Ravi V Shah

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

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Publications (85)475.24 Total impact

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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. · 3.12 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;
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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;
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    ABSTRACT: -Strategies for prevention of sudden cardiac death (SCD) focus on severe left ventricular (LV) dysfunction, though most SCD post-myocardial infarction occurs in patients with mild/moderate LV dysfunction. We tested the hypothesis that infarct heterogeneity by cardiac magnetic resonance (CMR) is associated with mortality beyond left ventricular ejection fraction (LVEF) in patients with coronary artery disease (CAD) and LV dysfunction. In addition, we examined the association between infarct heterogeneity and mortality in those with LVEF>35%.
    Circulation Cardiovascular Imaging 10/2014; · 5.80 Impact Factor
  • Ravi V Shah, Michael M Givertz
    Journal of cardiac failure. 09/2014;
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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; · 7.90 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; · 3.90 Impact Factor
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    ABSTRACT: -While pulmonary vein isolation (PVI) 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 (CMR) has a strong association with late recurrent AF following PVI.
    Circulation Cardiovascular Imaging 06/2014; · 5.80 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; · 6.87 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; · 14.29 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; · 2.36 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. · 4.65 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. · 1.17 Impact Factor
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    ABSTRACT: Diabetes and insulin resistance have a variety of detrimental effects on cardiovascular health and outcomes. Cardiac magnetic resonance offers a non-invasive means to obtain many layers of information at a tissue level, including fibrosis, edema, intramyocardial motion, triglyceride content, and myocardial energetics. The role of cardiovascular magnetic resonance is particularly important in the evaluation of recognized and unrecognized coronary artery disease. In this review, we address the current state-of-the-art in cardiac magnetic resonance imaging - for both clinical and investigational use - as it applies to diabetic cardiovascular disease.
    Current Cardiology Reports 02/2014; 16(2):449.
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    ABSTRACT: Right heart failure is poorly understood and treated. In left heart failure, ventricular restraint can reverse pathologic left ventricular remodeling. The effect of restraint in right heart failure, however, is not known. We hypothesize that ventricular restraint can be applied selectively to the right ventricle (RV) to promote RV reverse remodeling. Right heart failure was induced by right coronary artery ligation in a sheep model. Eight weeks later, a saline-filled epicardial balloon was placed around the RV surface for restraint. Restraint level was defined by measuring balloon luminal pressure at end-diastole. Maximum balloon pressure was determined by the amount of balloon pressure required to decrease systemic mean arterial pressure by 10 mm Hg. We determined end-diastolic transmural myocardial pressure, indices of myocardial oxygen consumption, and RV diastolic compliance at 4 different restraint levels. After coronary ligation, RV ejection fraction (EF) decreased from 0.574 ± 0.04 to 0.362 ± 0.03 (p < 0.05). End-diastolic RV volume increased from 70.8 mL/m(2) ± 9 to 82.2 mL/m(2) ± 7 (p < 0.05) by magnetic resonance imaging. After application of restraint to the RV only, RV transmural pressure decreased significantly by 27%. Greater levels of restraint also improved RV EF (0.347 ± 0.06 to 0.473 ± 0.05) but did not change RV end-diastolic volume. A model of ischemic right heart failure was successfully created. Selective RV restraint results in improved mechanical efficiency, decreased wall stress, and improved EF. The benefits of restraint in right heart failure warrant further investigation.
    The Annals of thoracic surgery 01/2014; · 3.45 Impact Factor
  • Circulation Heart Failure 01/2014; 7(1):203-14. · 6.68 Impact Factor
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    ABSTRACT: Objectives This study sought to define the relationship between body mass index (BMI) and mortality in heart failure (HF) across the world and to identify specific groups in whom BMI may differentially mediate risk. Background Obesity is associated with incident HF, but it is paradoxically associated with better prognosis during chronic HF. Methods We studied 6,142 patients with acute decompensated HF from 12 prospective observational cohorts followed-up across 4 continents. Primary outcome was all-cause mortality. Cox proportional hazards models and net reclassification index described associations of BMI with all-cause mortality. Results Normal-weight patients (BMI 18.5 to 25 kg/m2) were older with more advanced HF and lower cardiometabolic risk. Despite worldwide heterogeneity in clinical features across obesity categories, a higher BMI remained associated with decreased 30-day and 1-year mortality (11% decrease at 30 days; 9% decrease at 1 year per 5 kg/m2; p < 0.05), after adjustment for clinical risk. The BMI obtained at index admission provided effective 1-year risk reclassification beyond current markers of clinical risk (net reclassification index 0.119, p < 0.001). Notably, the “protective” association of BMI with mortality was confined to persons with older age (>75 years; hazard ratio [HR]: 0.82; p = 0.006), decreased cardiac function (ejection fraction <50%; HR: 0.85; p < 0.001), no diabetes (HR: 0.86; p < 0.001), and de novo HF (HR: 0.89; p = 0.004). Conclusions A lower BMI is associated with age, disease severity, and a higher risk of death in acute decompensated HF. The “obesity paradox” is confined to older persons, with decreased cardiac function, less cardiometabolic illness, and recent-onset HF, suggesting that aging, HF severity/chronicity, and metabolism may explain the obesity paradox.
    Journal of the American College of Cardiology 01/2014; 63(8):778–785. · 14.09 Impact Factor
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    ABSTRACT: 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).
    Journal of the American Heart Association. 01/2014; 3(3).
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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 01/2014; · 4.44 Impact Factor
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    ABSTRACT: We tested whether myocardial extracellular volume (ECV) is increased in patients with hypertension and atrial fibrillation (AF) undergoing pulmonary vein isolation and whether there is an association between ECV and post-procedural recurrence of AF. Hypertension is associated with myocardial fibrosis, an increase in ECV, and AF. Data linking these findings are limited. T1 measurements pre-contrast and post-contrast in a cardiac magnetic resonance (CMR) study provide a method for quantification of ECV. Consecutive patients with hypertension and recurrent AF referred for pulmonary vein isolation underwent a contrast CMR study with measurement of ECV and were followed up prospectively for a median of 18 months. The endpoint of interest was late recurrence of AF. Patients had elevated left ventricular (LV) volumes, LV mass, left atrial volumes, and increased ECV (patients with AF, 0.34 ± 0.03; healthy control patients, 0.29 ± 0.03; p < 0.001). There were positive associations between ECV and left atrial volume (r = 0.46, p < 0.01) and LV mass and a negative association between ECV and diastolic function (early mitral annular relaxation [E'], r = -0.55, p < 0.001). In the best overall multivariable model, ECV was the strongest predictor of the primary outcome of recurrent AF (hazard ratio: 1.29; 95% confidence interval: 1.15 to 1.44; p < 0.0001) and the secondary composite outcome of recurrent AF, heart failure admission, and death (hazard ratio: 1.35; 95% confidence interval: 1.21 to 1.51; p < 0.0001). Each 10% increase in ECV was associated with a 29% increased risk of recurrent AF. In patients with AF and hypertension, expansion of ECV is associated with diastolic function and left atrial remodeling and is a strong independent predictor of recurrent AF post-pulmonary vein isolation.
    JACC. Cardiovascular imaging 11/2013; · 14.29 Impact Factor

Publication Stats

597 Citations
475.24 Total Impact Points

Institutions

  • 2014
    • Beth Israel Deaconess Medical Center
      Boston, Massachusetts, United States
  • 2007–2014
    • Massachusetts General Hospital
      • • Division of Cardiology
      • • Department of Medicine
      Boston, Massachusetts, United States
  • 2006–2014
    • Harvard Medical School
      • Department of Medicine
      Boston, Massachusetts, United States
    • Brigham and Women's Hospital
      • • Division of Cardiac Surgery
      • • Department of Medicine
      • • Center for Brain Mind Medicine
      Boston, Massachusetts, United States
  • 2013
    • Beverly Hospital, Boston MA
      Beverly, Massachusetts, United States
    • St. James's Hospital
      Dublin, Leinster, Ireland
  • 2012
    • Joslin Diabetes Center
      Boston, Massachusetts, United States