Biomedical subjects

Eric Topol

Publications and source records attributed to Eric Topol.

8 recordsLinked to original sources

PubMed2006

Integrative medicine: implementation and evaluation of a professional development program using experiential learning and conceptual change teaching approaches.

OBJECTIVE: To meet the increasing patient interest in complementary and alternative medicine (CAM), conventional physicians need to understand CAM, be willing to talk with their patients about CAM, and be open to recommending selected patients to appropriate CAM modalities. We aimed to raise physicians' awareness of, and initiate attitudinal changes towards CAM in the context of integrative medical practice. We developed and implemented a professional development program involving experiential learning and conceptual change teaching approaches. METHODS: A randomized controlled study with a pre-post design in a large academic medical center. The 8-hour intervention used experiential and conceptual change educational approaches. Forty-eight cardiologists were randomized to participant and control groups. A questionnaire measured physicians' conceptions of, and attitudes to CAM, the likelihood of changing practice patterns, and the factors most important in influencing such changes. The questionnaire included an embedded control question on a topic that was not the focus of this program. We administered the questionnaire before (pretest) and after (posttest) the intervention. We compared differences in pre- and post-intervention scores between the participant (N = 20) and control (N = 16) groups. We used both groups to identify factors that influenced their practice patterns. The study was NIH-funded and IRB-exempt. RESULTS: Both groups initially had little knowledge about, and negative attitudes to CAM. The participant group had significant positive changes in their conceptions about, and attitudes to CAM after the program, and significant improvements when compared with the control group. Participant physicians significantly increased in their willingness to integrate CAM in their practices. Physicians (combined groups) rated research evidence as the most important factor influencing their willingness to integrate CAM. They requested more research evidence for CAM efficacy, and more information on non-conventional pharmacology. Participants reflected enthusiasm for the experiential program. CONCLUSIONS: The participants were able to experience the positive effects of selected CAM modalities. It is possible to increase physician knowledge and change attitudes towards integrative medicine with an eight-hour intervention using experiential and conceptual change teaching approaches. PRACTICE IMPLICATIONS: Professional development on integrative medicine can be offered to medical practitioners using experiential learning and conceptual change teaching approaches, with the help of local CAM practitioners.

Attitude of Health Personnel↗

PubMed2006

The influence of body mass index on outcomes and the benefit of antiplatelet therapy following percutaneous coronary intervention.

UNLABELLED: In general, obesity is associated with better outcome in patients undergoing percutaneous coronary interventions (PCI). One small study has suggested that these patients do not achieve adequate platelet inhibition with clopidogrel and that this may shape clinical outcomes. We evaluated the relationship between body mass index (BMI) and clinical outcomes at 1 year following PCI in patients randomized to clopidogrel or placebo in the CREDO trial. METHODS AND RESULTS: BMI, baseline clinical characteristics and clopidogrel regimen were assessed in 2,116 patients. The primary study endpoint was the 1-year composite of death, MI or stroke. A total of 342 patients had low or normal BMI (< 25 kg per m2), 847 were overweight (25-29.9 kg per m2), 810 were obese (30-39.9 kg per m2) and 113 were very obese (greater than or equal to 40 kg per m2). Obese patients were more likely to be young males with diabetes, hypertension and hyperlipidemia (p < 0.01). Bleeding complications occurred in 38% of low BMI, 32% of overweight/obese, and 25% of very obese patients (p = 0.03). Randomization to clopidogrel was associated with a 25% risk reduction in 1-year death, MI or stroke events, as BMI increased by every 5 kg per m2 (p = 0.009). CONCLUSION: In general, increasing BMI was associated with better efficacy and bleeding outcomes at 1 year in this nonurgent PCI population. Randomization to early- and long-term clopidogrel was associated with even further improvements in those with increasing BMI.

Aged↗

PubMed2005

Long-term cost effectiveness of early and sustained dual oral antiplatelet therapy with clopidogrel given for up to one year after percutaneous coronary intervention results: from the Clopidogrel for the Reduction of Events During Observation (CREDO) trial.

OBJECTIVES: This study sought to evaluate the long-term cost effectiveness of a clopidogrel loading strategy before percutaneous coronary intervention (PCI) followed by continued treatment for one year. BACKGROUND: The Clopidogrel for the Reduction of Events During Observation (CREDO) trial, a randomized trial of 2,116 patients, showed the effectiveness of antiplatelet therapy with clopidogrel 300 mg before PCI and 75 mg daily for one year afterward compared with placebo load and placebo days 29 to 365 in reducing the combined risk of death, myocardial infarction, and stroke. All patients received clopidogrel on days 1 to 28 and aspirin on days 1 to 365. METHODS: All hospitalizations were assigned a diagnosis-related group. Associated costs were estimated three ways (including professional costs): 1) Medicare costs, 2) MEDSTAT costs, and 3) blend with Medicare for those age > or = 65 years and MEDSTAT for those age <65 years. Clopidogrel 75 mg cost 3.22 dollars. Life expectancy in trial survivors was estimated using external data. Confidence intervals were assessed by bootstrap. RESULTS: The primary composite end point occurred in 89 (8.45%) clopidogrel patients and in 122 (11.48%) placebo patients (relative risk reduction [RRR] 26.9%; 95% confidence interval [CI] 3.9% to 44.4%). The number of life-years gained (LYG) with clopidogrel was 0.1526 (95% CI 0.0263 to 0.2838) using Framingham data and 0.1920 (95% CI 0.054 to 0.337) using Saskatchewan data. Average total costs were 664 dollars higher for the clopidogrel arm (95% CI -461 dollars to 1,784 dollars). The incremental cost-effectiveness ratios (ICERs) based on Framingham data ranged from 3,685 dollars/LYG to 4,353 dollars/LYG, with over 97% of bootstrap-derived ICER estimates below 50,000 dollars/LYG. The ICERs based on Saskatchewan data were 2,929 dollars/LYG to 3,460 dollars/LYG, with over 98% of estimates below 50,000 dollars/LYG. CONCLUSIONS: Platelet inhibition with clopidogrel loading before PCI followed by therapy for one year is highly cost effective.

Aspirin↗

PubMed2005

Aspirin resistance and its implications in clinical practice.

Recent studies have suggested that some patients may not obtain the full benefits of aspirin's antiplatelet effects. An international roundtable of experts was held November 6, 2004, in New Orleans, Louisiana, to address the concept of aspirin resistance and its clinical implications. Panelists discussed various definitions and possible mechanisms of aspirin resistance, along with several tests currently available to measure platelet function. They recommended that until the clinical importance of these tests is known, physicians should continue to prescribe low-dose aspirin therapy for individuals at high risk for cardiovascular events and patients currently taking aspirin should continue to comply with their prescribed therapy.

Aspirin↗

PubMed2005

Incidence, predictors, and outcomes of high-degree atrioventricular block complicating acute myocardial infarction treated with thrombolytic therapy.

BACKGROUND: In the fibrinolytic era, several studies have suggested that the rate of atrioventricular block (AVB) in the setting of acute myocardial infarction (MI) is high and is associated with increased short-term mortality. We sought to delineate predictors of AVB and determine long-term mortality of patients developing AVB in the setting of ST-segment elevation MI (STEMI) treated with thrombolytic therapy. METHODS: We combined data on patients from 4 similar studies of STEMI. We identified independent predictors of AVB and compared the 6-month and 1-year mortality rates of patients with AVB (5251) to the rates of patients without AVB (70 742). RESULTS: The incidence of AVB was 6.9%. Significant independent predictors of AVB included inferior MI, older age, worse Killip class at presentation, female sex, enrollment in the United States, current smoking, hypertension, and diabetes. Adjusted mortality was significantly higher in patients with AVB than in patients without AVB within 30 days (OR 3.2, 95% CI 2.7-3.7), 6 months (OR 1.6, 95% CI 1.5-1.8), and 1 year (OR 1.5, 95% CI 1.3-1.6). For patients with AVB and inferior MI, mortality odds ratios (ORs) were 2.2 (95% CI 1.7-2.7), 2.6 (95% CI 2.4-2.9), and 2.4 (95% CI 2.2-2.6) within 30 days, 6 months, and 1 year, respectively. For patients with AVB and anterior MI, mortality ORs were 3.0 (95% CI 2.2-4.1), 3.5 (95% CI 3.1-3.8), and 3.3 (95% CI 3.0-3.7) within 30 days, 6 months, and 1 year, respectively. CONCLUSIONS: In the thrombolytic era, AVB in the setting of STEMI is common and associated with higher mortality. Future studies should focus on determining therapies that are effective at reducing mortality rates in such patients.

Aged↗

PubMed2004

Convergence of atherosclerosis and Alzheimer's disease: inflammation, cholesterol, and misfolded proteins.

Late-onset sporadic Alzheimer's disease is a heterogeneous disorder. In elderly patients, increasing evidence suggests a link between this neurodegenerative disease, and vascular risk factors and atherosclerosis. The nature of this link remains speculative. Some investigators have suggested that the disease arises as a secondary event related to atherosclerosis of extracranial or intracranial vessels. A toxic effect of vascular factors on the microvasculature of susceptible brain regions has also been argued. An alternative explanation is that atherosclerosis and Alzheimer's disease are independent but convergent disease processes. This hypothesis is lent support by observations of shared epidemiology, pathophysiological elements, and response to treatment in both disorders. It provides a potential framework for an improved understanding of the pathogenesis of Alzheimer's disease, especially in elderly patients with vascular risk factors, and offers some promise toward the search for preventive and therapeutic treatments.

Aged↗

PubMed2004

Facilitated percutaneous coronary intervention versus primary percutaneous coronary intervention: design and rationale of the Facilitated Intervention with Enhanced Reperfusion Speed to Stop Events (FINESSE) trial.

BACKGROUND: Percutaneous coronary intervention (PCI) has emerged as the strategy of choice in reestablishing effective flow in occluded infarct-related arteries in patients with acute myocardial infarction (MI) if it can be administered in a timely fashion. Patients who enter the catheterization laboratory with Thrombolysis In Myocardial Infarction (TIMI) grade 3 blood flow in the infarct-related vessel have better clinical outcomes than patients presenting with impaired flow. We hypothesize that a strategy of early pharmacologic reperfusion therapy with abciximab alone or in conjunction with reduced-dose reteplase, followed by PCI will improve the outcome of patients eligible for primary PCI. STUDY DESIGN: The Facilitated Intervention with Enhanced Reperfusion Speed to Stop Events (FINESSE) study is a 3000-patient, prospective, multicenter, randomized, double-blind, placebo-controlled trial. The study is designed to compare the efficacy and safety of early administration of reduced-dose reteplase and abciximab combination therapy or abciximab alone followed by PCI with abciximab alone administered just before PCI for acute MI. Patients will be randomized to one of these 2 facilitated PCI treatments or primary PCI in a 1:1:1 fashion. The primary efficacy end point of FINESSE is the composite of all-cause mortality or post-MI complications within 90 days of randomization. The primary safety outcome assessment will be Thrombolysis In Myocardial Infarction (TIMI) major bleeding. CONCLUSIONS: The FINESSE study will answer important questions regarding the efficacy and safety of "upstream" medical therapy followed by planned intervention for patients with ST-elevation MI, potentially expanding the population eligible for a primary PCI approach. This study will also provide insight as to which facilitated regimen (reteplase/abciximab combination therapy or abciximab monotherapy) provides the best balance of efficacy and safety.

Abciximab↗

PubMed2002

Optimal treatment and current situation in reperfusion after thrombolysis for acute myocardial infarction.

Acute myocardial infarction is the leading cause of death in the industrialized world and the paramount goal is establishing early, complete, and sustained reperfusion at the myocardial tissue level. For hospitals without the capacity to perform emergent percutaneous coronary intervention, fibrinolytic therapy plays a critical role although it is limited by a 67% success rate. Despite promising pilot studies, reduced-dose fibrinolytic therapy with glycoprotein IIb/IIIa therapy (GUSTO-V) and full-dose fibrinolytic therapy with enoxaparin (ASSENT-3) or bivalirudin (HERO-2) provide only marginally improved clinical outcomes. Adjunctive in-hospital and secondary preventive measures should include an aspirin, a beta-blocker, an ACE inhibitor, and a statin, based on the Heart Protection Study, unless contraindicated. Patients should be risk stratified, participate in a cardiac rehabilitation program, cease smoking tobacco, and have an intracardiac defibrillator (ICD) implanted if their LV systolic function is < or = 30% at one month based on the MADIT-2 trial.

Adrenergic beta-Antagonists↗