Annapoorna S Kini

Icahn School of Medicine at Mount Sinai, Borough of Manhattan, New York, United States

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Publications (138)841.41 Total impact

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    ABSTRACT: Background: The optimal duration of dual antiplatelet therapy (DAPT) after drug-eluting stent (DES) implantation is unclear, and its risks and benefits may vary according to DES generation. Objectives: The goal of this study was to evaluate safety and efficacy of DAPT after DES implantation. Methods: We included randomized controlled trials (RCTs), which tested different duration of DAPT after DES implantation: shorter DAPT (S-DAPT) defined as the per-protocol minimum duration of DAPT after the procedure and longer DAPT (L-DAPT) defined as the per-protocol period of more prolonged DAPT. Primary efficacy and safety outcomes were definite/probable stent thrombosis (ST) and clinically significant bleeding (CSB), respectively. Results: Ten RCTs (n = 32,135) were included. Compared with L-DAPT, S-DAPT had an overall higher rate of ST (odds ratio [OR]: 1.71; 95% confidence interval [CI]: 1.26-2.32; p = 0.001). The effect on ST of S-DAPT was attenuated with use of second-generation DES (OR: 1.54; 95% CI: 0.96-2.47) compared with use of first-generation DES (OR: 3.94, 95% CI: 2.20-7.05; p for interaction = 0.008). S-DAPT had an overall significantly lower risk of CSB (OR: 0.63; 95% CI: 0.52-0.75; p < 0.001). Finally, a numerically lower all-cause mortality was observed with S-DAPT (OR: 0.87; 95%CI: 0.74-1.01; p = 0.073). Conclusions: S-DAPT had overall lower rates of bleeding yet higher rates of ST compared with L-DAPT; the latter effect was significantly attenuated with use of second-generation DES, although this analysis may have been limited by the different DAPT durations among studies. All-cause mortality was numerically higher with L-DAPT without reaching statistical significance. Prolonging DAPT requires careful assessment of the trade-off between ischemic and bleeding complications.
    Journal of the American College of Cardiology 02/2015; DOI:10.1016/j.jacc.2015.01.039 · 15.34 Impact Factor
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    ABSTRACT: To evaluate the efficacy of hemodynamic support using Impella 2.5 (IR2.5) vs intra-aortic balloon pump (IABP) in patients with 3-vessel coronary artery disease (3VD). PROTECT II demonstrated favorable 90-day outcomes in patients with impaired LVEF and left main or 3VD undergoing PCI with hemodynamic support with IR2.5 compared to IABP. It is unclear if this was due to a specific benefit in a patient sub-population and if certain patients may derive particular benefit from PCI with IR2.5 support. Patients in PROTECT II were stratified upon enrollment into the left main/last patent vessel or 3VD subgroups and randomized to IR2.5 or IABP within those groups. Patients in the 3VD substratum were required to have LVEF ≤30%. Among the 3VD subgroup (n = 325 patients; IR2.5 167, IABP 158) patients were well matched, except for prior heart failure or CABG, which were more common in the IR2.5 group (both P ≤ 0.01). Mean number of lesions treated was 3.0 ± 1.5 vs. 2.9 ± 1.4 (P = 0.61). At 30 days after PCI, patients that received IR2.5 compared to IABP support trended toward a reduction in incidence of major adverse events (MAE): 32.9% vs. 42.4% (P = 0.078). At 90 days after PCI, there was a significant difference favoring IR2.5 for incidence of MAE: 39.5% vs. 51.0% (P = 0.039), with this effect being consistent across multiple clinical subgroups. Use of IR2.5 was an independent predictor of improved 90-day outcomes. Patients with 3VD and reduced LVEF show improved outcomes when PCI is performed with IR2.5 hemodynamic support. (J Interven Cardiol 2015;28:32-40). © 2014, Wiley Periodicals, Inc.
    Journal of Interventional Cardiology 02/2015; 28(1):32-40. DOI:10.1111/joic.12166 · 1.50 Impact Factor
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    ABSTRACT: With each successive year, the number of Emergency Department (ED) visits related to illicit drug abuse has progressively increased. Cocaine is the most common illegal drug to cause a visit to the ED. Cocaine use results in a variety of pathophysiological changes with regards to the cardiovascular system, such as constriction of coronary vessels, dysfunction of vascular endothelium, decreased aortic elasticity, hemodynamic disruptions, a hypercoagulable state, and direct toxicity to myocardial as well as vascular tissue. The clinical course of patients with cocaine-induced chest pain is often challenging, and electrocardiographic findings can be potentially misleading in terms of diagnosing a myocardial infarction. In addition, there is no current satisfactory study regarding outcomes of use of various pharmacological drug therapies to manage cocaine associated chest pain. At present, calcium channel blockers and nitroglycerin are two pharmacological agents which are advocated as first-line drugs for cocaine-induced chest pain management, while the role of labetalol has been controversial and warrants further investigation. We performed an extensive search of available literature through a large number of scholarly articles previously published and listed on Index Medicus. In this review we put forward a concise summary of the current approach to a patient presenting to the ED with cocaine associated chest pain, and management of the clinical scenario. The purpose of this review is to summarize the understanding of cocaine's cardiovascular pathophysiology, and examine the current approach for proper evaluation and management of cocaine-induced chest pain.
    Cardiology in Review 01/2015; DOI:10.1097/CRD.0000000000000050 · 3.24 Impact Factor
  • Amir Ahmadi, Annapoorna Kini, Jagat Narula
  • Journal of Neurology 12/2014; 261(12):2449-50. DOI:10.1007/s00415-014-7510-9 · 3.84 Impact Factor
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    ABSTRACT: Percutaneous coronary intervention (PCI) of true bifurcation lesions (Medina classification 1, 1, 1; 1, 0, 1; or 0, 1, 1) is challenging and may involve either a 1-stent strategy with provisional side branch stenting, or a 2-stent strategy. Diabetes mellitus is associated with greater atherosclerotic burden and higher incidence of bifurcation lesions, and unfavorable outcomes after PCI. It is unknown whether use of newer everolimus-eluting stent (EES) implantation impacts relative outcomes of 1-stent and 2-stent strategies in patients with diabetes. We performed a retrospective analysis of consecutive patients with diabetes mellitus and complex true bifurcation lesions (side branch diameter >2.0 mm) who underwent PCI with EES between February 2010 and December 2011. We grouped subjects based on initial treatment to a 1-stent (n = 81) or 2-stent (n = 54) strategy, and compared baseline characteristics, quantitative coronary angiography, and 1-year major adverse cardiovascular event (MACE) rates, defined as death, myocardial infarction, target lesion revascularization (TLR), or target vessel revascularization (TVR). Baseline characteristics were well matched. A 2-stent strategy was associated with larger side-branch reference vessel diameter at baseline and post PCI. In-hospital events included 1 periprocedural myocardial infarction in each group and no deaths. At 1 year, there was no significant difference between 1-stent and 2-stent strategies in TVR rates (6.2% vs 3.7%; P=.53), TLR (both 3.7%; P>.99), or MACE (7.4% vs 3.7%; P=.37). In this series of diabetic patients undergoing complex bifurcation PCI using EES implantation, there was no difference between 1-stent and 2-stent strategies with respect to ischemic events at 1 year.
    The Journal of invasive cardiology 12/2014; 26(12):619-623. · 1.57 Impact Factor
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    ABSTRACT: Acute insult to the myocardium is associated with substantial loss of cardiomyocytes during the process of myocardial infarction. In this setting, apoptosis (programmed cell death) and necrosis may operate on a continuum. Because the latter is characterized by the loss of sarcolemmal integrity, we propose that an appropriately labeled tracer directed at a ubiquitously present intracellular moiety would allow non-invasive definition of cardiomyocyte necrosis. A trivalent arsenic peptide, GSAO (4-(N-(S-glutathionylacetyl)amino)phenylarsonous acid), is capable of binding to intracellular dithiol molecules such as HSP90 and filamin-A. Since GSAO is membrane impermeable and dithiol molecules abundantly present intracellularly, we propose that myocardial localization would represent sarcolemmal disruption or necrotic cell death. In rabbit and mouse models of myocardial infarction and post-infarct heart failure, we employed In-111-labelled GSAO for noninvasive radionuclide molecular imaging. (111)In-GSAO uptake was observed within the regions of apoptosis seeking agent- (99m)Tc-Annexin A5 uptake, suggesting the colocalization of apoptotic and necrotic cell death processes.
    Scientific Reports 10/2014; 4:6826. DOI:10.1038/srep06826 · 5.08 Impact Factor
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    ABSTRACT: To evaluate the relationship between lipid content and plaque morphometry as well as the process of lesion progression and regression in patients with significant coronary artery disease.
    European Heart Journal – Cardiovascular Imaging 09/2014; 16(1). DOI:10.1093/ehjci/jeu169 · 3.67 Impact Factor
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    ABSTRACT: Aims: The presence of thin-cap fibroatheromas (TCFA) is associated with high risk of acute coronary syndrome, hence their early detection may identify high-risk patients. In the present study we investigated the ability of a combined imaging catheter with near-infrared spectroscopy (NIRS) plus intravascular ultrasound (IVUS) to detect TCFA in patients with stable coronary artery disease. Methods and results: Optical coherence tomography (OCT) and combined NIRS-IVUS assessment were performed on identical coronary segments. IVUS analysis provided per-segment minimal cross-sectional area (CSA), plaque length (PL), plaque burden (PB), plaque volume (PV), and remodelling index (RI). OCT was used as the gold-standard reference to define TCFA (fibrous cap thickness <65 μm). Plaque lipid content was estimated by NIRS (lipid core burden index [LCBI]). OCT-defined TCFA was present in 18 of 76 segments. IVUS revealed that OCT-defined TCFA were positively remodelled lesions with greater PB and PV, smaller CSA, and longer PL, while NIRS revealed greater LCBI per 2 mm segment (LCBI2mm) (all p<0.001). Greatest accuracy for OCT-defined TCFA detection was achieved using LCBI2mm >315 with RI >1.046 as a combined criterion value. Conclusions: OCT-defined TCFA are characterised by positive vessel remodelling, high plaque burden and greater lipid core burden as assessed by dual NIRS-IVUS imaging.
    EuroIntervention: journal of EuroPCR in collaboration with the Working Group on Interventional Cardiology of the European Society of Cardiology 04/2014; 10(3). DOI:10.4244/EIJV10I3A53 · 3.17 Impact Factor
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    ABSTRACT: Despite the increasing use of percutaneous transluminal coronary angioplasty and intracoronary stent placement for the treatment of obstructive coronary artery disease, a large subset of coronary lesions cannot be adequately treated with balloon angioplasty and/or intracoronary stenting alone. Such lesions are often heavily calcified or fibrotic and undilatable with the present balloon technology and attempts to treat them with balloon angioplasty or intracoronary stent placement often lead to vessel dissection or incomplete stent deployment with resultant adverse outcomes. Rotational atherectomy remains a useful niche device for the percutaneous treatment of such complex lesions, usually as an adjunct to subsequent balloon angioplasty and/or intracoronary stent placement. In contrast to balloon angioplasty or stent placement that widen the coronary lumen by displacing atherosclerotic plaque, rotational atherectomy removes plaque by ablating the atherosclerotic material, which is dispersed into the distal coronary circulation. Other lesion subtypes amenable to treatment with this modality include ostial and branch-ostial lesions, chronic total occlusions, and in-stent restenosis. This review discusses the technique and principles of rotational atherectomy, the various treatment strategies for its use (including adjunctive pharmacotherapy), the lesion-specific applications for this device, and the complications unique to this modality. Recommendations are also made for its use in the current interventional era.
    Catheterization and Cardiovascular Interventions 04/2014; 62(4):485-98. DOI:10.1002/ccd.20081 · 2.51 Impact Factor
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    ABSTRACT: To compare the outcomes of initial one-stent (1S) versus dedicated two-stent (2S) strategies in complex bifurcation percutaneous coronary intervention (PCI) using everolimus-eluting stents (EES). PCI of true bifurcation lesions is technically challenging and historically associated with reduced procedural success and increased restenosis. Prior studies comparing initial one-stent (1S) versus dedicated two-stent (2S) strategies using first-generation drug-eluting stents have shown no reduction in ischemic events and more complications with a 2S strategy. We performed a retrospective study of 319 consecutive patients undergoing PCI at a single referral center with EES for true bifurcation lesions, defined by involvement of both the main vessel (MV) and side branch (SB). Baseline, procedural characteristics, quantitative coronary angiography and clinical outcomes in-hospital and at one year were compared for patients undergoing 1S (n=175) and 2S (n=144) strategies. Baseline characteristics were well-matched. 2S strategy was associated with greater SB acute gain (0.65±0.41mm vs. 1.11±0.47mm, p<0.0001). In-hospital serious adverse events were similar (9% with 2S vs. 8% with 1S, p=0.58). At one year, patients treated by 2S strategy had non-significantly lower rates of target vessel revascularization (5.8% vs. 7.4%, p=0.31), myocardial infarction (7.8% vs. 12.2%, p=0.31) and major adverse cardiovascular events (16.6% vs. 21.8%, p=0.21). In this study of patients undergoing PCI for true coronary bifurcation lesions using EES, 2S strategy was associated with superior SB angiographic outcomes without excess complications or ischemic events at one year.
    International journal of cardiology 03/2014; 174(1). DOI:10.1016/j.ijcard.2014.03.029 · 6.18 Impact Factor
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    ABSTRACT: To compare outcomes of elective percutaneous coronary interventions (PCI) in same-day discharge and overnight hospital stays. Advances in PCI techniques and equipment have allowed same-day discharge after elective PCI. In this study, we investigated the safety of same-day discharge ambulatory PCI in patients according to age, creatinine, and ejection fraction (ACEF) scores. The ambulatory PCI group consisted of all PCIs with same-day discharge, while the overnight-stay group consisted of all elective PCIs with in-hospital observation and discharge the following day. Patients were stratified into tertiles based on ACEF score: low (<1.08), mid (≥1.08 and <1.31), and high (≥1.31). The primary endpoint was 30-day major adverse cardiac events, defined as readmission, all-cause mortality, non-fatal myocardial infarction, and target lesion revascularization. Propensity score matching was done to evaluate outcomes based on similar baseline characteristics. There were 16,407 elective PCIs, of which 21.2% were in the ambulatory group. Patients who stayed overnight had similar 30-day composite outcomes as their same-day discharge counterparts in the high ACEF score (odds ratio [OR], 1.213; 95% confidence interval [CI], 0.625-2.355; P=.57) and mid ACEF score (OR, 0.636; 95% CI, 0.356-1.134; P=.13) comparisons, but had worse outcomes in the low ACEF score comparison (OR, 1.867; 95% CI, 1.134-3.074; P=.01). In this single-center registry, patients who underwent same-day discharge ambulatory PCI had no worse outcomes, and in some cases better outcomes, than overnight-stay patients; this result was found in the group as a whole, as well as in all ACEF score subcategories.
    The Journal of invasive cardiology 03/2014; 26(3):106-113. · 1.57 Impact Factor
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    ABSTRACT: Bleeding complications after percutaneous coronary intervention (PCI) have been associated with higher short and long-term mortality. Bivalirudin has been shown to reduce bleeding complications in patients who underwent PCI; however, the impact of anemia on bleeding complications and long-term mortality has not been studied. A total of 11,991 patients who underwent PCI over a period of 8 years with bivalirudin as the primary antithrombotic agent were included. Anemia was defined according to the World Health Organization definition. Bleeding complications were prospectively collected. Survival analysis was performed using multivariable Cox proportional hazards models. Of the 11,991 patients, 4,815 patients (40%) had baseline anemia. Major bleeding occurred in 3.3% of patients with anemia compared with 0.7% of patients without anemia (p <0.001) driven largely by transfusion events. In the overall study population, major bleeding was a significant predictor of mortality (hazard ratio [HR] 1.4, 95% confidence interval [CI] 1.04 to 1.8, p = 0.027) at a mean follow-up of 2.6 years (interquartile range 1.4 to 3.5). In patients with anemia, major bleeding remained an independent predictor of mortality (HR 1.5, 95% CI 1.1 to 2.0, p = 0.008); however, in patients without anemia, it did not (HR 1.25, 95% CI 0.52 to 3.03, p = 0.62). In patients who underwent PCI with bivalirudin therapy, major bleeding is associated with early and long-term mortality, which is more pronounced in patients with baseline anemia.
    The American journal of cardiology 02/2014; 113(9). DOI:10.1016/j.amjcard.2014.01.427 · 3.58 Impact Factor
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    ABSTRACT: A periprocedural myocardial infarction, defined as the advent of new Q-waves or a creatine kinase-MB elevation >83 normal has been previously validated as predictive of subsequent mortality. We examined the effects of using this clinically relevant definition of periprocedural myocardial infarction instead of the original protocol definition on outcomes in the recent PROTECT II [A Prospective, Multi-center, Randomized Controlled Trial of the IMPELLA RECOVER LP 2.5 System Versus Intra Aortic Balloon Pump (IABP) in Patients Undergoing Non Emergent High Risk PCI] trial. In this trial, patients who were undergoing high-risk percutaneous coronary intervention (PCI) were randomized to either an intraaortic balloon pump (IABP, n[211) or a left ventricular assist device (Impella, n[216). All eligible patients per study protocol were included in the analysis. Patient outcomes were compared up to 90 days, the longest available follow-up, on the composite end points of major adverse events (MAE) and major adverse cardiac and cerebral events (MACCE [ death, stroke, myocardial infarction, and repeat revascularization). At 90 days, the rates of both composite end points were lower in the Impella group compared with the IABP group (MAE, 37% vs 49%, p [ 0.014 respectively; MACCE, 22% vs 31%, p [ 0.034 respectively). There were no differences in death or large myocardial infarction between the 2 arms. By multivariable analysis, treatment with Impella as opposed to IABP was an independent predictor for freedom from MAE (odds ratio[0.75 [95% confidence interval 0.61 to 0.92], p[0.007) andMACCE (odds ratio[0.76 [95% confidence interval 0.61 to 0.96], p[0.020) at 90 days postprocedure. In conclusion, hemodynamic support with Impella compared with IABP during high-risk PCI in the PROTECT-II trial resulted in improved event-free survival at 3-month follow-up; this finding was further supported by multivariate analyses.
    The American journal of cardiology 01/2014; 113(2):222-8. DOI:10.1016/j.amjcard.2013.09.008 · 3.58 Impact Factor
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    ABSTRACT: Objective: To determine the impact of suture-mediated vascular closure devices on net adverse clinical events (NACE) after balloon aortic valvuloplasty (BAV). Background: Ischemic and bleeding complications are common following transfemoral BAV however; previous studies have been single center and limited by varying definitions of major bleeding. Methods: The Effect of Bivalirudin on Aortic Valve Intervention Outcomes (BRAVO) study was a retrospective observational study conducted at two high-volume academic centers over a 6-year period designed to compare the effect of bivalirudin versus unfractionated heparin. This is a sub-analysis of 428 consecutive patients who underwent BAV (with 10-13 French sheaths) to compare the effect of hemostasis with vascular closure devices versus manual compression utilizing standardized definitions. NACE was defined as the composite of major bleeding and major adverse clinical events (MACE). All events were adjudicated by an independent clinical events committee who were blinded to antithrombin use. Results: Pre-closure was performed in 269 (62.8%) of patients. While bivalirudin was used more frequently in those with pre-closure (60.6% vs. 37.7%, p<0.001), a history of prior BAV (11.1% vs. 3.6%, p=0.04) and peripheral vascular disease (30.7% vs. 19.7%, p=0.01) was more common in those not undergoing pre-closure (n=159, 37%). Other clinical and demographic features were well balanced between groups. Vascular closure was associated with a significant reduction in NACE (24.5% vs 10.0% p<0.001). Results remained significant after adjusting for baseline differences and bivalirudin use (OR 0.38, 95% CI: 0.21 - 0.68; p=0.001). Conclusions: Our study suggests that suture-mediated vascular closure is associated with a substantial reduction in NACE after transfemoral BAV. Large randomized clinical trials should be conducted to confirm our results. © 2013 Wiley Periodicals, Inc.
    Catheterization and Cardiovascular Interventions 01/2014; 83(1). DOI:10.1002/ccd.24892 · 2.51 Impact Factor
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    ABSTRACT: Aims: We sought to assess if bivalirudin use during balloon aortic valvuloplasty (BAV) would affect clinical outcomes compared with heparin. Methods and results: We compared the outcomes of consecutive patients who underwent elective or urgent BAV with intraprocedural use of bivalirudin or heparin at two high-volume centres. All in-hospital events post BAV were adjudicated by an independent, blinded clinical events committee. Of 427 patients, 223 patients (52.2%) received bivalirudin and 204 (47.8%) received heparin. Compared with patients who received heparin, patients who received bivalirudin had significantly less major bleeding (4.9% vs. 13.2%, p=0.003). Net adverse clinical events (NACE, major bleeding or major adverse cardiovascular events [MACE]) were also reduced (11.2% vs. 20.1%, p=0.01). There was no significant difference in the rates of MACE (mortality, myocardial infarction or stroke, 6.7% vs. 11.3%, p=0.1), or vascular complications (major, 2.7% vs. 2.0%; minor, 4.5% vs. 4.9%; p=0.83). After multivariate analysis controlling for vascular preclosure, the use of bivalirudin remained independently associated with reduced major bleeding (OR 0.37; 95% CI: 0.16 to 0.84; p=0.02) while the association was attenuated in propensity-adjusted analysis (OR 0.44, 95% CI: 0.18 to 1.07, p=0.08). Conclusions: In this registry of patients with severe aortic stenosis, bivalirudin as compared to heparin resulted in improved in-hospital outcomes post BAV in terms of reduced major bleeding, similar MACE and reduced NACE. If verified in a randomised study and extended to the transcatheter aortic valve implantation (TAVI) population, these results might indicate a potential benefit for patients undergoing such procedures.
    EuroIntervention: journal of EuroPCR in collaboration with the Working Group on Interventional Cardiology of the European Society of Cardiology 11/2013; 10(3). DOI:10.4244/EIJV10I3A54 · 3.17 Impact Factor
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    ABSTRACT: Introduction:Generic clopidogrel recently became available in the United States and was rapidly adopted as a cost-effective alternative to the brand name formulation. However, unlike other medications, subtle differences in clopidogrel bioavailability may lead to acute consequences including stent thrombosis (ST).Materials and METHODS: We studied the incidence of acute and subacute ST during the initial period of generic clopidogrel use (June 18, 2012-September 6, 2012 [80 days]) at a single percutaneous coronary intervention (PCI) center. There were 4 definite ST cases within 30 days of successful PCI in patients receiving generic clopidogrel, which were compared to historic control ST cases from 80 days prior to generic clopidogrel use and for 3 years from June 18, 2009 to June 17, 2012. During generic clopidogrel administration, 1054 PCIs were performed, giving a definite 30-day ST incidence of 0.38% (4 of 1054) among these patients. By comparison, there were 2 episodes of definite 30-day ST during the 80 days immediately preceding generic clopidogrel use (2 of 1114), while 3-year historic data indicated a definite 30-day ST incidence of 0.14% (20 of 14 432), representing a 2.7-fold increase in definite 30-day ST with generic clopidogrel use (P = .076). Exclusion of 3 historic controls with a defined reason for ST (noncompliance, marked thrombocytosis) gave a 3.2-fold increase in 30-day ST with generic clopidogrel (P = .050). An ST-predictive algorithm revealed no difference in the likelihood of ST between patients receiving generic clopidogrel and historic controls. We observed an unexpected >2-fold increase in ST coincident with generic clopidogrel use. Although we cannot ascribe causality, this observation warrants increased vigilance and close monitoring of patients receiving generic clopidogrel.
    Journal of Cardiovascular Pharmacology and Therapeutics 11/2013; DOI:10.1177/1074248413510605 · 3.07 Impact Factor
  • Umesh K Gidwani, Annapoorna S Kini
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    ABSTRACT: This article presents an overview of the evolution of cardiac critical care in the past half century. It tracks the rapid advances in the management of cardiovascular disease and how the intensive care area has kept pace, improving outcomes and incorporating successive innovations. The current multidisciplinary, evidence based unit is vastly different from the early days and is expected to evolve further in keeping with the concept of 'hybrid' care areas where care is delivered by the 'heart team'.
    Cardiology clinics 11/2013; 31(4):485-92. DOI:10.1016/j.ccl.2013.07.012 · 1.25 Impact Factor
  • Umesh K Gidwani, Samin K Sharma, Annapoorna S Kini
    Cardiology clinics 11/2013; 31(4):xiii-xiv. DOI:10.1016/j.ccl.2013.09.001 · 1.25 Impact Factor
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    ABSTRACT: BACKGROUND: RE-ENDOTHELIALIZATION IS DELAYED AFTER DRUG-ELUTING STENT (DES) IMPLANTATION. IN THIS SETTING, NEOINTIMA IS MORE PRONE TO BECOME LIPID LADEN AND DEVELOP NEOATHEROSCLEROSIS (NA), POTENTIALLY INCREASING PLAQUE VULNERABILITY.METHODS AND RESULTS: OPTICAL COHERENCE TOMOGRAPHY AND NEAR-INFRARED SPECTROSCOPY WITH INTRAVASCULAR ULTRASOUND WERE USED TO CHARACTERIZE NA IN 65 (51 DES AND 14 BARE-METAL STENTS) CONSECUTIVE SYMPTOMATIC PATIENTS WITH IN-STENT RESTENOSIS. MEDIAN DURATION POSTSTENT IMPLANTATION WAS 33 MONTHS. OPTICAL COHERENCE TOMOGRAPHYVERIFIED NA WAS OBSERVED IN 40 STENTS WITH IN-STENT RESTENOSIS (62%), WAS MORE PREVALENT IN DES THAN BARE-METAL STENTS (68% VERSUS 36%; P=0.02), AND DEMONSTRATED SIGNIFICANTLY HIGHER PREVALENCE OF THIN-CAP NEOATHEROMA (47% VERSUS 7%; P=0.01) IN DES. NEAR-INFRARED SPECTROSCOPY ASSESSMENT DEMONSTRATED THAT THE TOTAL LIPID CORE BURDEN INDEX (34 [INTERQUARTILE RANGE, 1292] VERSUS 9 [INTERQUARTILE RANGE, 032]; P0.001) AND THE DENSITY OF LIPID CORE BURDEN INDEX (LIPID CORE BURDEN INDEX/4 MM, 144 [INTERQUARTILE RANGE, 60285] VERSUS 26 [INTERQUARTILE RANGE, 086]; P0.001) WERE HIGHER IN DES COMPARED WITH BARE-METAL STENTS. TOPOGRAPHICALLY, NA WAS CLASSIFIED AS I (THIN-CAP NA), II (THICK-CAP NA), AND III (PERI-STRUT NA). TYPE I THIN-CAP NEOATHEROMA WAS MORE COMMON IN DES (20% VERSUS 3%; P=0.01) AND IN AREAS OF THE STENTED SEGMENT WITHOUT SIGNIFICANT IN-STENT RESTENOSIS (71%). PERIPROCEDURAL MYOCARDIAL INFARCTION OCCURRED ONLY IN DES (11 VERSUS 0; P =0.05), OF WHICH 6 (55%) COULD BE ATTRIBUTED TO SEGMENTS WITH 70% IN-STENT RESTENOSIS. BY LOGISTIC REGRESSION, PRIOR DES WAS THE ONLY INDEPENDENT PREDICTOR OF BOTH NA (ODDS RATIO, 7.0; 95% CONFIDENCE INTERVAL, 1.727; P=0.006) AND PERIPROCEDURAL MYOCARDIAL INFARCTION (ODDS RATIO, 1.8; 95% CONFIDENCE INTERVAL, 1.12.4; P=0.05).CONCLUSIONS: In-stent thin-cap neoatheroma is more prevalent, is distributed more diffusely across the stented segment, and is associated with increased periprocedural myocardial infarction in DES compared with bare-metal stents. These findings support NA as a mechanism for late DES failure.
    Circulation Cardiovascular Interventions 09/2013; 6(5). DOI:10.1161/CIRCINTERVENTIONS.112.000248 · 6.54 Impact Factor

Publication Stats

2k Citations
841.41 Total Impact Points

Institutions

  • 2002–2015
    • Icahn School of Medicine at Mount Sinai
      • • Division of Cardiology
      • • Department of Cardiothoracic Surgery
      Borough of Manhattan, New York, United States
  • 1997–2015
    • Mount Sinai Medical Center
      New York, New York, United States
  • 1998–2013
    • Sinai Hospital
      New York, New York, United States
    • Mount Sinai Hospital
      New York City, New York, United States
    • New York State
      New York City, New York, United States
  • 2004
    • State University of New York Downstate Medical Center
      • Department of Medicine
      Brooklyn, NY, United States