Ashok Krishnaswami

Kaiser Permanente · Department of Cardiology

Importance: Older patients using many prescription drugs (hyperpolypharmacy) may be at increased risk of adverse drug effects. Objective: To test the effectiveness and safety of a quality intervention intended to reduce hyperpolypharmacy. Design, setting, and participants: This randomized clinical trial allocated patients 76 years or older who...

We review a comprehensive risk assessment approach for percutaneous coronary interventions in older adults and highlight the relevance of geriatric syndromes within that broader perspective to optimize patient-centered outcomes in interventional cardiology practice. Reflecting the influence of geriatric principles in older adults undergoing percuta...

As the population ages, older adults represent an increasing proportion of patients referred to the cardiac catheterization laboratory. Older adults are the highest-risk group for morbidity and mortality, particularly after complex, high-risk percutaneous coronary interventions. Structured risk assessment plays a key role in differentiating patient...

Sarcopenia is the loss of muscle strength, mass, and function, which is often exacerbated by chronic comorbidities including cardiovascular diseases, chronic kidney disease, and cancer. Sarcopenia is associated with faster progression of cardiovascular diseases and higher risk of mortality, falls, and reduced quality of life, particularly among old...

Background and Aims Randomized clinical trials of hypertension treatment intensity evaluate effects on incident major adverse cardiovascular events (MACE) and serious adverse events (SAE). Occurrences after a non-fatal index event have not been rigorously evaluated. The current aim was to evaluate the association of intensive (<120 mmHg) to standar...

This editorial comments on the article by Nanna et al.

Limited English proficiency (LEP) is defined as individuals in whom English is not the primary language and who have limited ability to read, speak, write, or understand the English language. Cardiovascular (CV) team members routinely encounter language barriers in their practice. These barriers have a significant impact on the quality of CV care t...

Older adults with cardiovascular disease (CVD) contend with deficits across multiple domains of health due to age-related physiological changes and the impact of CVD. Multimorbidity, polypharmacy, cognitive changes, and diminished functional capacity, along with changes in the social environment, result in complexity that makes provision of CVD car...

Background: The optimal coronary revascularization strategy to maximize the patient-centered outcome of days alive and out of hospital (DAOH), in multimorbid older (≥65-years) adults after an acute coronary syndrome (ACS) is incompletely understood. Methods: Using Kaiser Permanente Northern California Health Plan databases, we identified 3871 pa...

Data No data sharing availability Background In the United States 2018 bradycardia guideline, the current class III recommendation that patients with permanent pacemaker (PPM) indications and high multimorbidity burden may not have meaningful clinical benefit from PPM therapy is based on limited data. Methods Observational study (1/1/2008–12/31/2...

Context: Medication deprescribing in palliative care settings has been insufficiently studied. Objective: To determine the feasibility of a deprescribing program in hospice patients with limited life expectancy. Design: Pharmacist-led, single arm, single-centered, retrospective analysis of a pilot deprescribing program in an integrated healthc...

The growing population of older adults (age ≥65 years) is expected to lead to higher rates of cardiovascular disease. The expansion of digital health (encompassing telehealth, telemedicine, mobile health, and remote patient monitoring), Internet access, and cellular technologies provides an opportunity to enhance patient care and improve health out...

Background To facilitate evidence-based medicine (EBM) on an individual level, it may be important for clinical practice guidelines (CPGs) to incorporate the performance parameters of diagnostic studies and therapeutic interventions (such as likelihood ratio and absolute benefit/harm), and to incorporate relevant patient contexts that may influence...

Angiogenesis inhibitors, also known as vascular endothelial growth factor (VEGF) or vascular signaling pathway (VSP) inhibitors, have improved care of neoplastic diseases over the past decade. However, cardiovascular toxicities associated with these agents, such as hypertension and less commonly left ventricular systolic dysfunction and heart failu...

Background Blood pressure (BP) treatment targets in older adults (≥75 years) remain controversial. Restricted mean survival time (RMST) analysis is an alternative to hazard ratios (decreased reliance on proportional hazards assumption) with an intuitive interpretation of a gain or loss in event-free days. This may be valuable when assessing effecti...

Background/objectives: Guideline-based management of cardiovascular disease often involves prescribing multiple medications, which contributes to polypharmacy and risk for adverse drug events in older adults. Deprescribing is a potential strategy to mitigate these risks. We sought to characterize and compare clinician perspectives regarding depres...

Context: Obesity is associated with increased incidence of chronic diseases such as type 2 diabetes mellitus, systemic hypertension, and other risk factors for cardiovascular disease. Obesity is also associated with increased use of outpatient clinical services, a metric of health care utilization. However, little is known of temporal changes in h...

Deprescribing, an integral component of a continuum of good prescribing practices, is the process of medication withdrawal or dose reduction to correct or prevent medication-related complications, improve outcomes, and reduce costs. Deprescribing is particularly applicable to the commonly encountered multimorbid older adult with cardiovascular dise...

Objective: To determine individual and joint effects of pulse pressure and blood pressure treatment intensity on serious adverse events in the Systolic Blood Pressure Intervention Trial (SPRINT). Methods: Pulse pressure = systolic - diastolic blood pressure. Blood pressure treatment intensity in the control arm was ≤ 140 mmHg and in the intensiv...

Heart failure (HF) is a quintessential geriatric cardiovascular condition, with more than 50% of hospitalizations occurring in adults age 75 years or older. In older patients, HF is closely linked to processes inherent to aging, which include cellular and structural changes to the myocardium, vasculature, and skeletal muscle. In addition, HF cannot...

Context: There are insufficient data on the long-term, nonsurgical, nonpharmacologic treatment of obesity. Objective: To determine changes in weight over 5 years in participants enrolled between April 1, 2007, and December 31, 2014, in a medically supervised weight management program at Kaiser Permanente Northern California Medical Centers. The...

Cardiovascular care for older adults has become increasingly complex due to a rise in the concurrent comorbidity burden that accompanies senescence. Internists, hospitalists, and cardiologists often encounter geriatric patients with multiple chronic conditions needing acute cardiovascular care. Abnormal cardiac biomarker levels in patients with mul...

Background The prognostic utility of 5 established variables (functional capacity, Duke treadmill score, chronotropic response to exercise, heart rate recovery, and premature ventricular contractions) together after routine exercise treadmill testing (ETT) has not been determined. Methods We assessed the combined prognostic ability of 5 establishe...

Background: The extent of coronary disease affects clinical outcomes and may predict the effectiveness of coronary revascularization with either coronary artery bypass graft (CABG) surgery or percutaneous coronary intervention (PCI). The SYNTAX (Synergy Between Percutaneous Coronary Intervention With Taxus and Cardiac Surgery) score quantifies the...

The use of predictive analytics in modern cardiology has had a significant impact in decreasing the subjectivity of forecasting cardiovascular events. The abundance of currently available clinical prediction models (CPMs) has been demonstrated by a recent systematic review.¹ This review unearthed 796 scientific articles on the topic of CPMs and car...

Background: The clinical effects of age occur over an age continuum, yet age as a primary predictor is often analyzed using arbitrary age cut-points. Objective: To assess whether transformation of a continuous variable such as age using a spline function can uncover nonlinear associations between age and cardiovascular outcomes. Design: Observ...

Background: The presence of multimorbidity is known to be related to adverse clinical outcomes. However, its association with mortality in patients undergoing cardiac valve replacement is not known. Methods: Multimorbidity (as a continuous variable) was characterized in adults receiving cardiac valve replacement surgery between 2008 and 2012 wit...

The optimal coronary revascularization strategy (coronary artery bypass grafting [CABG] or percutaneous coronary intervention [PCI]) in patients with end-stage renal disease (ESRD) remains uncertain. We performed an updated systematic review and meta-analysis of observational studies comparing CABG and PCI in patients with ESRD using a random-effec...

Background: Prospective clinical trials using clinical criteria and observational studies using diagnostic codes from electronic health records have reported seemingly contradictory cardiotoxicity risk for adjuvant trastuzumab (T). Accurate estimates of individualized patient specific cardiotoxicity risk are essential for treatment decisions in ear...

The increasing prevalence of severe symptomatic aortic stenosis (AS) in older adults is now considered a major public health concern. Since medical therapy has not been shown to improve prognosis, surgical aortic valve replacement (SAVR) and transcatheter aortic valve replacement (TAVR) are the best options currently available, yet not all patients...

Context: There is insufficient information on the effect that advancing age and multiple chronic conditions (MCC) have on mortality after placement of an implantable cardioverter-defibrillator in patients with end-stage renal disease (ESRD) vs non-ESRD. Objective: To assess whether a differential effect of age and MCC exists between ESRD and non...

To determine the relative risks of long-term mortality between coronary artery bypass grafting (CABG) and percutaneous coronary intervention (PCI) among patients with end-stage renal disease (ESRD). We identified 1015 patients with ESRD who underwent coronary revascularization between 1996 and 2008 within Kaiser Permanente Northern California. We o...

Background: Age is a known risk factor for mortality after cardiac valve replacement. Little is known of the interaction between age and end stage renal disease (ESRD). To better comprehend the relationship between age as a continuum and cardiovascular outcomes, assessment of nonlinear relationships needs to be undertaken. Methods: We enrolled 3,79...

A 29-year-old man presented to our hospital with palpitations, shortness of breath, and orthopnea. After being admitted, he progressed to cardiogenic shock and respiratory failure, which required ventilator support and cardioversion. Subsequent evaluation revealed a fibromuscular membrane across the left atrium, requiring urgent corrective surgery.

Background: Recent studies that have assessed the comparative effectiveness between coronary artery bypass grafting (CABG) and percutaneous coronary intervention (PCI) in patients with end-stage renal disease (ESRD) that have included analyses of temporal trends in mortality have noted mixed results. Methods: We conducted an observational longit...

Background Inadequate recruitment of women and an exclusion of patients with end-stage renal disease (ESRD) in coronary revascularization trials have led to knowledge gaps of gender-based outcomes.HypothesisWomen have equivalent cardiovascular outcomes when compared to men.Methods We conducted a retrospective observational study utilizing Kaiser Pe...

Background: Prior cardiovascular studies have often dichotomized the continuous variable age at a certain pre-specified cutoff which is thought to lead to a loss of information. Methods: To further understand this loss of information we conducted a retrospective cohort study within Kaiser Permanente Northern California and identified 1015 adults wi...

The purpose of this analysis was to assess in patients with type 2 diabetes and stable coronary artery disease (CAD) whether the risk of all-cause mortality and cardiovascular events varied according to the presence or absence of angina and angina equivalent symptoms. Data on the prognostic value of symptoms in these patients are limited. Post-hoc...

The aim of this study was to determine whether the presence of symptoms would aid in the detection of valvular heart disease (VHD) in those exposed to pergolide. Utilizing a prospective, cross-sectional study design, patients with an exposure to pergolide were asked regarding the presence or absence of chest pain, shortness of breath or lower extre...

Clinically stable patients with type 2 diabetes mellitus and coronary artery disease are not often thought to present with the symptom of typical angina. The aims of this study were to enumerate the proportion of patients presenting with typical angina or other cardiac symptoms and to elucidate what important clinical variables are associated with...

A subgroup of patients with normal stress myocardial perfusion imaging (MPI) have obstructive coronary artery disease (CAD) on coronary computed tomographic angiography (CCTA). A retrospective study was performed to identify factors associated with obstructive CAD in patients with normal MPI. Bivariate differences between patients with obstructive...

Effects were compared in patients in the Bypass Angioplasty Revascularization Investigation 2 Diabetes (BARI 2D) trial of 2 mechanistically different strategies for treatment of hyperglycemia, insulin-sensitizing and insulin-providing strategies, on biomarker profiles reflecting the balance between fibrinolysis and thrombosis and the intensity of i...

Objective: Patients infected with human immunodeficiency virus (HIV) have an increased risk for cardiovascular events and mortality. Elevated concentrations of asymmetric dimethylarginine (ADMA), an endogenous inhibitor of nitric oxide synthase, are associated with increased subclinical atherosclerosis and cardiovascular events. The objective of t...

The impact of mitral valve (MV) surgery on levels of B-type natriuretic peptide (BNP) postoperatively has not been clearly evaluated. The aim of this study was to assess whether BNP levels decrease three to six months after MV surgery in patients with severe mitral regurgitation (MR). We prospectively enrolled patients who were referred for MV surg...

A large number of cardiology clinical trials have mortality as an endpoint unless adequate surrogate endpoints are available. Although there are nine classes of agents used in the treatment of diabetes mellitus, none have shown a mortality benefit in clinical trials. The United Kingdom Prospective Diabetic Study was the first to suggest that metfor...

A large number of cardiology clinical trials have mortality as an endpoint unless adequate surrogate endpoints are available. Although there are nine classes of agents used in the treatment of diabetes mellitus, none have shown a mortality benefit in clinical trials. The United Kingdom Prospective Diabetic Study was the first to suggest that metfor...

In order to examine lipids, a major treatment parameter in those with diabetes and heart disease, the authors analyzed baseline data from the Bypass Angioplasty Revascularization Investigation 2 Diabetes (BARI 2D) trial. The study consisted of 2368 participants with type 2 diabetes and coronary artery disease from 49 sites in 6 countries (2295 prov...

Although considered a relatively benign congenital coronary anomaly, myocardial bridges have been associated with myocardial ischemia, infarctions, and sudden cardiac death. The aim of this study was to identify characteristics of myocardial bridges on computed tomographic angiography (CTA) associated with abnormal defects on myocardial perfusion i...

Natriuretic peptide (NP) physiology is a complex field. NPs also are known to be highly phylogenetically preserved. NPs can be thought of as counterregulatory hormones antagonizing the effects of the renin-angiotensin-aldosterone and sympathetic systems. These peptides are primarily responsible for maintaining salt and water homeostasis, but they a...

A 54-year-old man with end-stage renal disease presented with chest pain. Five months before presentation the patient had a right-foot cellulitis that was treated with amoxicillin clavulanate. Two weeks later, the patient suffered an inferior wall ST-elevation myocardial infarction that required immediate percutaneous coronary intervention with pac...

Rapid laboratory markers that correlate with patient risk would facilitate the decision making regarding admission of patients with chest pain (CP). Platelet contractile force (PCF) and clot elastic modulus (CEM) are elevated in patients undergoing coronary bypass grafting. This study assessed PCF, CEM, and platelet aggregation in patients presenti...

Platelet function and clot structure may be altered in diabetes. We have noted increased platelet contractile force (PCF) and clot elastic modulus (CEM) in patients presenting to the emergency department with chest pain. Twenty-six of the chest pain patients were diabetic. Here, we compare the PCF, CEM and platelet aggregation in diabetic chest pai...

Rapid laboratory markers that correlate with patient risk would facilitate the decision making regarding admission of patients with chest pain (CP). Platelet contractile force (PCF) and clot elastic modulus (CEM) are elevated in patients undergoing coronary bypass grafting. This study assessed PCF, CEM, and platelet aggregation in patients presenti...

We report the case of a middle-aged female who presented with an acute inferior myocardial infarction treated with intravenous thrombolytics. Immediate coronary angiography demonstrated the presence of a spiral dissection and a large thrombus. After 1 week of anticoagulation the thrombus had resolved, but a large spiral dissection persisted. This w...

We tested the hypothesis that cyclic alterations in coronary artery blood flow that occurred after coronary angioplasty could be attenuated or abolished by a monoclonal antibody to the platelet surface membrane GP IIb/IIIa receptor. Coronary artery cyclic flow variations may occur after coronary angioplasty in experimental animal models and humans....

A canine model with cyclic flow variations (CFVs) in stenosed and endothelium-injured coronary arteries was used to examine the role of active oxygen species in platelet aggregation in vivo. We studied 90 anesthetized dogs in which the pericardial cavity was opened and the heart was exposed. The velocity of blood flow in the left anterior descendin...

This study was designed to test the hypothesis that endogenously produced nitric oxide protects against platelet aggregation and cyclic flow variations in stenosed and endothelium-injured arteries of mongrel dogs. NG-Monomethyl-L-arginine (L-NMMA), an inhibitor of nitric oxide formation, was administered at 5 mg/kg to 15 dogs after the left anterio...