Marlene S Williams’s research while affiliated with Johns Hopkins University and other places

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Publications (38)


Antiplatelet therapy in stable ischemic heart disease without indication for chronic oral anticoagulation. DAPT = dual antiplatelet therapy; IHD = ischemic heart disease; OAC = oral anticoagulation; PCI = percutaneous coronary intervention; SAPT = single antiplatelet therapy
Should We Use Aspirin or P2Y12 Inhibitor Monotherapy in Stable Ischemic Heart Disease?
  • Literature Review
  • Publisher preview available

September 2024

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23 Reads

Current Atherosclerosis Reports

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Adhya Mehta

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Roger S. Blumenthal

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Marlene S. Williams

Purpose of Review To summarize the recent evidence and guideline recommendations on aspirin or P2Y12 inhibitor monotherapy in patients with stable ischemic heart disease and provide insights into future directions on this topic, which involves transition to a personalized assessment of bleeding and thrombotic risks. Recent Findings It has been questioned whether the evidence for aspirin as the foundational component of secondary prevention in patients with coronary artery disease aligns with contemporary pharmaco-invasive strategies. The recent HOST-EXAM study randomized patients who had received dual antiplatelet therapy for 6 to 18 months without ischemic or major bleeding events to either clopidogrel or aspirin for a further 24 months, and demonstrated that the patients in the clopidogrel arm had significantly lower rates of both thrombotic and bleeding complications compared to those in the aspirin arm. The patient-level PANTHER meta-analysis showed that in patients with established coronary artery disease, P2Y12 inhibitor monotherapy was associated with lower rates of myocardial infarction, stent thrombosis as well as gastrointestinal bleeding and hemorrhagic stroke compared to aspirin monotherapy, albeit with similar rates of all-cause mortality, cardiovascular mortality and major bleeding. Summary Long-term low-dose aspirin is recommended for secondary prevention in patients with stable ischemic heart disease, with clopidogrel monotherapy being acknowledged as a feasible alternative. Dual antiplatelet therapy for six months after percutaneous coronary intervention remains the standard recommendation for patients with stable ischemic heart disease. However, the duration of dual antiplatelet therapy may be shortened and followed by P2Y12 inhibitor monotherapy or prolonged based on individualized evaluation of the patient’s risk profile.

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2023 AHA/ACC/ACCP/ASPC/NLA/PCNA Guideline for the Management of Patients With Chronic Coronary Disease: A Report of the American Heart Association/American College of Cardiology Joint Committee on Clinical Practice Guidelines

July 2023

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213 Reads

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547 Citations

Circulation

AIM The “2023 AHA/ACC/ACCP/ASPC/NLA/PCNA Guideline for the Management of Patients With Chronic Coronary Disease” provides an update to and consolidates new evidence since the “2012 ACCF/AHA/ACP/AATS/PCNA/SCAI/STS Guideline for the Diagnosis and Management of Patients With Stable Ischemic Heart Disease” and the corresponding “2014 ACC/AHA/AATS/PCNA/SCAI/STS Focused Update of the Guideline for the Diagnosis and Management of Patients With Stable Ischemic Heart Disease.” Methods A comprehensive literature search was conducted from September 2021 to May 2022. Clinical studies, systematic reviews and meta-analyses, and other evidence conducted on human participants were identified that were published in English from MEDLINE (through PubMed), EMBASE, the Cochrane Library, Agency for Healthcare Research and Quality, and other selected databases relevant to this guideline. Structure This guideline provides an evidenced-based and patient-centered approach to management of patients with chronic coronary disease, considering social determinants of health and incorporating the principles of shared decision-making and team-based care. Relevant topics include general approaches to treatment decisions, guideline-directed management and therapy to reduce symptoms and future cardiovascular events, decision-making pertaining to revascularization in patients with chronic coronary disease, recommendations for management in special populations, patient follow-up and monitoring, evidence gaps, and areas in need of future research. Where applicable, and based on availability of cost-effectiveness data, cost–value recommendations are also provided for clinicians. Many recommendations from previously published guidelines have been updated with new evidence, and new recommendations have been created when supported by published data.


2023 AHA/ACC/ACCP/ASPC/NLA/PCNA Guideline for the Management of Patients With Chronic Coronary Disease: A Report of the American Heart Association/American College of Cardiology Joint Committee on Clinical Practice Guidelines

July 2023

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230 Reads

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163 Citations

Journal of the American College of Cardiology

Aim: The "2023 AHA/ACC/ACCP/ASPC/NLA/PCNA Guideline for the Management of Patients With Chronic Coronary Disease" provides an update to and consolidates new evidence since the "2012 ACCF/AHA/ACP/AATS/PCNA/SCAI/STS Guideline for the Diagnosis and Management of Patients With Stable Ischemic Heart Disease" and the corresponding "2014 ACC/AHA/AATS/PCNA/SCAI/STS Focused Update of the Guideline for the Diagnosis and Management of Patients With Stable Ischemic Heart Disease." Methods: A comprehensive literature search was conducted from September 2021 to May 2022. Clinical studies, systematic reviews and meta-analyses, and other evidence conducted on human participants were identified that were published in English from MEDLINE (through PubMed), EMBASE, the Cochrane Library, Agency for Healthcare Research and Quality, and other selected databases relevant to this guideline. Structure: This guideline provides an evidenced-based and patient-centered approach to management of patients with chronic coronary disease, considering social determinants of health and incorporating the principles of shared decision-making and team-based care. Relevant topics include general approaches to treatment decisions, guideline-directed management and therapy to reduce symptoms and future cardiovascular events, decision-making pertaining to revascularization in patients with chronic coronary disease, recommendations for management in special populations, patient follow-up and monitoring, evidence gaps, and areas in need of future research. Where applicable, and based on availability of cost-effectiveness data, cost-value recommendations are also provided for clinicians. Many recommendations from previously published guidelines have been updated with new evidence, and new recommendations have been created when supported by published data.


What Is the Optimal Duration of Antiplatelet Therapy for Patients with Coronary Heart Disease?

May 2023

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21 Reads

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2 Citations

Current Atherosclerosis Reports

Purpose of Review Optimal duration of antiplatelet therapy continues to attract extensive debates and has been progressively adjusted in the setting of advancements in stent design and assessment of patient clinical characteristics. Given the ever-changing landscape of antiplatelet therapy and the multitude of clinical trials that have examined this duration, there are varying scenarios for optimal duration based on patient presentation and risk profile. This review highlights the current concepts and recommendations regarding duration of antiplatelet therapy in coronary heart disease. Recent Findings In particular, we review the current data on the use of dual antiplatelet therapy in the different clinical scenarios. Relatively longer dual antiplatelet therapy is perhaps limited to patients with higher risk for cardiovascular events and/or high-risk lesions and shorter durations of dual antiplatelet therapy have been shown to reduce bleeding complications at the same time as stabilization of ischemic endpoints. Summary More recent trials have demonstrated the safety of shorter durations of dual antiplatelet therapy in appropriate patients with coronary heart disease.




Center Variation in Use of Preoperative Dual Antiplatelet Therapy and Platelet Function Testing at the Time of Coronary Artery Bypass Grafting in Maryland

April 2022

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29 Reads

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4 Citations

Anesthesia & Analgesia

Background: Patients presenting with acute coronary syndrome are administered a P2Y 12 inhibitor and aspirin before coronary catheterization to prevent further myocardial injury from thrombosis. Guidelines recommend a standard waiting period between the time patients are administered dual antiplatelet therapy (DAPT) and elective cardiac surgery. Since 25% to 30% of the population may be considered nonresponders to clopidogrel, platelet function testing can be utilized for timing of surgery and to assess bleeding risks. The extent to which a standard waiting period or platelet function testing is used across centers is not established, representing an important opportunity to standardize practice. Methods: We conducted a retrospective cohort study from 2011 to 2020 using data from the Maryland Cardiac Surgical Quality Initiative, a consortium of all 10 hospitals in the state performing cardiac surgery. The proportion of patients administered DAPT within 5 days of surgery was examined by hospital over the time period. Mixed-effects multivariable logistic regressions were used to examine the association of preoperative DAPT with ischemic and bleeding outcomes. Centers were surveyed on use or nonuse of preoperative platelet function testing, and bleeding outcomes were compared. Results: There was significant heterogeneity of preoperative DAPT usage across centers ranging from 2% to 54% ( P < .001). DAPT within 5 days of isolated coronary artery bypass grafting (CABG) was associated with higher odds of reoperation for bleeding (odds ratio [OR], 1.55; 95% confidence interval [CI], 1.19-2.01; P = .001), >2 units of red blood cells (RBCs) transfused (OR, 1.62; 95% CI, 1.44-1.81; P < .001), and >2 units of non-RBCs transfused (OR, 1.79; 95% CI, 1.60-2.00; P < .001). In the 5 hospitals using preoperative platelet function testing to guide timing of surgery, there were greater odds for DAPT within 5 days (OR, 1.33; 95% CI, 1.22-1.45; P < .001), fewer RBCs >2 units transfusions (22% vs 33%; P < .001), and non-RBCs >2 units (17% vs 28%; P < .001) transfusions within DAPT patients. Conclusions: There is significant variability in DAPT usage within 5 days of CABG between hospital centers. Preoperative platelet function testing may allow for earlier timing of surgery for those on DAPT without increased bleeding risks.


The Trajectory of Lipoprotein(a) During the Peri- and Early Postinfarction Period and the Impact of Proprotein Convertase Subtilisin/Kexin Type 9 Inhibition

March 2022

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28 Reads

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18 Citations

The American Journal of Cardiology

Lipoprotein(a), or Lp(a), levels and the effect of proprotein convertase subtilisin/kexin type 9 (PCSK9) inhibition on Lp(a) during the peri-infarction and early postinfarction period are not well characterized. This study aimed to describe the trajectory of Lp(a), as well as the effect of PCSK9 inhibition on that trajectory during the peri-infarction and early postinfarction period. Lp(a) levels were obtained within 24 hours of hospital admission as well as within 24 hours of hospital discharge and at 30 days from 74 participants who presented with a NSTEMI (troponin I >5 ng/ml) or with a STEMI and were enrolled in 2 randomized, double-blind trials of evolocumab and placebo (Evolocumab in Acute Coronary Syndrome [EVACS I]; ClinicalTrials.gov, NCT03515304 and Evolocumab in Patients With STEMI [EVACS II]; ClinicalTrials.gov Identifier: NCT04082442). There was a significant increase from the pretreatment level in the placebo-treated patients, from 64 (41,187) nmol/L to 80 (47, 172) nmol/L at hospital discharge and to 82 (37, 265) at 30 days. This was primarily driven by the results from participants with high Lp(a) at hospital admission (>75 nmol/L) in whom the median increase was 28% as compared with a 10% increase in those with pretreatment Lp(a) of <75 nmol/L. In contrast, there was no significant change from the pretreatment level in the evolocumab-treated patients regardless of pretreatment Lp(a) levels. In conclusion, Lp(a) rises during the peri-infarction and early postinfarction period in patients with acute myocardial infarction. The increase was prevented by a single dose of subcutaneous evolocumab given within 24 hours of hospital admission.


Figure 1 CCT of ASA. Cardiac computed tomographic images demonstrate redundant atrial septal tissue with a large ASA protruding into the right atrium (RA). (A) Multiplanar reconstruction, oblique axial orientation, apical four-chamber display of the interatrial septum. Temporal resolution of CCT results in a degree of blurring of the image at the tip of the ASA, and grossly, no interatrial shunt is visualized. (B) Three-dimensional volume-rendered reconstruction image of the whole heart, highlighting the large ASA. LA, left atrium; LV, left ventricle; RCA, right coronary artery; RV, right ventricle.
Figure 2 Apical four-chamber view of ASA. A still frame of the apical four-chamber view on TTE is shown. Following agitated saline injection, there is evidence of a well-delineated large ASA protruding into the right atrium.
Right heart chamber size and function
Large Atrial Septal Aneurysm Associated with Secundum Atrial Septal Defect

March 2022

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54 Reads

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4 Citations

CASE

• A structured multimodality approach is imperative in evaluating interatrial anatomy. • Secundum ASDs may be associated with ASA. • Interatrial shunts may be missed, especially when aneurysms are large. • Three-dimensional TEE allows careful interrogation of concomitant septal defects.


Citations (28)


... To promote healthy behaviours among young populations, it might be particularly interesting to draw their attention to the "immediate" benefits of a healthy lifestyle; among these benefits, the perception of well-being and improved quality of life may play a pivotal role [9]. It might be particularly appropriate to change young adults' "point of view" [10][11][12] via preventive strategies, focusing more on well-being and the promotion of healthy behaviours (in particular, a physically active life, healthy nutrition, non-smoking, stress management, and sleep hygiene) than solely on reducing traditional cardio-metabolic risk factors (such as high cholesterol level, high blood pressure, overweight/obesity, etc), which often are within the normal range. Recently, we have shown [9] that young employees present a worse lifestyle than older ones, even without alterations in anthropometric, metabolic, lipid, and haemodynamic parameters. ...

Reference:

Assessing Lifestyle in a Large Cohort of Undergraduate Students: Significance of Stress, Exercise and Nutrition
2023 AHA/ACC/ACCP/ASPC/NLA/PCNA Guideline for the Management of Patients With Chronic Coronary Disease: A Report of the American Heart Association/American College of Cardiology Joint Committee on Clinical Practice Guidelines
  • Citing Article
  • July 2023

Journal of the American College of Cardiology

... As the name suggests, CCD, a direct byproduct of atherosclerosis, is a chronic disease, and therefore, it is imperative to be informed of the up-to-date guidelines. In 2023, Visani et al. published the American Heart Association (AHA) guidelines regarding the management of patients with CCD [99]. The guidelines include weight management techniques, lipid-lowering strategies, blood pressure control, and interventions for specific populations such as women and individuals with valvular problems or CKD. ...

2023 AHA/ACC/ACCP/ASPC/NLA/PCNA Guideline for the Management of Patients With Chronic Coronary Disease: A Report of the American Heart Association/American College of Cardiology Joint Committee on Clinical Practice Guidelines
  • Citing Article
  • July 2023

Circulation

... Baseline CAD (history of heart attack and/or stent procedure) and chronic kidney disease (CKD) were assessed utilizing self-report. Non-contrast computed tomography (CT) scans of the chest were used to quantify CAC burden by Agatston score, quantified by a single fellowship-trained cardiothoracic radiologist (C.T.L.) as described previously [23]. ...

Urine and Plasma Markers of Platelet Activation and Respiratory Symptoms in COPD
  • Citing Article
  • January 2022

Chronic Obstructive Pulmonary Diseases Journal of the COPD Foundation

... Acute myocardial infarction (AMI) is a common manifestation of ischemic heart disease, characterized by myocardial cell death due to sudden reduction in coronary artery blood flow and subsequent myocardial ischemia [3]. Typical symptoms include chest discomfort or pain that is more severe than angina pectoris [4]. The high incidence and mortality rates associated with AMI lead to substantial healthcare costs, impacting individuals, families, healthcare systems, and nations economically [5]. ...

2022 ACC/AHA Key Data Elements and Definitions for Chest Pain and Acute Myocardial Infarction
  • Citing Article
  • August 2022

Journal of the American College of Cardiology

... Of particular interest, ACS often begins with patient-reported chest pain, which can be described in various word descriptors (e.g., dull, pressure, stabbing, heaviness, or squeezing). 2 These symptoms reflect the pathophysiological process of myocardial damage, most commonly due to blockage of coronary arteries. [2][3][4] The timing of chest pain or other anginal equivalent symptoms helps clinicians determine the urgency of care and eligibility for specific time-sensitive therapies such as percutaneous coronary intervention (PCI). ...

2022 ACC/AHA Key Data Elements and Definitions for Chest Pain and Acute Myocardial Infarction: A Report of the American Heart Association/American College of Cardiology Joint Committee on Clinical Data Standards
  • Citing Article
  • August 2022

Circulation Cardiovascular Quality and Outcomes

... One example of bringing evidence into practice with robust data from within and across multiple institutions is reducing variation in practice. Practice variation is a common problem, as shown by Hensley et al. 22 Health care centers should collaboratively strive to reduce variability by following PBM evidence and guidelines while using robust outcome data to track and identify areas in which care could be improved. ...

Center Variation in Use of Preoperative Dual Antiplatelet Therapy and Platelet Function Testing at the Time of Coronary Artery Bypass Grafting in Maryland
  • Citing Article
  • April 2022

Anesthesia & Analgesia

... It includes defects that involve the true septal membrane and those that allow communication between both atria [1]. Aneurysmal ASDs refer to an abnormal localized bulging or enlargement of the atrial septum, with an incidence of 1-2.5% in the general population [2], while typical ASDs involve a straightforward, uniform defect in the interatrial septum without any associated aneurysm formation [3]. The management of patients with aneurysmal ASDs poses challenges as it requires careful observation and earlier intervention to mitigate complications such as cardioembolic stroke. ...

Large Atrial Septal Aneurysm Associated with Secundum Atrial Septal Defect

CASE

... A pooled analysis [70] of patients enrolled in the EVACS I and in the EVACS II trial (still ongoing), including 74 patients with an ACS diagnosis, who were randomized to receive evolocumab or placebo within 24 hours of hospitalization, revealed that the early use of PCSK9Is is not associated to a surge in Lp(a) levels at 30 days, which occurred in the placebo group. In fact, at 30 days, the placebo group showed a significant increase in Lp(a) to 82 nmol/L (24% median percentage increase, p < 0.01), while the evolocumab group exhibited no significant change (44 nmol/L, 0% median percentage change, p = 0.86) [70]. ...

The Trajectory of Lipoprotein(a) During the Peri- and Early Postinfarction Period and the Impact of Proprotein Convertase Subtilisin/Kexin Type 9 Inhibition
  • Citing Article
  • March 2022

The American Journal of Cardiology

... Inhibition of P-selectin is being tested to prevent the detrimental effects of immunothrombosis in various settings, including in patients with COVID-19 [18,19]. We tested the effects of an anti-P-selectin blocking antibody on the frequency of the PLAs in the blood of 3 patients with COVID-19 in noncritical conditions. ...

Effect of Crizanlizumab, a P-Selectin Inhibitor, in COVID-19

JACC Basic to Translational Science

... Dentro de las experiencias internacionales, a la fecha de publicación, no se encontraron resultados de unidades reconvertidas con presencia de VM con máquinas de anestesia. Son varios los artículos que hacen referencia a los desafíos de trasladar la UCI a otras dependencias; respecto a espacio, staff, equipamiento, manejo de infecciones y bioseguridad [1], [8], [10], [15], [16], desafíos que también tuvieron que ser resueltos en nuestro centro. ...

Alternative Cardiac Intensive Care Unit Locations during the COVID-19 pandemic at an Academic Medical Center
  • Citing Article
  • January 2021

Heart & Lung