Jerome L Fleg

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

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Publications (316)2350.06 Total impact

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    ABSTRACT: Background: Psychosocial factors may influence adherence with exercise training for heart failure (HF) patients. We aimed to describe the association between social support and barriers to participation with exercise adherence and clinical outcomes. Methods and results: Of patients enrolled in Heart Failure: A Controlled Trial Investigating Outcomes of Exercise Training (HF-ACTION), 2279 (97.8%) completed surveys to assess social support and barriers to exercise, resulting in the perceived social support score (PSSS) and barriers to exercise score (BTES). Higher PSSS indicated higher levels of social support, whereas higher BTES indicated more barriers to exercise. Exercise time at 3 and 12 months correlated with PSSS (r= 0.09 and r= 0.13, respectively) and BTES (r=-0.11 and r=-0.12, respectively), with higher exercise time associated with higher PSSS and lower BTES (All P<0.005). For cardiovascular death or HF hospitalization, there was a significant interaction between the randomization group and BTES (P=0.035), which corresponded to a borderline association between increasing BTES and cardiovascular death or HF hospitalization in the exercise group (hazard ratio 1.25, 95% confidence interval 0.99, 1.59), but no association in the usual care group (hazard ratio 0.83, 95% confidence interval 0.66, 1.06). Conclusions: Poor social support and high barriers to exercise were associated with lower exercise time. PSSS did not impact the effect of exercise training on outcomes. However, for cardiovascular death or HF hospitalization, exercise training had a greater impact on patients with lower BTES. Given that exercise training improves outcomes in HF patients, assessment of perceived barriers may facilitate individualized approaches to implement exercise training therapy in clinical practice. Clinical trial registration: URL: Unique identifier: NCT00047437.
    No preview · Article · Nov 2015 · Circulation Heart Failure
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    ABSTRACT: Coronary CT angiography (CCTA) is used in patients with low-intermediate chest pain presenting to the emergency department for its reliability in excluding acute coronary syndrome (ACS). However, its influence on medication modification in this setting is unclear. We sought to determine whether knowledge of CCTA-based coronary artery disease (CAD) was associated with change in statin and aspirin prescription. We used the CCTA arm of the Rule Out Myocardial Infarction using Computed Angiographic Tomography II multicenter, randomized control trial (R-II) and comparison cohort from the observational Rule Out Myocardial Infarction using Computed Angiographic Tomography I cohort (R-I). In R-II, subjects were randomly assigned to CCTA to guide decision making, whereas in R-I patients underwent CCTA with results blinded to caregivers and managed according to standard care. Our final cohort consisted of 277 subjects from R-I and 370 from R-II. ACS rate was similar (6.9% vs 6.2% respectively, p = 0.75). For subjects with CCTA-detected obstructive CAD without ACS, initiation of statin was significantly greater after disclosure of CCTA results (0% in R-I vs 20% in R-II, p = 0.009). Conversely, for subjects without CCTA-detected CAD, aspirin prescription was lower with disclosure of CCTA results (16% in R-I vs 4.8% in R-II, p = 0.001). However, only 68% of subjects in R-II with obstructive CAD were discharged on statin and 65% on aspirin. In conclusion, physician knowledge of CCTA results leads to improved alignment of aspirin and statin with the presence and severity of CAD although still many patients with CCTA-detected CAD are not discharged on aspirin or statin. Our findings suggest opportunity for practice improvement when CCTA is performed in the emergency department.
    No preview · Article · Nov 2015 · The American journal of cardiology
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    ABSTRACT: Objectives: This study compared diagnostic accuracy of conventional troponin/traditional coronary artery disease (CAD) assessment and highly sensitive troponin (hsTn) I/advanced CAD assessment for acute coronary syndrome (ACS) during the index hospitalization. Background: hsTnI and advanced assessment of CAD using coronary computed tomography angiography (CTA) are promising candidates to improve the accuracy of emergency department evaluation of patients with suspected ACS. Methods: We performed an observational cohort study in patients with suspected ACS enrolled in the ROMICAT II (Rule Out Myocardial Infarction/Ischemia using Computer Assisted Tomography) trial and randomized to coronary CTA who also had hsTnI measurement at the time of the emergency department presentation. We assessed coronary CTA for traditional (no CAD, nonobstructive CAD, ≥50% stenosis) and advanced features of CAD (≥50% stenosis, high-risk plaque features: positive remodeling, low <30-Hounsfield units plaque, napkin-ring sign, spotty calcium). Results: Of 160 patients (mean age: 53 ± 8 years, 40% women) 10.6% were diagnosed with ACS. The ACS rate in patients with hsTnI below the limit of detection (n = 9, 5.6%), intermediate (n = 139, 86.9%), and above the 99(th) percentile (n = 12, 7.5%) was 0%, 8.6%, and 58.3%, respectively. Absence of ≥50% stenosis and high-risk plaque ruled out ACS in patients with intermediate hsTnI (n = 87, 54.4%; ACS rate 0%), whereas patients with both ≥50% stenosis and high-risk plaque were at high risk (n = 13, 8.1%; ACS rate 69.2%) and patients with either ≥50% stenosis or high-risk plaque were at intermediate risk for ACS (n = 39, 24.4%; ACS rate 7.7%). hsTnI/advanced coronary CTA assessment significantly improved the diagnostic accuracy for ACS as compared to conventional troponin/traditional coronary CTA (area under the curve 0.84, 95% confidence interval [CI] 0.80 to .88 vs. 0.74, 95%CI 0.70 to 0.78; p < 0.001). Conclusions: hsTnI at the time of presentation followed by early advanced coronary CTA assessment improves the risk stratification and diagnostic accuracy for ACS as compared to conventional troponin and traditional coronary CTA assessment. (Multicenter Study to Rule Out Myocardial Infarction/Ischemia by Cardiac Computed Tomography [ROMICAT-II]; NCT01084239).
    No preview · Article · Oct 2015 · JACC. Cardiovascular imaging
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    ABSTRACT: Background: -Limited data exist regarding the impact of aldosterone antagonist therapy on cardiac structure and function in heart failure with preserved ejection fraction (HFpEF) and on the prognostic relevance of changes in cardiac structure and function in HFpEF. Methods and results: -Cardiac structure and function were assessed by quantitative echocardiography at baseline and 12-18 month follow-up in 239 patients with HFpEF (left ventricular [LV] ejection fraction [LVEF] ≥45%) enrolled in the Treatment Of Preserved Cardiac Function Heart Failure with an Aldosterone Antagonist (TOPCAT) trial. The impact of spironolactone therapy on measures of cardiac structure and function was assessed in the study population overall, and change in echocardiographic measures was associated with the subsequent occurrence of the primary composite outcome of cardiovascular (CV) death, heart failure (HF) hospitalization, or aborted cardiac arrest. Spironolactone was not associated with alterations in cardiac structure and function compared to placebo. Decrease in left atrial (LA) volume at follow-up was associated with a lower risk of subsequent occurrence of the primary outcome. Conclusions: -Twelve to 18 months of spironolactone therapy was not associated with alterations in cardiac structure or function in patients with HFpEF. Reduction in LA volume at follow-up was associated with a lower risk of subsequent occurrence of the primary composite outcome. Clinical Trial Registration-URL: http:/// Unique identifier: NCT00094302.
    No preview · Article · Oct 2015 · Circulation Heart Failure
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    ABSTRACT: Background: There are no proven strategies to prevent atrial fibrillation (AF) in patients with type 2 diabetes (T2DM). We compared standard blood pressure (BP) lowering vs. intensive BP lowering in reducing incidence of AF or P-wave indices (PWI-ECG markers of left atrial abnormality that are considered intermediate phenotypes of AF) in patients with T2DM. Methods: We analyzed data from the ACCORD BP trial-a randomized controlled nonblinded trial (2001-2009) which randomized patients with T2DM and systolic BP (SBP) 130-180mm Hg on ≤3 antihypertensive medications aged 40-79 years with cardiovascular disease (CVD) or aged 55-79 years with subclinical CVD or ≥2 CVD risk factors to standard BP lowering (SBP <140mm Hg) vs. intensive BP lowering (SBP <120mm Hg). The primary outcome was a composite of incident AF and PWI. Results: Data from 3,087 participants (mean age, 62.2 years; women, 48.2%; non-White, 39.2%) were analyzed. During a mean follow-up of 4.4 years, the primary outcome occurred in 1,063 participants (incidence rate, 84.5 per 1,000 person-years in the standard-therapy group vs. 73.9 per 1,000 person-years in the intensive-therapy group). The adjusted hazard ratios (95% confidence intervals) of intensive-therapy group for the primary outcome and for incident PWI alone were 0.87 (0.77-0.98), P = 0.02 and 0.87 (0.76-0.98), P = 0.02, respectively. The effect of intensive therapy on the incidence of AF alone did not reach statistical significance. Conclusions: In patients with T2DM, intensive BP lowering reduces the incidence of the composite outcome of AF and PWI, suggesting a potential benefit from stringent BP control in patients with T2DM.clinical trials registrationTrial Number NCT00000620.
    No preview · Article · Oct 2015 · American Journal of Hypertension
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    ABSTRACT: Aims: While mineralocorticoid receptor antagonists (MRAs) have been shown to benefit patients with reduced left ventricular ejection fraction (LVEF), spironolactone did not reduce the primary endpoint of cardiovascular death, heart failure hospitalization, or aborted cardiac arrest in patients with heart failure with preserved ejection fraction (HFpEF) in the TOPCAT trial, which enrolled patients with LVEF of 45% or greater. We utilized data from TOPCAT to assess the relationship between LVEF as well as outcomes and efficacy of spironolactone. Methods and results: We assessed differences in baseline characteristics and outcomes across LVEF categories in 3444 patients with HFpEF, and determined whether LVEF modified the treatment effect of spironolactone. Ejection fraction ranged from 44 to 85%. Patients with higher ejection fraction were older, more likely to be female, less likely to have a history of myocardial infarction, and more likely to have a history of hypertension and diabetes. The incidence of the primary endpoint and cardiovascular death was highest in patients at the lower end of the ejection fraction spectrum. Ejection fraction modified the spironolactone treatment effect, particularly in the patients enrolled in the Americas, for the primary outcome (P = 0.046) and for heart failure hospitalization (P = 0.039), with stronger estimated benefits of spironolactone at the lower end of the ejection fraction spectrum with respect to the primary endpoint (LVEF <50%: HR 0.72, 95% CI 0.50, 1.05; LVEF ≥60%: HR 0.97, 95% CI 0.76, 1.23) and heart failure hospitalization (LVEF <50%: HR 0.76, 95% CI 0.46, 1.27; LVEF ≥60%: HR 0.98, 95% CI 0.74, 1.30). Conclusion: In patients with HFpEF enrolled in TOPCAT, patient characteristics and outcomes varied substantially by LVEF. The potential efficacy of spironolactone was greatest at the lower end of the LVEF spectrum. Clinicaltrialsgov number: NCT00094302.
    Full-text · Article · Sep 2015 · European Heart Journal
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    ABSTRACT: Aerobic exercise training in sedentary individuals improves physical fitness and various cardiovascular (CV) biomarkers. Nevertheless, there has been controversy as to whether exercise training may adversely affect some biomarkers in a small segment of the population. The purpose of this study was to investigate whether clinically significant worsening of CV biomarkers was more prevalent among individuals randomized to a supervised endurance training program as compared to those randomized to a control condition. Baseline and end of study measurements of fasting insulin (FI), triglycerides (TG), resting systolic blood pressure (SBP), and HDL-cholesterol (HDL-C) were obtained on 1188 healthy sedentary subjects from four clinical studies. Each study randomized subjects to 4- to 6-month supervised aerobic exercise programs or to a control group of no supervised exercise training. For each of the 4 CV biomarkers, we calculated the respective proportions of control and exercise group subjects whose baseline-to-followup changes were greater than or equal to previously reported adverse change (AC) thresholds. Those thresholds were increases of ≥ 24 pmol[BULLET OPERATOR]Lfor FI, ≥ 0.42 mmol[BULLET OPERATOR]L for TG, ≥ 10 mm Hg for SBP, and a decrease of ≥ 0.12 mmol[BULLET OPERATOR]L for HDL-C. The respective proportions of subjects meeting the AC threshold in the control and exercise groups were 15.2% vs. 9.6% (p=0.02) for FI, 14.9% vs. 13.1% (p=0.37) for TG, 16.9% vs. 15.8% (p=0.52) for SBP, and 28.6% vs. 22.5% (p=0.03) for HDL-C. All were nonsignificant at the 0.0125 Bonferroni threshold adjusting for multiple comparisons. These findings do not support the concept that aerobic exercise training increases the risk of adverse changes in the CV biomarkers we studied.
    No preview · Article · Aug 2015 · Medicine and science in sports and exercise
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    ABSTRACT: The beneficial effects of physical activity (PA) are well documented, yet the mechanisms by which PA prevents disease and improves health outcomes are poorly understood. To identify major gaps in knowledge and potential strategies for catalyzing progress in the field, the NIH convened a workshop in late October 2014 entitled "Understanding the Cellular and Molecular Mechanisms of Physical Activity-Induced Health Benefits." Presentations and discussions emphasized the challenges imposed by the integrative and intermittent nature of PA, the tremendous discovery potential of applying "-omics" technologies to understand interorgan crosstalk and biological networking systems during PA, and the need to establish an infrastructure of clinical trial sites with sufficient expertise to incorporate mechanistic outcome measures into adequately sized human PA trials. Identification of the mechanisms that underlie the link between PA and improved health holds extraordinary promise for discovery of novel therapeutic targets and development of personalized exercise medicine. Copyright © 2015 Elsevier Inc. All rights reserved.
    No preview · Article · Jun 2015 · Cell metabolism
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    ABSTRACT: -Although studies have shown that depression is associated with worse outcomes in heart failure (HF) patients, most studies have been in White patients. The impact of depression on outcomes in African Americans (AAs) with HF has not been studied. -We analyzed 747 AAs and 1,420 Whites enrolled in HF-ACTION, which randomized 2,331 patients with ejection fraction ≤35% to usual care with or without exercise training. We examined the association between depressive symptoms assessed by the Beck Depression Inventory II (BDI-II) at baseline and after 3 months with all-cause mortality/hospitalization. A race by baseline BDI-II interaction was observed (P=.003) in which elevated baseline scores were associated with worse outcomes in AAs versus Whites. In AAs, the association was non-linear with a hazard ratio of 1.44 (95% CI: 1.24-1.68) when comparing the 75(th) and 25(th) percentile of BDI-II (score of 15 and 5, respectively). Among Whites, the association was linear and not significant (HR 1.08, 95% CI: 0.96-1.21). No race interaction was observed for mortality (P=.34). There was no differential association between BDI-II change and outcomes in AAs vs. Whites. In AAs, an increase in BDI-II score from baseline to 3 months was associated with increased mortality/hospitalization (HR 1.33, 95% CI: 1.12-1.57 per 10 point increase), while a decrease was not related to outcomes. -In AAs with HF, baseline symptoms of depression and worsening of symptoms over time are associated with increased all-cause mortality/hospitalization. Routine assessment of depressive symptoms in AAs with HF may help guide management. Clinical Trial Registration-URL: Unique identifier: NCT00047437.
    Full-text · Article · Apr 2015 · Circulation Heart Failure

  • No preview · Article · Apr 2015 · Circulation Heart Failure
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    ABSTRACT: Heart failure (HF) is a complex syndrome in which structural or functional cardiac abnormalities impair the filling of ventricles or left ventricular ejection of blood. HF disproportionately occurs in those ≥65 years of age. 1 Among the estimated 1.5 to 2 million residents in skilled nursing facilities (SNFs) in the United States, cardiovascular disease is the largest diagnostic category, and HF is common. 2,3 Despite the high prevalence of HF in SNF residents, none of the large randomized clinical trials of HF therapy included SNF residents, and very few included patients >80 years of age with complex comorbidities. Several issues make it important to address HF care in SNFs. The healthcare environment and characteristics of SNF residents are distinct from those of communitydwelling adults. Comorbid illness unrelated to HF (eg, dementia, hip fracture) increases with age >75 years, and these conditions may complicate both the initial HF diagnosis and ongoing management. 4-6 Morbidity and mortality rates are significantly increased for hospitalized older adults with HF discharged to SNFs compared with those discharged to other sites. 7Transitions between hospitals and SNFs may be problematic. 8 SNF 30-day rehospitalization rates for HF range from 27% to 43%, 7,9,10 and long-term care residents sent to the emergency department are at increased risk for hospital admission and death. 11 The purpose of this scientific statement is to provide guidance for management of HF in SNFs to improve patient-centered outcomes and reduce hospitalizations. This statement addresses unique issues of SNF care and adapts HF guidelines and other recommendations to this setting. © 2015 Elsevier, Inc. All Rights Reserved, and by the American Heart Association, Inc.
    No preview · Article · Apr 2015 · Journal of cardiac failure

  • No preview · Article · Mar 2015 · Journal of the American College of Cardiology

  • No preview · Article · Mar 2015 · Journal of the American College of Cardiology

  • No preview · Article · Mar 2015 · Journal of the American College of Cardiology
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    ABSTRACT: Background: In the HF-ACTION trial, exercise training improved functional capacity in heart failure with reduced ejection fraction (HFrEF). Previous studies have suggested that diabetes mellitus (DM) may be associated with an attenuated response to exercise. We explored whether DM attenuated the improvement in functional capacity with exercise. Methods/results: HF-ACTION randomized 2,331 patients with HFrEF to medical therapy with or without exercise training over a median follow-up of 2.5 years. We examined the interaction between DM and exercise response measured by change in 6-minute walk distance (6MWD) and peak VO2. We also examined outcomes by DM status. In HF-ACTION, 748 (32%) patients had DM. DM patients had lower functional capacity at baseline and had lower exercise volumes at 3 months. There was a significant interaction between DM status and exercise training for change in peak VO2 (interaction p=0.02), but not 6MWD. In the exercise arm, DM patients had a smaller mean increase in peak VO2 than non-DM patients (p=0.03). There was no interaction between DM and exercise on clinical outcomes. After risk adjustment, DM was associated with increased all-cause mortality/hospitalization (p=0.03). Conclusions: In HF-ACTION, DM was associated with lower baseline functional capacity, an attenuated improvement in peak VO2 and increased hospitalizations.
    No preview · Article · Mar 2015 · Journal of the American College of Cardiology
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    ABSTRACT: Whether a coronary artery calcium (CAC) scan provides added value to coronary computed tomographic angiography (CCTA) in emergency department patients with acute chest pain remains unsettled. We sought to determine the value of CAC scan in patients with acute chest pain undergoing CCTA. In the multicenter Rule Out Myocardial Infarction using Computer-Assisted Tomography (ROMICAT) II trial, we enrolled low-intermediate risk emergency department patients with symptoms suggesting acute coronary syndrome (ACS). In this prespecified subanalysis of 473 patients (54±8 years, 53% men) who underwent both CAC scanning and CCTA, the ACS rate was 8%. Overall, 53% of patients had CAC=0 of whom 2 (0.8%) developed ACS, whereas 7% had CAC>400 with 49% whom developed ACS. C-statistic of CAC>0 was 0.76, whereas that using the optimal cut point of CAC≥22 was 0.81. Continuous CAC score had lower discriminatory capacity than CCTA (c-statistic, 0.86 versus 0.92; P=0.03). Compared with CCTA alone, there was no benefit combining CAC score with CCTA (c-statistic, 0.93; P=0.88) or with selective CCTA strategies after initial CAC>0 or optimal cut point CAC≥22 (P≥0.09). Mean radiation dose from CAC acquisition was 1.4±0.7 mSv. Higher CAC scores resulted in more nondiagnostic CCTA studies although the majority remained interpretable. In emergency department patients with acute chest pain, CAC score does not provide incremental value beyond CCTA for ACS diagnosis. CAC=0 does not exclude ACS, nor a high CAC score preclude interpretation of CCTA in most patients. Thus, CAC results should not influence the decision to proceed with CCTA, and the decision to perform a CAC scan should be balanced with the additional radiation exposure required. Unique identifier: NCT01084239. © 2015 American Heart Association, Inc.
    Full-text · Article · Mar 2015 · Circulation Cardiovascular Imaging
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    ABSTRACT: To the Editor:In our study showing no increase in the rate of falls with intensive blood pressure (BP) control in the ACCORD trial, Dr. Jolobe inquires whether the prevalence of orthostatic hypotension differed between the intensive and standard BP control groups. He further notes that orthostatic hypotension may not be accompanied by symptoms. The ACCORD BP trial did gather data on orthostatic BP change and dizziness on standing in a subgroup of participants. Of the 3,099 participants included in our analysis, orthostatic BP measurements and reports of dizziness or lightheadedness on standing during the measurement are available on 905 participants at baseline. We also have data on a subgroup of 607 participants who were assessed for health-related quality of life at baseline and 12 months. This included a question about dizziness on standing within the previous month.Seated and standing brachial artery BP was measured using an Omron model HEM-907 automatic sphygmomanometer. After 7 m ...
    No preview · Article · Feb 2015 · Journal of General Internal Medicine
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    ABSTRACT: -Previous studies have demonstrated the psychosocial impact of Heart Failure in patients with reduced ejection fraction (EF). However, the effects on patients with preserved EF have not yet been elucidated. The present study aimed to determine the baseline characteristics of participants with Heart Failure with preserved ejection fraction (HFpEF) as it relates to impaired quality of life (QOL) and depression, identify predictors of poor QOL and depression, and determine the correlation between QOL and depression. -Among patients enrolled in the TOPCAT trial, 3400 patients completed the Kansas City Cardiomyopathy Questionnaire (KCCQ), 3395 patients completed EuroQOL 5D Visual Analog Scale (EQ-5D VAS), and 1431 patients in US and Canada completed the Patient Health Questionnaire-9. The mean summary score on the KCCQ was 54.8; and on EQ-5D VAS was 60.3; 27% of patients had moderate to severe depression. Factors associated with better KCCQ and EQ-5D VAS via multiple logistic regression analysis (MLRA) were American region, older age; no history of angina pectoris or asthma, no use of hypoglycemic agent; more activity level; and lower NYHA class. Factors associated with depression via MLRA included younger age, female gender, comorbid angina, COPD, use of a hypoglycemic agent, lower activity level, higher NYHA class, and SSRI use. There were significant correlations between each of the QOL scores and depression. -Patients with HFpEF who were younger, had higher NYHA class or comorbid angina pectoris, had lower activity levels, lived in Eastern Europe or were taking hypoglycemic agents, were more likely to have impaired QOL and depression. Clinical Trial Registration-URL: Unique identifier: NCT00094302.
    Preview · Article · Feb 2015 · Circulation Heart Failure
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    Full-text · Article · Jan 2015 · Circulation Heart Failure
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    ABSTRACT: -Treatment of Preserved Cardiac Function Heart Failure With an Aldosterone Antagonist (TOPCAT) patients with heart failure and preserved left ventricular ejection fraction assigned to spironolactone did not achieve a significant reduction in the primary composite outcome (time to cardiovascular death, aborted cardiac arrest, or hospitalization for management of heart failure) compared with patients receiving placebo. In a post hoc analysis, an ≈4-fold difference was identified in this composite event rate between the 1678 patients randomized from Russia and Georgia compared with the 1767 enrolled from the United States, Canada, Brazil, and Argentina (the Americas). -To better understand this regional difference in clinical outcomes, demographic characteristics of these populations and their responses to spironolactone were explored. Patients from Russia/Georgia were younger, had less atrial fibrillation and diabetes mellitus, but were more likely to have had prior myocardial infarction or a hospitalization for heart failure. Russia/Georgia patients also had lower left ventricular ejection fraction and creatinine but higher diastolic blood pressure (all P<0.001). Hyperkalemia and doubling of creatinine were more likely and hypokalemia was less likely in patients receiving spironolactone in the Americas with no significant treatment effects in Russia/Georgia. All clinical event rates were markedly lower in Russia/Georgia, and there was no detectable impact of spironolactone on any outcomes. In contrast, in the Americas, the rates of the primary outcome, cardiovascular death, and hospitalization for heart failure were significantly reduced by spironolactone. -This post hoc analysis demonstrated greater potassium and creatinine changes and possible clinical benefits with spironolactone in patients with heart failure and preserved ejection fraction from the Americas. Clinical Trial Registration-URL: Unique identifier: NCT00094302.
    Preview · Article · Nov 2014 · Circulation

Publication Stats

15k Citations
2,350.06 Total Impact Points


  • 2005-2015
    • National Heart, Lung, and Blood Institute
      • Division of Cardiovascular Sciences (DCVS)
      베서스다, Maryland, United States
    • Tufts University
      • Jean Mayer USDA Human Nutrition Research Center on Aging
      Georgia, United States
  • 1982-2014
    • National Institute on Aging
      • • Laboratory of Cardiovascular Science (LCS)
      • • Clinical Research Branch (CRB)
      • • Laboratory of Clinical Investigation (LCI)
      • • Human Cardiovascular Studies Unit
      Baltimore, MD, United States
  • 2013
    • Durham University
      Durham, England, United Kingdom
    • Brigham and Women's Hospital
      • Division of Cardiovascular Medicine
      Boston, Massachusetts, United States
  • 2011
    • American College of Cardiology
      Washington, Washington, D.C., United States
  • 2010
    • Henry Ford Hospital
      Detroit, Michigan, United States
  • 2002-2008
    • National Institutes of Health
      • Laboratory of Cardiovascular Science (LCS)
      Maryland, United States
    • University of Pittsburgh
      • Department of Human Genetics
      Pittsburgh, Pennsylvania, United States
  • 1986-2008
    • Johns Hopkins Medicine
      • • Department of Medicine
      • • Division of Cardiology
      Baltimore, Maryland, United States
  • 1987-2004
    • Johns Hopkins University
      • • Division of Cardiology
      • • Department of Medicine
      • • Department of Environmental Health Sciences
      Baltimore, MD, United States
  • 2001-2003
    • University of Maryland, College Park
      • Department of Kinesiology
      College Park, MD, United States
    • Duke University
      Durham, North Carolina, United States
  • 1982-2001
    • University of Maryland, Baltimore
      • Department of Medicine
      Baltimore, Maryland, United States
  • 2000
    • University of Maryland Eastern Shore
      • Department of Physical Therapy
      Maryland, United States
  • 1999
    • Osaka University
      Suika, Ōsaka, Japan
  • 1994
    • University of Saskatchewan
      Saskatoon, Saskatchewan, Canada