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446

New England journal of medicine. 2020:382(25):2441-2448.DOI: 10.1056/NEJMoa2008975

Renin-Angiotensin-Aldosterone System Inhibitors and Risk of Covid-19

Reynolds, Harmony R; Adhikari, Samrachana; Pulgarin, Claudia; Troxel, Andrea B; Iturrate, Eduardo; Johnson, Stephen B; Hausvater, Anaïs; Newman, Jonathan D; Berger, Jeffrey S; Bangalore, Sripal; Katz, Stuart D; Fishman, Glenn I; Kunichoff, Dennis; Chen, Yu; Ogedegbe, Gbenga; Hochman, Judith S
BACKGROUND:There is concern about the potential of an increased risk related to medications that act on the renin-angiotensin-aldosterone system in patients exposed to coronavirus disease 2019 (Covid-19), because the viral receptor is angiotensin-converting enzyme 2 (ACE2). METHODS:We assessed the relation between previous treatment with ACE inhibitors, angiotensin-receptor blockers, beta-blockers, calcium-channel blockers, or thiazide diuretics and the likelihood of a positive or negative result on Covid-19 testing as well as the likelihood of severe illness (defined as intensive care, mechanical ventilation, or death) among patients who tested positive. Using Bayesian methods, we compared outcomes in patients who had been treated with these medications and in untreated patients, overall and in those with hypertension, after propensity-score matching for receipt of each medication class. A difference of at least 10 percentage points was prespecified as a substantial difference. RESULTS:Among 12,594 patients who were tested for Covid-19, a total of 5894 (46.8%) were positive; 1002 of these patients (17.0%) had severe illness. A history of hypertension was present in 4357 patients (34.6%), among whom 2573 (59.1%) had a positive test; 634 of these patients (24.6%) had severe illness. There was no association between any single medication class and an increased likelihood of a positive test. None of the medications examined was associated with a substantial increase in the risk of severe illness among patients who tested positive. CONCLUSIONS:We found no substantial increase in the likelihood of a positive test for Covid-19 or in the risk of severe Covid-19 among patients who tested positive in association with five common classes of antihypertensive medications.
PMID: 32356628
ISSN: 1533-4406
CID: 4412912
Annals of vascular surgery. 2020:65:55-65.DOI: 10.1016/j.avsg.2019.10.055

High Prevalence and Mortality Associated with Upper Extremity Deep Venous Thrombosis in Hospitalized Patients at a Tertiary Care Center

Rokosh, Rae S; Ranganath, Neel; Yau, Patricia; Rockman, Caron; Sadek, Mikel; Berland, Todd; Jacobowitz, Glenn; Berger, Jeff; Maldonado, Thomas S
OBJECTIVE:MATERIAL AND METHODS: This is a single tertiary care center retrospective cohort study of all consecutive inpatients diagnosed with acute VTE from June 2015 to December 2015. During this period, 4495 patients underwent venous duplex examination (622 UE and 3873 LE), identifying 83 inpatient DVTs. Chronic DVT as well as those diagnosed in the outpatient population were excluded. DVTs were classified as either provoked or unprovoked. Provoked DVT were defined as the presence of any of the following factors within 30 days prior to diagnosis: major surgery, immobilization (greater than 3 days of bedrest), trauma, infection requiring antibiotics, central venous access, pregnancy, and/or hormonal medication use. Inpatient pulmonary embolisms (PE) detected on chest computed tomography (CT) were also evaluated during this time frame. Patient data were collected including age, gender, race, lifestyle factors, comorbidities, VTE risk factors, symptomatology at presentation, management including anticoagulation choice and filter placement if applicable, as well as discharge disposition. Statistical analysis was performed using GraphPad Prism 8.0 (GraphPad Software, San Diego, California, USA), and a threshold p-value of < 0.05 set for significance. RESULTS:During the study period, 83 DVTs (48 LEDVT, 35 UEDVT) and 24 PE were identified in 96 inpatients. Of these DVTs, 77.1% of these were defined as provoked. Eleven patients had simultaneous DVT and PE, and thirteen patients had PE with presumed occult pelvic or LEDVT. UEDVT patients had a higher proportion of comorbidities than LEDVT patients: coronary artery disease (25.7% vs. 13.1%, p=0.16), congestive heart failure (20% vs. 6.6%, p=0.09), as well as a trend toward higher incidence of malignancy (60% vs. 42.6%, p=0.13). Of provoked VTE, UEDVT correlated more significantly with central venous catheters (88.4% vs. 12.5%, p=<0.0001), but was less commonly associated with prolonged bed rest (19.2% vs. 39.5%, p=0.11). PE was diagnosed in 24/96 (25%) of the study population. Patients with LEDVT were found to have a significantly higher incidence of PE compared to those with UEDVT (34.4% vs. 8.6%, p=0.006). Same-admission mortality for patients with VTE was 13/96 (13.5%). Of these, patients with UEDVT had significantly higher all-cause mortality than patients with LEDVT (28.5% vs. 4.9%, p=0.004). When catheter-related UEDVT were excluded, there remained a significant difference in mortality between non-catheter related UEDVT and LEDVT (33.3% vs. 4.9% p=0.0119). CONCLUSIONS:This study demonstrates a high prevalence of UEDVT in hospitalized patients who experience VTE. Despite a lower incidence of synchronous PE, patients with UEDVT had a higher prevalence of significant medical comorbidities and higher all-cause mortality on the index hospital admission.
PMID: 31669473
ISSN: 1615-5947
CID: 4162582
New England journal of medicine. 2020:382(17):1608-1618.DOI: 10.1056/NEJMoa1915925

Management of Coronary Disease in Patients with Advanced Kidney Disease

Bangalore, Sripal; Maron, David J; O'Brien, Sean M; Fleg, Jerome L; Kretov, Evgeny I; Briguori, Carlo; Kaul, Upendra; Reynolds, Harmony R; Mazurek, Tomasz; Sidhu, Mandeep S; Berger, Jeffrey S; Mathew, Roy O; Bockeria, Olga; Broderick, Samuel; Pracon, Radoslaw; Herzog, Charles A; Huang, Zhen; Stone, Gregg W; Boden, William E; Newman, Jonathan D; Ali, Ziad A; Mark, Daniel B; Spertus, John A; Alexander, Karen P; Chaitman, Bernard R; Chertow, Glenn M; Hochman, Judith S; Abdallah, Abdallah M; Moreyra, Abel E; Laddu, Abhay A; Dubey, Abhishek; Goyal, Abhishek; Knighton, Abigail; Adeboye, Adedayo; Juceviciene, Agne; Urboniene, Agne; Szramowska, Agnieszka; Abdel-Latif, Ahmed; Ayoub, Ahmed; Elghamaz, Ahmed; Kamal, Ahmed; Talaat, Ahmed; Sharma, Ajay; Narula, Ajit Singh; Bagai, Akshay; Smigelskaite, Akvile; Raymond, Alain; Rheault, Alain; Loehr, Alaine Melanie; Varga, Albert; Maggioni, Aldo P; Moorman, Alec; Chevaile Ramos, Alejandro; Gisbert, Alejandro; Fratczak, Aleksandra; Laucevicius, Aleksandras; Chernyavskiy, Alexander M; Borisov, Alexander Sergeevich; Craft, Alexandra; Hunter, Alexandra; Hueb, Alexandre Ciappina; Schaan de Quadros, Alexandre; Muller, Alice Manica; Deiro, Aline Peixoto; Stone, Allegra; Castro, Almudena; Uxa, Amar; Van Craenenbroeck, Amaryllis; Roy, Ambuj; Kakkar, Amit; Flowers, Amy; Iskandrian, Amy; Djordjevic-Dikic, Ana D; Gomes Almeida, Ana; Francisco, Ana Rita; Mladenovic, Ana S; Santana, Ana; Lahiri, Anandaroop; Kuzmina-Krutetskaya, Anastasia M; Vamvakidou, Anastasia; Vertes, Andras; Gabriel, Andre; Bartykowszki, Andrea; Lorimer, Andrea; Pascual, Andrea; Coelho, Andreia; Rocha, Andreia; García-Rincón, Andrés; Starovoytov, Andrew; Łabyk, Andrzej; Kawakami, Anelise; Hoye, Angela; Nobre, Angelo; Acharya, Anjali; Anand, Anjali; Rishmawi, Anjana; Banfield, Ann; Luyten, Ann; Cichocka-Radwan, Anna; Fojt, Anna; Plachcinska, Anna; Teresinska, Anna; Webb, Anne Marie; Heath, Anne; Mathew, Anoop; Vega, Antonia; Carvalho, Antonio; Colombo, Antonio; Fiarresga, Antonio; Tharini, Anu; Rao, Anupama; Valdespino-Estrada, Aquiles; Diaz, Ariel; Asif, Arif; Seto, Arnold H; Campos-Santaolalla, Arturo S; Cheema, Asim N; Ahmed, Asker; Mathur, Atul; Leong, Audrey W; Ã…kerblom, Axel; Fuentes, Axelle; Naher, Aynun; Valaiyapathi, Badhma; Srinivasan, Balaji; Kaur, Baljeet; Bhargava, Balram; Guruge, Bandula; Wicklund, Barbara; Czarniak, Bartosz; Singh, Bebek; Igual, Begoña; Merkely, Bela; Shah, Benoy N; de Bruyne, Bernard; Abramson, Beth; Stefanchik, Beth; Harvey, Bethany; Shivalkar, Bharati; Malik, Bilal; Kurian, Binoy Mannekkattukudy; Hammouche, Bougrida; Beleslin, Branko D; Ferguson, Bruce; McManus, Bruce; Ascoli, Bruna Maria; Smith, Bryn; Allen, Byron J; Gibson, C Michael; Bairey Merz, C Noel; Pop, Calin; Gagné, Carl-Éric; Ohmart, Carly; Kartje, Carol M; Alsweiler, Caroline; Rodgers, Caroline; Spindler, Caroline; Gruber, Carolyn J; Albert, Catherine; Bone, Catherine; Lemay, Catherine; Kepka, Cezary; Suvarna, Chandini; Mercure, Chantale; Wiyarand, Charlene; Patel, Chetan; Attanasio, Chiara; Chow, Chi-Ming; Er, Ching Min; Ong, Ching-Ching; Manjunath, Cholenahally Nanjappa; Buller, Chris; Vassaliere, Christel; Vrints, Christiaan; Witzke, Christian; Ballantyne, Christie; Björklund, Christina; Roraff, Christine; Laure, Christophe; Thuaire, Christophe; Chan, Christopher; Fordyce, Christopher; Kinsey, Christopher; Xia, Chunli; Schultz, Cidney; Held, Claes; Cortés, Claudia; Escobar, Claudia; Freixo, Cláudia; Kadalie, Clemens T; Thobois, Corine; Page, Courtney; Bare, Cristina; Espinosa, Dalisa; Gao, Dan; Rizk, Dana; Puzhevsky, Daniela; Analyst, Data; Charytan, David M; Williams, David O; Booth, David; Charytan, David; Cohen, David; DeMets, David; Foo, David; Goldfarb, David; Schlichting, David; Sisson, David; Taggart, David; Waters, David; Wheeler, David; Williams, David; Vo, Davis; Teodorczyk, Dawid; Shelstad, Dawn D; Kereiakes, Dean; Yip, Deborah; Ramaswamy, Deepa; Mattina, Deirdre; Murphy, Deirdre; Jiang, Dengke; Cyr, Derek; Cukali, Diana; Camara, Diane; Stournaras, Dimitrios; Patel, Dipti; Li, Dongze; Exley, Donna; Reimann, Doreen; Schwartz, Doron; Cacela, Duarte; Conway, Dwayne S G; Punnoose, Eapen; Tay, Edgar L; Karanjah, Edgar; Gomes Lima, Eduardo; Hernandez-Rangel, Eduardo; Nicol, Edward D; Kaczmarska, Edyta; Refoyo Salicio, Elena; Feen, Eli; Durán-Cortés, Elihú; Janzen, Elisabeth M; van Dongen, Elise; Restelli Piloto, Elissa; Srbinovska Kostovska, Elizabeta; Capasso-Gulve, Elizabeth; Zbyshevskaya, Elizaveta V; Fridell, Ellie; Lader, Ellis W; Gosmanova, Elvira; Tachot, Emilie; Howard, Emma; Sorbets, Emmanuel; Alonso-Álvarez, Encarnación; Daugas, Eric; Alexánderson Rosas, Erick; Montpetit, Estelle; Passamani, Eugene; Shutov, Evgeny; Szczerba, Ewa; Wojtala, Ewelina; Ribeiro Silva, Expedito Eustáquio; Fimiani, Fabio; Hage, Fadi; Jafary, Fahim Haider; Feng, Fang; Ranjbaran, Fatima; Pinto, Fausto J; Caeiro, Fernando; Nolasco, Fernando; Silva, Filipa; Ottani, Filippo; Al Solaiman, Firas; Egydio, Flávia; Chereches, Florina; De Micco, Francesca; Bianchini, Francesca; Pietrucci, Francesca; Orso, Francesco; Pisano, Francesco; Patuleia Figueiras, Francisca; Madore, François; Harrell, Frank; Rockhold, Frank; Van de Werf, Frans; Guenther, Franziska; Mohr, Fred; Karthikeyan, G; Galeote, Gabriel; Grossmann, Gabriel; Steg, Gabriel; Guzman, Gabriela; Gabrielli, Gabriele; Chen, Gang; Sharma, Gautam; Petty, Gaylin; Mikolaitiene, Gelmina; Yee, Gennie; Devlin, Gerard Patrick; Esposito, Gerard; Ágoston, Gergely; Lamas, Gervasio; Cobb, Gia; Perna, Gian Piero; Leone, Gianpiero; Mishra, Girish; Barge-Caballero, Gonzalo; Young, Grace M; Scaro, Graciela; Wong, Graham; Pressman, Gregg; Simonis, Gregor; Steinmaurer, Gudrun; Portugal, Guilherme; Cantinho Lopes, Guilhermina; Garcia-Garcia, Guillermo; Wang, Guoqin; Wander, Gurpreet S; Gulati, Gurpreet; Zhang, Haibo; Marciniak, Halina; Dai, Hao; Dong, Haojian; Franch, Harold; White, Harvey; Elabd, Hatem; Pomeroy, Hayley; Golden, Heather; Wilson, Heidi; Abergel, Helene; Siddaram, Hemalata; Mahapatra, Hemant Shakhar; Stokes, Henry C; Osseni, Hermine; Schuchlenz, Herwig; Skali, Hicham; Mattix-Kramer, Holly; Cheng, Hong; Mahrous, Hossam; Pejkov, Hristo; Marques, Hugo; Zhong, Hui; El Fishawy, Hussien; Webb, Ian; Kullo, Iftikhar; Grazhdankin, Igor O; Hassan, Ikraam; Pina, Ileana L; Tamasauskiene, Ilona; Cabrita, Inês Zimbarra; Rodrigues, Ines; Soveri, Inga; Mitevska, Irena Peovska; Lang, Irene Marthe; Subbotina, Irina; Kalibataite-Rutkauskiene, Irma; Roy, Isabelle; Tejani, Ishita; Naryshkin, Ivan A; Jankovic, Ivana; Niedzwiecka, Iwona; Kusmierek, Jacek; Chow, Jackie; Heo, Jaekyeong; Maksym, Jakub; Davies, James E; Jang, James J; Hirsch, James; Tatoulis, James; Henzel, Jan; Oliveira, Janaina; Rangaswami, Janani; Eckstein, Jane; Raj, Janitha; Pozzibon, Jaqueline; Drozdz, Jaroslaw; Kwok Kong, Jason Loh; Call, Jason T; Linefsky, Jason; Garcia, Javier J; Meisner, Jay; Scales, Jayne; Juliard, Jean Michel; Diodati, Jean; Juliard, Jean-Michel; Russo, Jeanne; Schoep, Jeannette J M; Leimberger, Jeff; Milliken, Jeffrey C; Anderson, Jeffrey; Kanters, Jeffrey; Lorin, Jeffrey; Moses, Jeffrey; Stepanovic, Jelena J; Celutkiene, Jelena; Stojkovic, Jelena; Jose, Jenne M; Stanford, Jennifer L; Hogan, Jennifer; Horst, Jennifer; Isaacs, Jennifer; Thomson, Jennifer; Tomfohr, Jennifer; White, Jennifer; Yee, Jerry; Berg, Jessica; Peteiro, Jesus; Peteiro, Jesús; Li, Jia; Liu, Jiamin; Zhang, Jianxin; Marcus, Jill; Blankenship, Jim; Dong, Jing; Chen, Jiyan; Evans, Jo; Peñafiel, Joaquín V; Sabik, Joe; Christopher, Johann; Kostis, John B; Graham, John Joseph; Doan, John; Jose, John; Kotter, John; Lehman, John; Middleton, John; Pownall, John; Gleadle, Jonathan M; Chavez-Iñiguez, Jonathan S; Byrne, Jonathan; Himmelfarb, Jonathan; Lebowitz, Jonathan; Thorsen, Jonean; Carrillo Calvillo, Jorge; Escobedo, Jorge; Ortega-Ramírez, José A; Cuenca-Castillo, José J; Diez, Jose L; Narro Villanueva, José Luis; da Costa Vieira, José Luiz; Flores-Palacios, José M; Fragata, Jose; Lopes, Jose; Lopez-Sendon, Jose; Lopez-Sendon, José; Rueda, Jose; Selvanayagam, Joseph B; Sacco, Joseph; Loh, Joshua P; Burkhardt, Joy; López Quijano, Juan Manuel; Gaztanaga, Juan; Sebo, Judit; Wright, Judith; Stumpf, Juergen; de Aveiro Morata, Julia; Figal, Julio César; Hernandez Jaras, Julio; Yang, Junqing; Garg, Jyotsna; Rani, K Manjula; Preethi, K; Goetschalckx, Kaatje; Calfas, Karen; Petrosyan, Karen; Servilla, Karen; Swan, Karen; Ploetze, Karin; Kryczka, Karolina; Wojtczak-Soska, Karolina; Wojtera, Karolina; Ramasamy, Karthik; Łuczak, Katarzyna; Malinowska, Katarzyna; Knaut, Katharina; Martin, Katherine; Claes, Kathleen; Mason, Kathryn; Mahaffey, Ken; Gin, Kenneth; Lee, Kerry; Bonin, Kerstin; Mikes, Kerstin; Bainey, Kevin R; Harley, Kevin T; Marzo, Kevin; McMahon, Kevin; Abdul-Nour, Khaled; Alfakih, Khaled; Dajani, Khaled; Kushniriuk, Khrystyna; Poh, Kian-Keong; Holland, Kim; Halverson, Kimberly E; Murphy, Kinnari; Reddy, Kiran; Quiles, Kirsten J; Abercrombie, Kirsty; Matschke, Klaus; Szymczyk, Konrad; Chan, Koo Hui; Mavromatis, Kreton; Hongalgi, Krishnakumar; Thygesen, Kristian; Salmi, Kristin M; Newby, Kristin; Arges, Kristine; Teoh, Kristine; Drzymalski, Krzysztof; Kumbar, Lalathaksha; Matics, Laszlone; Hickson, LaTonya J; Keinaite, Laura; Sarti, Laura; True, Laura; Phillips, Lawrence M; Friedman, Lawrence; Maranan, Leandro C; Lotaif, Leda; Dharmarajan, Lekshmi; Bockeria, Leo A; Pizzol Caetano, Leonardo; Bridi, Leonardo; Bershtein, Leonid L; Yan, Li Hai; Li, Li; Sousa, Lidia; Xu, Lihong; Zhang, Lihua; Zhang, Lili; Mazza Barbosa, Lilian; Tozija, Liljana; Arcand, Linda; Patricio, Lino; Zhang, Liping; Hatch, Lisa; Jiang, Lixin; Low, Liz; Salman, Loay; Lopez, Lorena; Pritchard, Lori; Bernanrdes, Luis; Guzman, Luis; Teo, Lynette L; Reddy, M Sowjanya; Simoons, Maarten; Konigstein, Maayan; Selas, Mafalda; Madero, Magdalena; Miller, Magdalena; Misztal-Teodorczyk, Magdalena; Abdelhamid, Magdy; Fahim, Magid; Mylarappa, Mahevamma; Joseph, Majo X; Frach, Malgorzata; Rani, Manjula; Galvani, Marcello; Demkow, Marcin; Szkopiak, Marcin; De Fabritis, Marco; Magnoni, Marco; Marini, Marco; Sicuro, Marco; Roik, Marek; Alfonso, Maria A; Pereira de Moraes, Maria Antonieta; Martínez-Ruíz, María Dolores; Canziani, Maria Eugenia; Martin, Maria Eugenia; Caetano, Maria Inês; Corral, Maria P; Pérez García, Maria; Andreasson, Maria; Posada, Maria; Dracoulakis, Marianna D A; Rubio, Mariano; Petrovic, Marija T; Vieira, Marina; Garcia, Mario J; D'arezzo, Mario; Orgera, Maris; Miglinas, Marius; Garand, Mark; Peterson, Mark; Xavier, Mark; Mosley, Marlowe; Capinha, Marta; Swiderek, Marta; Meyer, Martha; Ceseri, Martina; Tricoli, Martinia; Wiilliams, Mary; Champagne, Mary Ann; Streif, Mary; Leesar, Massoud; Claudia, Matei; Solecki, Mateusz; Mungo, Matías Nicolás; Shinseki, Matthew; Weir, Matthew; Nédio, Maura Carina; Winter, Max-Paul; Krishnam, Mayil S; Mishra, Meenakshi; Hwang, Mei; Srilatha, Melemadathil; LeFevre, Melissa; Simegn, Mengistu; Gibson, Michael A; Rubens, Michael B; Shapiro, Michael D; Chobanian, Michael; Davidson, Michael; Farkouh, Michael; Mack, Michael; Wlodarczyk, Michal; Khouri, Michel G; Crowder, Michelle; Ratliff, Michelle; Borges Santos, Miguel; Nobre Menezes, Miguel; Perez Fontan, Miguel; Barrero, Miguel; Tapolyai, Mihaly; Torosoff, Mikhail T; Dobric, Milan R; Gadkari, Milind Avdhoot; Kyaw, Min Tun; Revivo, Miri; Lustre, Mitchel B; Adel, Mohamed; Hassan, Mohamed; El-Hajjar, Mohammad; Hussain, Mohammed; Saleem, Mohammed; Blanco-Calvo, Moisés; Jiménez-Santos, Moisés; Laukyte, Monika; Saric, Muhamed; Takiuti, Myrthes Emy; Asif, Nadia; Moorthy, Nagaraja; Ogletree, Naima L; Katamadze, Nana O; Nataraj, Nandita; Uchida, Naomi; Ismail, Nasrul; Oliveira, Natalia S; de Carvalho Maffei, Natalia; Brosens, Nathalie; Aslam, Naved; Akhtar, Naveed; Mowafy, Neamat; Pandit, Neeraj; Parakh, Neeraj; Pannu, Neesh; Duncan, Neill; Garcevic, Nevena; Meadows, Ngaire; Danchin, Nicholas; Deming, Nicole; Boskovic, Nikola N; Karogiannis, Nikolaos; Zhang, Ning; Kumar, Nirmal; Sharma, Niruta; Chadha, Nitika; Naik, Nitish; Durfee, Noelle M; Cosgrove, Nora M; Urbanski, Norbert; Hogg, Norma; Walesiak, Olga; ZdoÅ„czyk, Olga; Zhdanova, Olga; Anaya, Olivia; Bello, Olugbenga; Almousalli, Omar; Thompson, Omar; Kliuk, Orit; Méndiz, Oscar; Prada-Delgado, Óscar; Shapira, Oz; Raffaele, Pablo; Salanger, Page; Maurovich-Horvat, Pal; Garg, Pallav; Moraga, Paloma; Singh, Pam; Ouyang, Pamela; Woodard, Pamela; Poggio Smanio, Paola Emanuela; Smanio, Paola; Calabro, Paolo; Nguyen, Patricia K; Alarie, Patricia; Carrilho, Patricia; Endsley, Patricia; Pellikka, Patricia; Lebioda, Patrycja; Der Mesropian, Paul; Hauptman, Paul; García-González, Paula; Wilson, Paula; Cury Rezende, Paulo; Novis Rocha, Paulo; Canas Silva, Pedro; Farto E Abreu, Pedro; Píccaro de Oliveira, Pedro; Carvalho, Pedro; Modas, Pedro; Rio, Pedro; He, Peiyu; McCullough, Peter A; Stone, Peter H; Douglass, Peter; Sizeland, Peter; Voros, Peter; Steg, Philippe Gabriel; Genereux, Philippe; Généreux, Philippe; Menasche, Philippe; Rheault, Philippe; Tassinario, Piero; Gervais, Pierre; Calvillo, Pilar; Chai, Ping; Jakubowski, Piotr; Pruszczyk, Piotr; Loh, Poay-Huan; Samadi, Pouneh; Deedwania, Prakash; Patel, Pranav M; Polamuri, Praneeth; Sharma, Pratiksha; Kamath, Preeti; Thomas, Prince; Arambam, Priyadarshani; Sodhi, Puneet; Naik, Pushpa; Zhong, Qi; Zhao, Qian; Yuan, Qianqian; Xie, Qiulan; Murphy, Rachel; Lyubarova, Radmila; Lyubarova, Radmilar; Fisher, Raewyn; Diaz, Rafael; Maldonado, Rafael; Selgas, Rafael; Bugiardini, Raffaele; Chaudhry, Rafia; Kavalakkat, Raisa; Vs, Rajalekshmi; Nair, Rajesh Gopalan; Narang, Rajiv; Yadav, Rakesh; Carvalho, Ramiro; Jesús-Pérez, Ramon de; Leng, Ran; Kachru, Ranjan; Sanchez, Raquel; Dwyer, Raven R; Lee, Raven; Wyman, Ray; Wong, Raymond C; Hampson, Reinette; Karam Kalil, Renato Abdala; Lopes, Renato D; Eick, Renato George; Lopes, Renato; Ravindran, Reshma; Gamma, Reto Andreas; Costa, Ricardo; Bhatt, Richa; Trimlett, Richard H J; Patel, Risha; Coram, Rita; Riezebos, Robert K; Donnino, Robert M; Guyton, Robert; Harrington, Robert; Malecki, Robert; Favaloro, Roberto René; Elliott, Robyn; Lima, Rodolfo G S D; Tandon, Rohit; Doerr, Rolf; Tewari, Roma; Wald, Ron; Hu, Rongrong; Collins, Rory; Mehran, Roxana; Senior, Roxy; Baleón-Espinosa, Rubén; Ramos, Ruben; Ferreira, Rui; Kirby, Ruth; Pérez-Fernández, Ruth; Ramakrishnan, S; Dwivedi, S K; Lubna, Sadath; Ahmed, Sadiq; Govindan, Sajeev Chakanalil; Alfalahi, Salamah; Cruz-Flores, Salvador; Costa, Salvatore P; Setty, Sampoornima; Nwosu, Samuel; Mahajan, Sandeep; Seth, Sandeep; Singh, Sandeep; Niehe, Sander R; Carr, Sandy; Ogrizovic, Sanja Simic; Ogrizovic, Sanja; Gulati, Sanjeev; Sharma, Sanjeev; Fernandez, Sara; Williams, Sarah; Ralhan, Sarju; Kedev, Sasko; Singh, Satinder; Sankaranarayanan, Satish; Manjunath, Satvic Cholenahally; Lee, Sau; Thaxton, Schawana; O'Brien, Sean M; Sobczak, Sebastian; Nour, Seema; Sayganov, Sergey A; Bravo Baptista, Sérgio; Draibe, Sergio; Sokol, Seth; Chandra, Sharad; Mackedanz, Shari; Goodman, Shaun; Shirazian, Shayan; Karwa, Sheetal Rupesh; Ussery, Sheri; Bajaj, Sheromani; Heydari, Shirin; Choudhary, Shiv Kumar; Patel, Shivali; Pandey, Shruti; Zhang, Shuyang; Gadage, Siddharth; Tan, Sik-Yin V; Poletti, Sílvia Zottis; Valbuena, Silvia; Savaris, Simone; Yakubov, Solomon; Zhu, Songlin; Gupta, Sonika; Brener, Sorin; Gurunathan, Sothinathan; Nayak, Soundarya; Reddy, Sowjanya; Cobos, Stanley E; Weikl, Stefan; Lane, Stephanie M; Ferket, Stephanie; Mavromichalis, Stephanie; Fremes, Stephen; Fein, Steven A; Sedlis, Steven P; Giovannone, Steven; Weitz, Steven; Banerjee, Subhash; Hegde, Sudhanva S; Hosino, Suellen; Mookherjee, Sulagna; Singh, Suman; Abeygunasekara, Sumith; Mishra, Sundeep; Verma, Sunil Kumar; Kumar, Suresh; Narayanappa, Suryaprakash; Milbrandt, Susan K; Silva, Susana; Stevens, Susanna; Kolhe, Suvarna; Tavares, Suzana; Welsh, Suzanne; Kishore, T A; Colaiácovo Soares, Tamara; Pillay, Tapan Umesh; Rashid, Tarek; Mittal, Tarun K; Duarte, Tauane Bello; Dutoiu, Téodora; Delgadillo, Teresa; Chua, Terrance; Welch, Terrance; Kofidis, Theodoros; Lefevre, Thierry; Silva, Tiago; Boros, Timea; Lau, Titus; Formisano, Tiziana; Ciurus, Tomasz; Tarchalski, Tomasz; Tan, Tracy; Lingaraj, Umesh; Bahl, V K; Narain, V S; Pellu, Valentina; Lobo, Valentine; Robesyn, Valerie; Yadav, Vandana; Gupta, Veerabhadra; Mathew, Verghese; Miro, Vicente; Gumerova, Victoria; Hernandez, Victoria; Kher, Vijay; Kumar, Vijay; Makkar, Vikas; Reddy, Vikranth; Bulkley, Viktoria; David, Vinoi George; Misra, Virendra; Fernández-Figares, Virginia; Ryasniansky, Vladimir; Giga, Vojislav L; Almahmeed, Wael A; Chan, Wan Xian; Marfori, Wanda C; Parker, Wanda; Pennachi, Wayne; Lau, Wei Ling; Xing, Weibing; Bian, Weijing; Stewart, Wendy L; Drewes, Wendy; Hueb, Whady; Weintraub, William; Sia, Winnie C; Flores-Ríos, Xacobe; Ma, Xiang; Gu, Xiangqiong; Li, Xiaomei; Xu, Xiaoyi; Fu, Xin; Li, Xuemei; Wang, Xutong; Pépin-Dubois, Yanek; Arbel, Yaron; Han, Yechen; Lit, Yiming; Sia, Ying Tung; Wang, Ying; Yang, Yining; Ma, Yitong; Peralta, Yolayfi; Smets, Yves; Taul, Yvonne; Kudzoeva, Zalina; Markovic, Zeljko Z; Liu, Zhangsuo; Liu, Zhenyu; Ye, Zhiming; Yu, Zixiang; Davidovits, Zoltan; Petronijevic, Zvezdana
BACKGROUND:Clinical trials that have assessed the effect of revascularization in patients with stable coronary disease have routinely excluded those with advanced chronic kidney disease. METHODS:We randomly assigned 777 patients with advanced kidney disease and moderate or severe ischemia on stress testing to be treated with an initial invasive strategy consisting of coronary angiography and revascularization (if appropriate) added to medical therapy or an initial conservative strategy consisting of medical therapy alone and angiography reserved for those in whom medical therapy had failed. The primary outcome was a composite of death or nonfatal myocardial infarction. A key secondary outcome was a composite of death, nonfatal myocardial infarction, or hospitalization for unstable angina, heart failure, or resuscitated cardiac arrest. RESULTS:At a median follow-up of 2.2 years, a primary outcome event had occurred in 123 patients in the invasive-strategy group and in 129 patients in the conservative-strategy group (estimated 3-year event rate, 36.4% vs. 36.7%; adjusted hazard ratio, 1.01; 95% confidence interval [CI], 0.79 to 1.29; P = 0.95). Results for the key secondary outcome were similar (38.5% vs. 39.7%; hazard ratio, 1.01; 95% CI, 0.79 to 1.29). The invasive strategy was associated with a higher incidence of stroke than the conservative strategy (hazard ratio, 3.76; 95% CI, 1.52 to 9.32; P = 0.004) and with a higher incidence of death or initiation of dialysis (hazard ratio, 1.48; 95% CI, 1.04 to 2.11; P = 0.03). CONCLUSIONS:Among patients with stable coronary disease, advanced chronic kidney disease, and moderate or severe ischemia, we did not find evidence that an initial invasive strategy, as compared with an initial conservative strategy, reduced the risk of death or nonfatal myocardial infarction. (Funded by the National Heart, Lung, and Blood Institute and others; ISCHEMIA-CKD ClinicalTrials.gov number, NCT01985360.).
PMID: 32227756
ISSN: 1533-4406
CID: 5451232
New England journal of medicine. 2020:382(15):1395-1407.DOI: 10.1056/NEJMoa1915922

Initial Invasive or Conservative Strategy for Stable Coronary Disease

Maron, David J; Hochman, Judith S; Reynolds, Harmony R; Bangalore, Sripal; O'Brien, Sean M; Boden, William E; Chaitman, Bernard R; Senior, Roxy; López-Sendón, Jose; Alexander, Karen P; Lopes, Renato D; Shaw, Leslee J; Berger, Jeffrey S; Newman, Jonathan D; Sidhu, Mandeep S; Goodman, Shaun G; Ruzyllo, Witold; Gosselin, Gilbert; Maggioni, Aldo P; White, Harvey D; Bhargava, Balram; Min, James K; Mancini, G B John; Berman, Daniel S; Picard, Michael H; Kwong, Raymond Y; Ali, Ziad A; Mark, Daniel B; Spertus, John A; Krishnan, Mangalath N; Elghamaz, Ahmed; Moorthy, Nagaraja; Hueb, Whady A; Demkow, Marcin; Mavromatis, Kreton; Bockeria, Olga; Peteiro, Jesus; Miller, Todd D; Szwed, Hanna; Doerr, Rolf; Keltai, Matyas; Selvanayagam, Joseph B; Steg, P Gabriel; Held, Claes; Kohsaka, Shun; Mavromichalis, Stavroula; Kirby, Ruth; Jeffries, Neal O; Harrell, Frank E; Rockhold, Frank W; Broderick, Samuel; Ferguson, T Bruce; Williams, David O; Harrington, Robert A; Stone, Gregg W; Rosenberg, Yves; Ricci, Joseph; 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Ireland, Kim F; Holland, Kim; Byrne, Kimberly Ann; Halverson, Kimberly E; Elmore, Kimberly; Miller-Cox, Kimberly; Reddy, Kiran; Quiles, Kirsten J; Abercrombie, Kirsty; Matschke, Klaus; Szymczyk, Konrad; Chan, Koo Hui; Preethi, Kotiboinna; Sokhon, Kozhaya; Meemuk, Krissada; Thygesen, Kristian; Salmi, Kristin M; Newby, Kristin; Wippler, Kristina; Arges, Kristine; Teoh, Kristine; Etherington, Krystal; Łoboz-GrudzieÅ„, Krystyna; Reczuch, Krzysztof W; Bury, Krzysztof; Drzymalski, Krzysztof; KukuÅ‚a, Krzysztof; Sung, Kuo-Tzu; Huber, Kurt; Douangvila, Ladda; Sullenberger, Lance; Trama, Larissa Miranda; Matics, Laszlone; Drew, Laura; Flint, Laura; Keinaite, Laura; Sarti, Laura; Kolakaluri, Laurel; Phillips, Lawrence M; Friedman, Lawrence; Phillips, Lawrence; Velicki, Lazar; Howell, Leah; Maranan, Leandro C; Cox, Leanne; Daba, Ledjalem; Zhang, Lei; Dharmarajan, Lekshmi; Bockeria, Leo; Pizzol Caetano, Leonardo; Bridi, Leonardo; Bershtein, Leonid L; Sokalski, Leszek; Yan, Li Hai; Li, Li; Nijmeijer, Lia; Sousa, Lidia; Xu, Lihong; Zhang, Lihua; Zhang, Lili; Schiavi, Lilia; Barbosa, Lilian Mazza; Khor, Lillian L; Felix-Stern, Lina; Hall, Linda L; Hollenweger, Linda M; Arcand, Linda; Davidson-Ray, Linda; Schwarz, Linda; Sikora, Lindsey N; Chi, Lingping; Patricio, Lino; Zhang, Liping; Chaytor, Lisa; Hatch, Lisa; McCloy, Lisa; Wong, Lisa; Persson, Liselotte; Jiang, Lixin; Low, Liz; Pupic, Ljiljana; Bière, Loïc; Monti, Lorenzo; Christensen, Lori; Pritchard, Lori; Black, Loriane; Desimone, Lori-Ann; Larmand, Lori-Ann; McGregor, Lorraine; Morby, Louise; Thomson, Louise; Harvey, Luc; de Pádua Baptista, Luciana; Garcia, Lucilla; Eliahou, Ludivine; Helmer, Ludmila; Smidt, Luis F; Bernanrdes, Luis; Guzman, Luis; Carvalho, Luiz A; Xiong, Luyang; Teo, Lynette L; Neeson, Lynn M; Winstanley, Lynne; Srichai-Parsia, M Barbara; Quintana Giner, M; Sowjanya Reddy, M; Valdés Chávarri, M; Grazia Rossi, M; Simoons, Maarten; Konigstein, Maayan; Lesiak, Maciej; Olsowka, Maciej; Selas, Mafalda; Corfias, Magalie; Madero Rovalo, Magdalena; Łanocha, Magdalena; Miller, Magdalena; Misztal-Teodorczyk, Magdalena; Rantinella, Magdalena; Abdelhamid, Magdy; Jimenez, Magnolia; Alam, Mahboob; Mylarappa, Mahevamma; El Shahawy, Mahfouz; Mohamed, Mahmoud; Al-Bustami, Mahmud; Joseph, Majo X; Frach, Malgorzata; CeliÅ„ska-Spodar, MaÅ‚gorzta; Helm, Malte; Chacko, Manas; Murphy, Mandy; Vinod, Manitha; Rani, Manjula; Dhawan, Manu; Mombelli, Manuela; Weber, Marcel; Galvani, Marcello; Rodrigues, Marcelo Jamus; Dubin, Marcia F; Werner Bayer, Marcia F; Szkopiak, Marcin; Monsalve, Marco Antonio; Santos, Marco Bizzaro; Magnoni, Marco; Marini, Marco; Sicuro, Marco; Zenati, Marco; Coimbra Resende, Marcos Valério; Roik, Marek; Bentzvi, Margalit; Gilsenan, Margaret; Iraola, Margaret; Quinn, Margot C; Alfonso, Maria A; Pereira Moraes, Maria Antonieta; Martínez-Ruíz, María Dolores; Canales, María Fernanda; Caetano, Maria Inês; Corral, Maria P; Pérez García, Maria; Actis, Maria Victoria; Aguirre, Maria; Andreasson, Maria; Aprile, Maria; Colton, Maria; Martin, Maria Eugenia; Lasala, Maria; Lorenzo, Maria; Posada, Maria; Shier, Maria; Thottam, Maria; Furtado, Mariana V; Okada, Mariana Yumi; Dracoulakis, Marianna D A; De Andrade, Marianne; Rubio, Mariano; Essermark, Marie; Scherrer-Crosbie, Marielle; Petrovic, Marija T; Zdravkovic, Marija; Black, Marilyn; Garcia, Marina; Garcia, Mario J; Szulik, Mariola; Orgera, Marisa; de Belder, Mark A; Harbinson, Mark; Hyun, Mark; Peterson, Mark; Xavier, Mark; Mosley, Marlowe; Capinha, Marta; Marcinkiewicz-Siemion, Marta; Swiderek, Marta; Meyer, Martha; Ceseri, Martina; Tricoli, Martina; Kronenberg, Marvin; Williams, Mary; Champagne, Mary Ann; Rogge, Mary Colleen; Soltau, Mary R; Streif, Mary; Villella, Massimo; Leesar, Massoud; Claudia, Matei; Solecki, Mateusz; Mungo, Matías Nicolás; Wall, Matthew Jr; Budoff, Matthew; Jezior, Matthew; Luckie, Matthew; Friedrich, Matthias; Haeffner, Mauren P; Tscharre, Maximilian; Winter, Max-Paul; Almeida, Mayana; Krishnam, Mayil S; Patel, Mayuri; Mishra, Meenakshi; Manocchia, Megan; Kakade, Meghana; Munro, Melanie J; Chaplin, Melissa D; LeFevre, Melissa; Andiapen, Mervyn; Gibson, Michael A; Rubens, Michael B; Turner, Michael C; Shapiro, Michael D; Lee, Michael W; Berlowitz, Michael; Davidson, Michael; Mack, Michael; McDaniel, Michael; Mumma, Michael; Wlodarczyk, Michal; Khouri, Michel G; Slama, Michel S; Rawlins, Michele; Bonner, Michelle M; Seib, Michelle M; Chang, Michelle; Crowder, Michelle; Dixon, Michelle; Mayon, Michelle; McEvoy, Michelle; Yee, Michelle; Fernandes, Miguel M; Nobre Menezes, Miguel; Souto Bayarri, Miguel; Barrero, Miguel; Torosoff, Mikhail T; Dobric, Milan R; Dobric, Milan; Dekleva, Milica Nikola; Gadkari, Milind Avdhoot; Gomez, Millie; Kyaw, Min Tun; Brooks, Miriam; Stevo Martinovic, Miroslav; Lustre, Mitchel B; Vakani, Mohammad Tariq; El-Hajjar, Mohammad; Al-Amoodi, Mohammed; Hussain, Mohammed; Saleem, Mohammed; Blanco-Calvo, Moisés; Jiménez-Santos, Moisés; Bhatia, Mona; Rosca, Monica; Laukyte, Monika; Gracida Blanca, Montserrat; Vila Perales, Montserrat; Al-Mallah, Mouaz H; de Oliveira Filho, Moysés; Ntsekhe, Mpiko; Saric, Muhamed; Chen, Mulei; Brousseau, Myriam; Takiuti, Myrthes Emy; Cemerlic-Adjic, Nada; Asif, Nadia; Gakou, Nadia; Hussain, Nafisa; Katamadze, Nana O; Clapp, Nancy L; Aedy, Nancy; Nataraj, Nandita; Wenger, Nanette K; Uchida, Naomi; Ismail, Nasrul; Oliveira, Natalia S; de Carvalho Maffei, Natalia; Spitzer, Natalie; Putnam, Natasha C; Aslam, Naved; Mowafy, Neamat; Pandit, Neeraj; Parakh, Neeraj; Garcevic, Nevena; Meadows, Ngaire; Tran, Nhi N; Danchin, Nicholas; Lakeman, Nicki; Johnston, Nicola; Shammas, Nicolas W; Saint Vrestil, Nicole; Deming, Nicole; Zhong, Nier; Patel, Niket; Boskovic, Nikola N; Karogiannis, Nikolaos; Werner, Nikos; Johnston, Nina; Zhang, Ning; Zhou, Ning; Hindoyan, Niree; Kumar, Nirmal; Chadha, Nitika; Naik, Nitish; Aripova, Nodira; Mtana, Noloyiso; Eskelson, Nona A; Mokhtar, Noor Syamira; Taksaudom, Noppon; Basri, Nor Asiah; Marchelletta, Nora; Hogg, Norma; Jungla, Nungshi; Ferreira, Nuno; Lubyanaya, Oksana A; Nikolaeva, Olga B; Cañavate, Olga; Sobrino, Olga; Walesiak, Olga; Walter, Olga; ZdoÅ„czyk, Olga; Lim, Olivia J; Anaya, Olivia; Mancilla, Olivia; Dubourg, Olivier; Bello, Olugbenga; Almousalli, Omar; Thompson, Omar; Olurinde, Oni; Harel, Or; Raheem, Osama; Méndiz, Oscar; Prada-Delgado, Óscar; Shapira, Oz; Schulze, P Christian; Panpunuan, Pachara; Maurovich-Horvat, Pal; Garg, Pallav; Moraga, Paloma; Singh, Pam; Julian, Pamela; Ouyang, Pamela; Sigel, Pamela; Woodard, Pamela; Zhou, Panpan; Poggio, Paola Emanuela; Smanio, Paola; Calabro, Paolo; Jeetley, Paramjit; Goube, Pascal; Nguyen, Patricia K; Alarie, Patricia; Arakelian, Patricia; Arsenault, Patricia; Blaise, Patricia; Brito, Patricia; Cowper, Patricia; Endsley, Patricia; Mieses, Patricia; Alexander, Patrick B; Donnelly, Patrick; Wilmot, Patrick; Lebioda, Patrycja; Gordon, Paul C; Mesropian, Paul Der; Galiwango, Paul; Hauptman, Paul; Kennedy, Paul; Beardsley, Paula; García-González, Paula; Rezende, Paulo Cury; Caramori, Paulo Ricardo; Kozlov, Pavel S; Canas Silva, Pedro; Melo Barros E Silva, Pedro Gabriel; Píccaro de Oliveira, Pedro; Carvalho, Pedro; Modas, Pedro; Rio, Pedro; Jain, Peeyush; He, Peiyu; McCullough, Peter A; Stone, Peter H; Pollak, Peter M; Douglass, Peter; Henriksen, Peter; OKane, Peter; Ong, Peter; Jones, Philip; Rogal, Philip; Généreux, Philippe; Menasche, Philippe; Rheault, Philippe; Goold, Phoebe; Gervais, Pierre; Michaud, Pierre; Calvillo, Pilar; Chai, Ping; Jakubowski, Piotr; Pruszczyk, Piotr; Slomka, Piotr; Sritara, Piyamitr; Loh, Poay-Huan; Sonawane, Poonam; Samadi, Pouneh; Parikh, Pragnesh P; Deedwania, Prakash; Patel, Pranav M; Polamuri, Praneeth; Sharma, Pratiksha; Vasquez, Precilia; Kamath, Preeti; Thomas, Prince; Arambam, Priyadarshani; Mehta, Puja K; Grant, Purvez; Naik, Pushpa; Zhong, Qi; Zhao, Qian; Zhou, Qiang; Yuan, Qianqian; Yu, Qin; Li, Qingxian; Xie, Qiulan; Zeng, Qiutang; Vindhya, R J; Gerlach, R James; King, Rachel; Vučić, Rada; Lyubarova, Radmila; Pracon, Radoslaw; Fisher, Raewyn; Beyar, Rafael; Diaz, Rafael; Selgas, Rafael; Bugiardini, Raffaele; Fanelli, Raffaele; Kavalakkat, Raisa; Rajalekshmi, V S; Barua, Rajat S; Menon, Rajeev; Nair, Rajesh Gopalan; Francis, Rajesh; Narang, Rajiv; Yadav, Rakesh; Huston, Ralph Alan; Ramakrishnan, T; de Silva, Ramesh; Mahmoud, Rami El; Carvalho, Ramiro; de Jesús-Pérez, Ramon; Stevens, Ramona; Leng, Ran; Kachru, Ranjan; Nath, Ranjit Kumar; Sanchez, Raquel; Dwyer, Raven R; Lee, Raven; Wyman, Ray; Wong, Raymond C; Little, Raymond W; Ocaranza Sanchez, Raymundo; Wimmer, Rebecca J; Bariciano, Rebecca; Otis, Rebecca; Herrmann, Rebekah R; Yunis, Reem; Hampson, Reinette; Karam, Renato Abdala; Hessian, Renee C; Kaneshiro, Renee; Ravindran, Reshma; Gamma, Reto Andreas; Bhandari, Reyna; Arsanjani, Reza; Lopes, Ricardo L; Mendes Oliveira, Ricardo; Costa, Ricardo; Bhatt, Richa; Davies, Richard F; Trimlett, Richard H J; Goldweit, Richard; Hermanides, Rik; Nakanishi, Rine; Sidh, Rinu R; Patel, Risha; Coram, Rita; Siddiqui, Rizwan A; Beanlands, Rob S; Hamburger, Robert J; Riezebos, Robert K; Donnino, Robert M; Bojar, Robert; Chilton, Robert; Guyton, Robert; Henderson, Robert; Kornberg, Robert; Leber, Robert; Mao, Robert; Stenberg, Robert; Santos, Roberta P; Favaloro, Roberto René; Amati, Roberto; Lima, Rodolfo G S D; Cerci, Rodrigo J; Tumelero, Rogerio; Tandon, Rohit; Tewari, Roma; Miranda-Peats, Romalisa; Wald, Ron; Mastouri, Ronald A; Morford, Ronald G; Schwartz, Ronald G; Pedalino, Ronald P; Hu, Rongrong; Hansen, Ronnell A; Cohen, Ronny A; Hachamovitch, Rory; Homem, Rosa; Sandonato, Rosa; Laimer, Rosane; Gans, Rosann; Yost, Roxanne; Mathew, Roy; Baleón-Espinosa, Rubén; Ramos, Ruben; Gevorgyan, Rubine; Ferreira, Rui; Jing, Rui; Pérez-Fernández, Ruth; Dwivedi, S K; Ramakrishnan, S; Khan, Saadat; Bokhari, Sabahat; Thomas, Sabu; Lubna, Sadath; Khan, Sajeeda Parveen; Govindan, Sajeev Chakanalil; Girotra, Saket; Kassam, Saleem; Canada, Sallie; Cruz-Flores, Salvador; Mohamed, Samaa; Ly, Samantha; El Kaffas, Sameh; Massalha, Samia; Setty, Sampoornima; Nwosu, Samuel; Seth, Sandeep; Singh, Sandeep; Niehe, Sander R; Rivest, Sandra M; Zier, Sandra S; Ahoud, Sandra; Carr, Sandy; Ganapathi, Sanjay; Shetty, Sanjay; Sharma, Sanjeev; Jimenez, Santa; Satheesh, Santhosh; Garcia, Santiago A; Fernandez, Sara; Karlsson, Sara; Salkind, Sara; Temiyasathit, Sara; Medina Rodriguez, Sarah; Beaudry, Sarah; Hadjih, Sarah; Williams, Sarah; Zahrani, Sarah; Ralhan, Sarju; Hinic, Sasa; Kedev, Sasko; Singh, Satinder; Yasuda, Satoshi; Manjunath, Satvic Cholenahally; Lee, Sau; Kaczkowski, Scott M; Kinlay, Scott; Hayes, Sean W; Sobczak, Sebastian; Asier, Senait; Sayganov, Sergey A; Sokol, Seth I; Pandie, Shaheen; Yahaya, Shaiful Azmi; Mehta, Shamir; Nie, Shao-Ping; Chandra, Sharad; Islam, Sharder; Tai, Sharon; Karwa, Sheetal Rupesh; Ussery, Sheri; Bajaj, Sheromani; Crook, Sherron C; Nishimura, Shigeyuki; Nakano, Shintaro; Heydari, Shirin; Choudhary, Shiv Kumar; Patel, Shivali; Ganesan, Shobana; Pandey, Shruti; Zhang, Shuyang; Hande, Shweta; Gadage, Siddharth; Tan, Sik-Yin V; Zottis Poletti, Silvia; Riera, Silvia; Valbuena, Silvia; Walsh, Simon; Maspoli, Simona; Savaris, Simone; Feng, Si-Ting; Cho, So Yang; Yakubov, Solomon; Zhu, Songlin; Wang, Songtao; Guerrero, Sonia; Gupta, Sonika; Salinger Martinovic, Sonja; Brons, Sonya; Brener, Sorin; Gurunathan, Sothinathan; Saba, Souheil; Nayak, Soundarya; Reddy, Sowjanya; Potluri, Srinivasa; Sudarshan, Sriram; Kuanprasert, Srun; Van Oosterhout, Stacie; Lerakis, Stamatios; Cobos, Stanley E; Bertog, Stefan C; Simović, Stefan M; Weikl, Stefan; Di Marco, Stefano; Provasoli, Stefano; Tirado, Stephanie A; Boer, Stephanie C; Lane, Stephanie M; Ferket, Stephanie; Kelly, Stephanie; Wasmiller, Stephanie; McKellar, Stephen H; Hoole, Stephen P; Fremes, Stephen; Preston, Stephen; Leung, Steve; Fein, Steven A; Lindsay, Steven J; Sedlis, Steven P; Giovannone, Steven; Michael, Steven; Weitz, Steven; van Vugt, Stijn; Banerjee, Subhash; Naik, Sudhir; Hosino, Suellen; Desire, Sukie; Yamwong, Sukit; Thambar, Suku T; Mookherjee, Sulagna; Singh, Suman; Mishra, Sundeep; Verma, Sunil Kumar; Kulthawong, Supap; Khwakhong, Supatchara; Naik, Surendra; Babu, Suresh; Woragidpoonpol, Surin; Narayanappa, Suryaprakash; Derbyshire, Susan; Gent, Susan; Mathus, Susan; Milbrandt, Susan; Moore, Susan; Regan, Susan; Stinson, Susan; Webber, Susan; Silva, Susana; Stevens, Susanna; Gruensfelder, Susanne; Aramcharoen, Suthara; Kolhe, Suvarna; Tavares, Suzana; Arnold, Suzanne; Welsh, Suzanne; Apostolovic, Svetlana; Kunhunny, Swapna; Hung, Ta-Chuan; Zappernick, Taissa; Sharir, Tali; Silva, Talita; Soares, Tamara Colaiácovo; Pillay, Tapan Umesh; Mittal, Tarun K; Trifonova, Tatiana; Duarte, Tauane Bello; Huk, Tauqir; Dutoiu, Téodora; Chua, Terrance; Weyand, Terry; Charles, Thabitha; Kofidis, Theodoros; McCreary, Theresa; Lefevre, Thierry; Arumairajah, Thippeekaa; Tepsuwan, Thitipong; Mulhearn, Thomas J; Meyer, Thomas M; Rocco, Thomas P; Downes, Thomas R; Crain, Thomas; Haldis, Thomas; Mathew, Thomas; Redick, Thomas; Devi, Thounaojam Indira; Nageh, Thuraia; Cauthren, Tia; Silva, Tiago; Little, Tiffany; Andric, Tijana; Harding, Tina; Lau, Titus; Formisano, Tiziana; Moccetti, Tiziano; Ciurus, Tomasz; Mazurek, Tomasz; Tarchalski, Tomasz; Nagai, Toshiyuki; Tran, Tri; Youn, Tricia; Tucker, Trish; Milner, Trudie; Bose, Tuhina; Kotecha, Tushar; Sechtem, Udo; Valeti, Uma S; Cucchini, Umberto; Badami, Umesh; Kaul, Upendra; Bahl, V K; Narain, V S; Casali, Valentina; Godoy, Valeria; Robesyn, Valerie; Priya, Vamshi P; Yadav, Vandana; McKinney, Vera; De Lenges, Veronica; Tinnirello, Veronica; Miro, Vicente; Navarro, Victor; Gumerova, Victoria; Hernandez, Victoria; Seeratan, Vidya; Kumar, Vijay; Kozulin, Vikentiy Y; Bulkley, Viktoria; Veiga, Vilmar Jr; Setang, Vincent; Vineeth, C P; Pubull Nuñez, Virginai; Fernández-Figares, Virginia; Gomes, Vitor; Gabriel, Viviana; Dos Santos, Viviane; Almeida, Viviane; Iliescu, Vlad A; Mudrenovic, Vladan; Dzavik, Vladimir; Giga, Vojislav L; Mogrovejo, Walter Enrique; Chan, Wan Xian; Marfori, Wanda C; Parker, Wanda; Mekara, Warangkana; Nona, Wassim; Old, Wayne; Pennachi, Wayne; Nawarawong, Weerachai; Chen, Wei; Su, Wei; Xing, Weibing; Lan, Wei-Ren; Crawford, Wenda; Stewart, Wendy L; Drewes, Wendy; Lin, Wenhua; Abernethy, William B; Salerno, William D; Fearon, William F; Vergoni, William; Weintraub, William; Sia, Winnie C; Musial, Wlodzimierz J; Flores-Ríos, Xacobe; Garcia-Moll Marimon, Xavier; Su, Xi; Ma, Xiang; Gu, Xiangqiong; Wang, Xiao; Li, Xiaomei; Yao, Xiaowei; Fu, Xin; Su, Xin; Zeng, Xin; Yang, Xinchun; Li, Xiuhong; Fang, Xuehua; Wang, Xutong; Geng, Yaming; Yan, Yan; Pépin-Dubois, Yanek; Wang, Yanfu; Wang, Yang; Tian, Yanmeng; Huang, Yaping; Han, Yechen; Zambrano, Yesenia; Yang, Yi-Hsuan; Sia, Ying Tung; Yang, Yining; Ma, Yitong; Peralta, Yolayfi; Wu, Yongjian; Kunwu, Yu; Zhao, Yu; Peng, Yudong; Lin, Yueh-Hung; Zhao, Yulan; Dong, Yumei; Zhao, Yunhai; Wannasopha, Yutthaphan; Taul, Yvonne; Sahul, Zakir; Kudzoeva, Zalina; Kalarus, Zbigniew; Markovic, Zeljko Z; Huang, Zhen; Ji, Zheng; Liu, Zhenyu; Yue, Zhou; Zhang, Zhulin; Li, Zhuxi; Singh Meharwal, Zile; Bai, Ziliang; Yu, Zixiang; Huda, Zohra; Davidovits, Zoltan
BACKGROUND:Among patients with stable coronary disease and moderate or severe ischemia, whether clinical outcomes are better in those who receive an invasive intervention plus medical therapy than in those who receive medical therapy alone is uncertain. METHODS:We randomly assigned 5179 patients with moderate or severe ischemia to an initial invasive strategy (angiography and revascularization when feasible) and medical therapy or to an initial conservative strategy of medical therapy alone and angiography if medical therapy failed. The primary outcome was a composite of death from cardiovascular causes, myocardial infarction, or hospitalization for unstable angina, heart failure, or resuscitated cardiac arrest. A key secondary outcome was death from cardiovascular causes or myocardial infarction. RESULTS:Over a median of 3.2 years, 318 primary outcome events occurred in the invasive-strategy group and 352 occurred in the conservative-strategy group. At 6 months, the cumulative event rate was 5.3% in the invasive-strategy group and 3.4% in the conservative-strategy group (difference, 1.9 percentage points; 95% confidence interval [CI], 0.8 to 3.0); at 5 years, the cumulative event rate was 16.4% and 18.2%, respectively (difference, -1.8 percentage points; 95% CI, -4.7 to 1.0). Results were similar with respect to the key secondary outcome. The incidence of the primary outcome was sensitive to the definition of myocardial infarction; a secondary analysis yielded more procedural myocardial infarctions of uncertain clinical importance. There were 145 deaths in the invasive-strategy group and 144 deaths in the conservative-strategy group (hazard ratio, 1.05; 95% CI, 0.83 to 1.32). CONCLUSIONS:Among patients with stable coronary disease and moderate or severe ischemia, we did not find evidence that an initial invasive strategy, as compared with an initial conservative strategy, reduced the risk of ischemic cardiovascular events or death from any cause over a median of 3.2 years. The trial findings were sensitive to the definition of myocardial infarction that was used. (Funded by the National Heart, Lung, and Blood Institute and others; ISCHEMIA ClinicalTrials.gov number, NCT01471522.).
PMID: 32227755
ISSN: 1533-4406
CID: 5451242
Journal of the American College of Cardiology. 2020:Conference:(ACC).DOI: 10.1016/S0735-2D1097-252820-252932843-2D6

INVESTIGATION OF CIRCULATING PCSK9, SYSTEMICALLY ALTERED PATHWAYS AND IMPAIRED VASCULAR HEALTH IN PSORIASIS [Meeting Abstract]

Grattan, R; Garshick, M S; Barrett, T; Tawil, M; Fisher, E; Krueger, J; Berger, J
Background Psoriasis is an inflammatory disease of the skin associated with heightened cardiovascular (CV) disease. Serum levels of proprotein convertase subtilisin/kexin type 9 (PCSK9) associates with future CV risk and vascular dysfunction. We aimed to identify the relationship between pro-inflammatory pathways, circulating PCSK9, and vascular health in psoriasis. Methods Whole blood transcriptomics and serum proteomics was performed in 20 patients with psoriasis (mean age 42 +/- 14 years, 55% male, psoriasis area and severity index [PASI] 5 [3 - 11]) and 15 controls (mean age 41 +/- 14 years, 53% male) recruited into a clinical trial to assess vascular health in psoriasis (NCT03228017). Vascular health was assessed through flow mediated dilatation (FMD) and harvesting and analysis of brachial vein endothelial cells. Results Circulating PCSK9 was found to be 1.13-fold higher in psoriasis compared to controls (p=0.02) despite no difference in LDL-C (108 +/- 38 mg/dl vs. 90 +/- 25 mg/dl, respectively p=0.31). Circulating PCSK9 was correlated with psoriasis area severity index (PASI score, r=0.43, p=0.04) even after adjustment for age, gender, BMI and LDL-C (beta=0.02, p=0.03). Integration of the whole blood transcriptome yielded 322 transcripts which correlated with circulating PCSK9 (FDR<0.05). Network analysis of these transcripts highlighted interferon signaling (p=7.2x10-6), a known pathogenic process in psoriasis, as a key regulator of PCSK9. Finally, circulating PCSK9 positively correlated with brachial vein endothelial expression of the pro-inflammatory transcripts CXCL10 (r=0.69, p<0.001), ICAM1 (r=0.49, p=0.02) and IL1beta (r=0.38, p<0.01) and inversely correlated with the functional measure of endothelial health, FMD (r=-0.52, p=0.03). Conclusion Circulating PCSK9 is elevated in psoriasis and associated with impaired vascular health. Analysis of the relationship between PCSK9 and systemic pathways revealed prominent interactions between PCSK9 and interferon signaling. Further research to better characterize these transcriptome and proteome variations and how it impacts vascular health in psoriasis may help elucidate new targets for therapeutic interventions.
Copyright
EMBASE:2005039249
ISSN: 1558-3597
CID: 4381112
Journal of the American College of Cardiology. 2020:Conference:(ACC).DOI:

CHRONIC KIDNEY DISEASE IN HEART FAILURE PATIENTS UNDERGOING NON-CARDIAC SURGERY [Meeting Abstract]

Li, B; Wilcox, T; Smilowitz, N R; Newman, J; Berger, J
Background Heart failure (HF) and chronic kidney disease (CKD) commonly co-exist, and are associated with adverse postoperative cardiovascular outcomes. The impact of CKD in HF patients undergoing noncardiac surgery is uncertain. Methods Patients with HF undergoing non-cardiac surgery were identified from the National Surgical Quality Improvement Program between 2009-2015. Patients were classified into 5 groups based on estimated glomerular filtration rate (eGFR) and requirement of dialysis and were followed prospectively for the primary outcome of death and major adverse cardiovascular events (MACE; a composite of death, myocardial infarction (MI), and stroke) within 30-days post-operatively. Multivariable logistic regression models adjusted for age, sex, race, surgery type, and clinical history and surgery type were generated to estimate the association between CKD stage and outcomes. Results Among 27,612 HF patients undergoing surgery, 65.1% had CKD (19.7% with eGFR 45-60, 20.3% eGFR 30-45, and 25.1% eGFR < 30 with or without dialysis). The incidence of postoperative death and MACE increased with worsening CKD (Table). After multivariable adjustment, eGFR <60 was associated with increased odds of MI and cardiac arrest and eGFR <45 was associated with postoperative mortality. No association was observed between CKD and stroke. Conclusion Among HF patients, the presence of CKD is common and is associated with increased risk for postoperative mortality and MACE. [Figure presented]
Copyright
EMBASE:2005039289
ISSN: 0735-1097
CID: 4367642
Vascular medicine. 2020.DOI: 10.1177/1358863X19898253

Heparin-induced thrombocytopenia (HIT): Review of incidence, diagnosis, and management

Hogan, Marie; Berger, Jeffrey S
Heparin-induced thrombocytopenia (HIT) is a life and limb-threatening complication of heparin exposure. Here, we review the pathogenesis, incidence, diagnosis, and management of HIT. The first step in thwarting devastating complications from this entity is to maintain a high index of clinical suspicion, followed by an accurate clinical scoring assessment using the 4Ts. Next, appropriate stepwise laboratory testing must be undertaken in order to rule out HIT or establish the diagnosis. In the interim, all heparin must be stopped immediately, and the patient administered alternative anticoagulation. Here we review alternative anticoagulation choice, therapy alternatives in the difficult-to-manage patient with HIT, and the problem of overdiagnosis.
PMID: 32195628
ISSN: 1477-0377
CID: 4353772
Arteriosclerosis, thrombosis, & vascular biology. 2020.DOI: 10.1161/ATVBAHA.119.314008

Activated Platelets Induce Endothelial Cell Inflammatory Response in Psoriasis Via COX-1 (Cyclooxygenase-2)

Garshick, Michael S; Tawil, Michael; Barrett, Tessa J; Salud-Gnilo, Charissa M; Eppler, Michael; Lee, Angela; Scher, Jose U; Neimann, Andrea L; Jelic, Sanja; Mehta, Nehal N; Fisher, Edward A; Krueger, James G; Berger, Jeffrey S
OBJECTIVE:=0.02). CONCLUSIONS:In patients with psoriasis, platelets are activated and induce endothelial cell inflammation. Low-dose aspirin improved endothelial cell health in psoriasis via platelet COX-1 inhibition. These data demonstrate a previously unappreciated role of platelets in psoriasis and endothelial cell inflammation, which suggests that aspirin may be effective in improving vascular health in patients with psoriasis. Registration: URL: http://www.clinicaltrials.gov. Unique identifier: NCT03228017.
PMID: 32131611
ISSN: 1524-4636
CID: 4339722
Atherosclerosis. 2020:297:149-156.DOI: 10.1016/j.atherosclerosis.2019.12.016

Chronic kidney disease and outcomes of lower extremity revascularization for peripheral artery disease

Smilowitz, Nathaniel R; Bhandari, Nipun; Berger, Jeffrey S
BACKGROUND & AIMS/OBJECTIVE:Renal disease is a risk factor for peripheral artery disease (PAD), yet its impact on outcomes after lower extremity (LE) revascularization is not well established. We aimed to characterize the association between chronic kidney disease (CKD) and/or end stage renal disease (ESRD) and post-procedural outcomes in PAD patients undergoing LE revascularization in the United States. METHODS:Adults age ≥18 years undergoing surgical or endovascular LE revascularization for PAD with and without CKD or ESRD were identified from the 2014 Nationwide Readmissions Database. Major adverse cardiovascular events (MACE), defined as a composite of death, myocardial infarction or ischemic stroke, were identified for patients with and without renal disease. All-cause hospital readmissions within 6 months of discharge were determined for all survivors. RESULTS:Among 39,441 patients with PAD hospitalized for LE revascularization, 10,530 had renal disease (26.7%), of whom 69% had CKD without ESRD and 31% had ESRD. Patients with renal disease were more likely to have MACE after LE revascularization (5.2% vs. 2.5%; adjusted OR [aOR] 1.74, 95% CI 1.40-2.16), require LE amputation (26.1% vs. 12.2%; aOR 1.33, 95% CI 1.19-1.50), and require hospital readmission within 6 months (61.0% vs. 43.6%; adjusted HR [aHR] 1.38, 95% CI 1.28-1.48) compared to those without renal disease. CONCLUSIONS:Renal disease is common among patients undergoing LE revascularization for PAD and was independently associated with in-hospital MACE, LE amputation, and hospital readmission within 6 months. Additional efforts to improve outcomes of patients with renal disease and PAD requiring LE revascularization are necessary.
PMID: 31948675
ISSN: 1879-1484
CID: 4264552
EPMA journal. 2020:11(1):53-64.DOI: 10.1007/s13167-019-00196-9

Evaluation of machine learning methodology for the prediction of healthcare resource utilization and healthcare costs in patients with critical limb ischemia-is preventive and personalized approach on the horizon?

Berger, Jeffrey S; Haskell, Lloyd; Ting, Windsor; Lurie, Fedor; Chang, Shun-Chiao; Mueller, Luke A; Elder, Kenneth; Rich, Kelly; Crivera, Concetta; Schein, Jeffrey R; Alas, Veronica
Background/UNASSIGNED:Critical limb ischemia (CLI) is a severe stage of peripheral arterial disease and has a substantial disease and economic burden not only to patients and families, but also to the society and healthcare systems. We aim to develop a personalized prediction model that utilizes baseline patient characteristics prior to CLI diagnosis to predict subsequent 1-year all-cause hospitalizations and total annual healthcare cost, using a novel Bayesian machine learning platform, Reverse Engineering Forward Simulation™ (REFS™), to support a paradigm shift from reactive healthcare to Predictive Preventive and Personalized Medicine (PPPM)-driven healthcare. Methods/UNASSIGNED:Patients ≥ 50 years with CLI plus clinical activity for a 6-month pre-index and a 12-month post-index period or death during the post-index period were included in this retrospective cohort of the linked Optum-Humedica databases. REFS™ built an ensemble of 256 predictive models to identify predictors of all-cause hospitalizations and total annual all-cause healthcare costs during the 12-month post-index interval. Results/UNASSIGNED:The mean age of 3189 eligible patients was 71.9 years. The most common CLI-related comorbidities were hypertension (79.5%), dyslipidemia (61.4%), coronary atherosclerosis and other heart disease (42.3%), and type 2 diabetes (39.2%). Post-index CLI-related healthcare utilization included inpatient services (14.6%) and ≥ 1 outpatient visits (32.1%). Median annual all-cause and CLI-related costs per patient were $30,514 and $2196, respectively. REFS™ identified diagnosis of skin and subcutaneous tissue infections, cellulitis and abscess, use of nonselective beta-blockers, other aftercare, and osteoarthritis as high confidence predictors of all-cause hospitalizations. The leading predictors for total all-cause costs included region of residence and comorbid health conditions including other diseases of kidney and ureters, blindness of vision defects, chronic ulcer of skin, and chronic ulcer of leg or foot. Conclusions/UNASSIGNED:REFS™ identified baseline predictors of subsequent healthcare resource utilization and costs in CLI patients. Machine learning and model-based, data-driven medicine may complement physicians' evidence-based medical services. These findings also support the PPPM framework that a paradigm shift from post-diagnosis disease care to early management of comorbidities and targeted prevention is warranted to deliver a cost-effective medical services and desirable healthcare economy.
PMCID:7028871
PMID: 32140185
ISSN: 1878-5077
CID: 4340842