obesity was associated with lower all-cause mortality (adjusted HR, 0.76; 95% CI, 0.60–0.96). However, after excluding underweight individuals (body mass index [BMI] <22 kg/m2) and smokers, neither obesity nor IFG was associated with all-cause mortality, but IFG identifies individuals at greater risk in the nonobese population. Although obesity appeared protective against mortality, this association was not significant in never-smokers or after exclusion of BMI <22 kg/m2. The obesity paradox may result from confounding by a sicker, underweight referent population and smoking.
    Journal of Clinical Hypertension 04/2014; 16(6). DOI:10.1111/jch.12325 · 2.96 Impact Factor
  • Ravi V Shah · James L Januzzi
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    ABSTRACT: Circulating biomarkers that directly reflect disease progression, hemodynamics, and ventricular remodeling at a molecular level are critical to risk stratification in heart failure (HF), affording unique insights into pathophysiology not fully captured by traditional risk markers. Despite the wealth of data confirming the importance of natriuretic peptides in HF diagnosis and prognosis, residual clinical risk in HF suggests that additional biomarkers complementary to natriuretic peptides may be useful. In this article, the current literature addressing the role of these biomarkers in the clinical diagnosis and risk stratification in HF is summarized.
    Clinics in laboratory medicine 03/2014; 34(1):87-97. DOI:10.1016/j.cll.2013.11.009 · 1.35 Impact Factor

Publication Stats

1k Citations
692.10 Total Impact Points

Institutions

  • 2014–2015
    • Beth Israel Deaconess Medical Center
      • CardioVascular Institute
      Boston, Massachusetts, United States
  • 2012–2015
    • Brigham and Women's Hospital
      • • Department of Medicine
      • • Division of Cardiac Surgery
      Boston, Massachusetts, United States
  • 2009–2014
    • Massachusetts General Hospital
      • • Department of Medicine
      • • Division of Cardiology
      Boston, Massachusetts, United States
    • University of Wisconsin–Madison
      Madison, Wisconsin, United States
  • 2008–2014
    • Harvard University
      Cambridge, Massachusetts, United States
  • 2006–2014
    • Harvard Medical School
      • Department of Medicine
      Boston, Massachusetts, United States
  • 2013
    • St. James's Hospital
      Dublin, Leinster, Ireland