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Kim A Eagle

Publications and source records attributed to Kim A Eagle.

At least 19 recordsLinked to original sources
PubMed2003

Clinical profiles and outcomes of acute type B aortic dissection in the current era: lessons from the International Registry of Aortic Dissection (IRAD).

BACKGROUND: Clinical profiles and outcomes of patients with acute type B aortic dissection have not been evaluated in the current era. METHODS AND RESULTS: Accordingly, we analyzed 384 patients (65+/-13 years, males 71%) with acute type B aortic dissection enrolled in the International Registry of Acute Aortic Dissection (IRAD). A majority of patients had hypertension and presented with acute chest/back pain. Only one-half showed abnormal findings on chest radiograph, and almost all patients had computerized tomography (CT), transesophageal echocardiography, magnetic resonance imaging (MRI), and/or aortogram to confirm the diagnosis. In-hospital mortality was 13% with most deaths occurring within the first week. Factors associated with increased in-hospital mortality on univariate analysis were hypotension/shock, widened mediastinum, periaortic hematoma, excessively dilated aorta (>or=6 cm), in-hospital complications of coma/altered consciousness, mesenteric/limb ischemia, acute renal failure, and surgical management (all P<0.05). A risk prediction model with control for age and gender showed hypotension/shock (odds ratio [OR] 23.8, P<0.0001), absence of chest/back pain on presentation (OR 3.5, P=0.01), and branch vessel involvement (OR 2.9, P=0.02), collectively named 'the deadly triad' to be independent predictors of in-hospital death. CONCLUSIONS: Our study provides insight into current-day profiles and outcomes of acute type B aortic dissection. Factors associated with increased in-hospital mortality ("the deadly triad") should be identified and taken into consideration for risk stratification and decision-making.

Aged↗
PubMed2003

Comparison of patients with acute coronary syndrome with and without systemic hypertension.

The role of systemic hypertension in acute coronary syndrome (ACS) has not been well studied. We studied consecutive subjects admitted to the University of Michigan Health System (Ann Arbor, Michigan) with symptoms of ACS. Data were collected using a standardized form. This observational study is currently ongoing; we collected data from May 1999 to December 2000 for 979 subjects, 890 of whom also had 6-month follow-up data. Hypertensives represented 64.4% (n = 630) of the total population. In general, hypertensive patients were older than normotensives (66.3 vs 59.9 years, p <0.0001), more often women (38.7% vs 26.9%, p = 0.0002), and had more comorbidities, such as previous myocardial infarction (47.9% vs 33.8%, p <0.0001), congestive heart failure (25.7% vs 12.0%, p <0.0001), and diabetes (36.9% vs 17.8%, p <0.0001). At admission, hypertensives had higher systolic blood pressure. Hypertensives had fewer electrocardiographic abnormalities indicating ischemic changes (67.9% vs 76.3%, p = 0.01) and had fewer incident of acute myocardial infarction (AMI) (70.7% vs 76.1%, p = 0.07) than normotensives. There was consistency over different levels of admission systolic blood pressure. Hypertensives received more oral cardiovascular drugs, and had undergone more invasive procedures. The lower rate of AMI in hypertensives seemed to be related to the higher frequency of a history of percutaneous coronary intervention and coronary artery bypass grafting. However, at 6-month follow-up, age- and gender-adjusted odds ratios for adverse events were equivalent in hypertensives and normotensives, suggesting no continuing differential treatment benefit for hypertensives in the months after the initial ACS episode.

Acute Disease↗
PubMed2003

Influence of concurrent renal dysfunction on outcomes of patients with acute coronary syndromes and implications of the use of glycoprotein IIb/IIIa inhibitors.

OBJECTIVES: The purpose of this study was to examine the in-hospital outcome and influence of glycoprotein (GP) IIb/IIIa antagonists on patients with acute coronary syndromes (ACS) across a range of renal function. BACKGROUND: Recent studies demonstrate increasing cardiovascular risk with progressive renal dysfunction. Previous studies investigating GP IIb/IIIa antagonist use have excluded patients with renal dysfunction. METHODS: Patients presenting with ACS between January 1999 and May 2000 were identified, and data on demographics, in-hospital management, and clinical events were collected using standardized definitions. Patients were stratified according to renal function assessed by calculated creatinine clearance (CrCl) at presentation. Primary outcome measures included in-hospital mortality and major bleeding events. RESULTS: Renal insufficiency was present in 312 of 889 patients. There were 40 in-hospital deaths. In non-dialysis-dependent patients, as CrCl worsened, there was a decline in utilization of routine diagnostics and therapeutics, an increase in in-hospital mortality (p = 0.002), and an increase in major bleeding (p = 0.03). Although the use of GP IIb/IIIa antagonists was associated with an increase in major bleeding (p < 0.001), there was a protective effect on in-hospital mortality (p = 0.04) after controlling for CrCl. CONCLUSIONS: Renal dysfunction is present in a substantial proportion of patients with ACS and is associated with increased in-hospital death. Although GP IIb/IIIa antagonist use in patients with ACS and renal insufficiency resulted in increased bleeding events, its administration was associated with a decreased risk of in-hospital mortality. These preliminary findings need to be confirmed in future randomized clinical trials.

Age Factors↗
PubMed2003

Revised guidelines for the management of non-ST-segment elevation acute coronary syndromes.

Unstable angina (UA) and non-ST-segment elevation myocardial infarction (NSTEMI) refer to a spectrum of acute severe cardiac disorders characterized by myocardial oxygen demand and supply mismatch, caused by atherosclerotic coronary artery disease. Patients presenting with acute coronary syndromes represent a major medical problem, accounting for 2.5 million hospitalizations and 500000 deaths annually in the United States alone. Of these, 1.5 million have a final diagnosis of UA, and myocardial infarction (ST-segment and non-ST-segment elevation) accounts for the remaining 1 million. The management of UA/NSTEMI presents a challenge to the cardiologist because treatment strategies continue to evolve. A number of trials have now assessed the safety and efficacy of early revascularization strategies in the treatment of patients with UA/NSTEMI, whereas others have focused on pharmacologic adjunctive therapy. An optimal single strategy encompassing most patients' needs is not clear. This review focuses on the revised American College of Cardiology/American Heart Association guidelines for the management of patients presenting with UA/NSTEMI.

Acute Disease↗
PubMed2003

Use patterns of low-molecular weight heparin and the impact on length of stay in patients hospitalized for atrial fibrillation.

BACKGROUND: Low-molecular weight heparin, although unproven as a protective anticoagulant in atrial fibrillation, is not uncommonly used in this clinical setting. This investigation sought to assess the prevalence of its use for atrial fibrillation and its impact on length of hospital stay. METHODS: A retrospective analysis of patients admitted to the cardiology service at a university hospital with the primary diagnosis of atrial fibrillation was conducted for a 6-month interval in 3 consecutive years. Baseline demographic and clinical information, anticoagulation status, and length of hospital stay were compared. RESULTS: A total of 213 patients were identified and divided into 2 groups (before and after low-molecular weight heparin availability). Low-molecular weight heparin use increased with time (0% in 1997, 16.9% in 1998, 24.1% in 1999) and was associated with a significant reduction in length of hospital stay, from 3.3 +/- 2.8 days to 2.4 +/- 2.1 days (P =.03), and a trend toward a decreased international normalized ratio. CONCLUSIONS: This investigation noted the increasing trend toward the use of low-molecular weight heparin as a protective anticoagulant for atrial fibrillation, despite the lack of controlled data about its efficacy. The observed reduction in length of hospital stay is implicated as a potential reason for the use of low-molecular weight heparin.

Aged↗
PubMed2003

Reducing costs and improving outcomes of percutaneous coronary interventions.

OBJECTIVE: To describe cost reduction and quality improvement efforts in our percutaneous coronary intervention (PCI) program and how risk adjustment was used to assess the effects of these changes. STUDY DESIGN: Single center registry analysis. PATIENTS AND METHODS: Data were collected on 2158 PCIs performed between July 1, 1994, and June 30, 1997. Of these, 1126 PCIs reflected care provided after implementation of competitive bidding for catheterization lab supplies, and efforts to reduce the use of postprocedure heparin and to implement early arterial sheaths removal (postbidding period). Hospital costs were estimated using a microcost accounting method. In-hospital mortality rates during the 2 time periods were compared using standardized mortality ratio estimated with a previously validated risk adjustment model for in-hospital mortality. RESULTS: Compared with the prebidding period, the postbidding period was characterized by a significantly higher utilization of new technology (coronary stents and atherectomy devices 46% vs 25%; abciximab 19.1% vs 3.7, P<.01), and an overall increase in case complexity. Despite these changes, the average and median postbidding cost per case was dollars 1223 and dollars 1444 lower, respectively, than in the prebidding period. After adjustment for comorbidities, procedure variables, complications, and length of hospital stay, multivariate regression modeling identified the postbidding period as an independent predictor of lower hospital costs (P<.001) with an estimated adjusted cost savings of dollars 460. These cost savings were associated with trends toward a lower observed mortality rate, a higher predicted mortality rate, and a significantly lower standardized mortality ratio (SMR .71; 95% CI 0.48-0.9; P<.05). CONCLUSION: Despite an increase in case complexity and utilization of new technology, cost reductions can be achieved through competitive bidding for supplies and modifications of periprocedure care. Risk adjustment appears to be a valid tool for assessing the effectiveness of these efforts independently from changes in case mix.

Aged↗
PubMed2002

Nephropathy requiring dialysis after percutaneous coronary intervention and the critical role of an adjusted contrast dose.

This study was undertaken to determine the incidence, risk factors, and in-hospital outcome of nephropathy requiring dialysis (NRD) after percutaneous coronary intervention (PCI), and to evaluate the role of a weight- and creatinine-adjusted maximum radiographic contrast dose (MRCD) on NRD. Data were obtained from a registry of 16,592 PCIs. The data were divided into development and test sets. Univariate predictors were identified and a multivariate logistic regression model was developed. The MRCD was calculated for each patient as: MRCD = 5 ml x body weight (kilograms)/serum creatinine (milligrams per deciliter). Predictive accuracy was assessed by receiver-operating characteristic curve analysis. In the development set, 41 patients (0.44%) developed NRD with a subsequent in-hospital mortality rate of 39.0%. NRD increased with worsening baseline renal dysfunction. Other risk factors included peripheral vascular disease, diabetes mellitus, congestive heart failure, and cardiogenic shock. There was a direct relation between the number of risk factors and NRD. After adjustment for baseline risk factors, MRCD was the strongest independent predictor of NRD (adjusted odds ratio 6.2, 95% confidence interval 3.0 to 12.8). NRD and in-hospital mortality were both significantly higher in patients who exceeded the MRCD compared with patients who did not (p <0.001). In conclusion, NRD following PCI is a rare complication with a poor prognosis. Baseline clinical characteristics identify patients at greatest risk for NRD. Optimization of procedural variables such as timing of the intervention relative to the diagnostic catheterization, staging coronary procedures, or dosing within the MRCD may help reduce the risk of this complication in high-risk patients. A risk prediction tool for NRD with guidelines for prevention is presented.

Aged↗
PubMed2002

Syncope in acute aortic dissection: diagnostic, prognostic, and clinical implications.

BACKGROUND: Syncope is a well-recognized symptom of acute aortic dissection, often indicating the development of dangerous complications such as cardiac tamponade. SUBJECTS AND METHODS: We identified consecutive patients with acute aortic dissection at 18 referral centers in six countries. Data on key clinical findings and outcomes were collected via extensive questionnaires. Multiple logistic regression models were used to determine the association between syncope and in-hospital mortality, adjusting for demographic characteristics, dissection type, comorbid conditions, and complications (e.g., cardiac tamponade). RESULTS: Syncope was reported in 96 (13%) of 728 patients. Patients with syncope were more likely to die in the hospital (34% [n = 33 deaths]) than were those without syncope (23% [144/632], P = 0.01). They were also more likely to have cardiac tamponade (28% [n = 27] vs. 8% [n = 49], P <0.001), stroke (18% [n = 17] vs. 4% [n = 27], P <0.001), and other neurologic deficits (25% [n = 24] vs. 14% [n = 88], P = 0.005). After multivariate adjustment, clinical factors independently associated with the occurrence of syncope included a proximal dissection (odds ratio [OR] = 5.5; 95% confidence interval [CI]: 2.5 to 12; P <0.001), cardiac tamponade (OR = 3.1; 95% CI: 1.7 to 5.4; P <0.001), and stroke (OR = 3.5; 95% CI: 1.7 to 7.2; P = 0.001). There was a significant association between in-hospital death and syncope after adjustment for demographic characteristics alone (OR = 2.0; 95% CI: 1.2 to 3.5; P = 0.01), but not after adjustment for dissection type, comorbid conditions, and complications. CONCLUSION: Patients with dissections complicated by cardiac tamponade or stroke are significantly more likely to present with syncope. If these complications are excluded, syncope alone does not appear to increase the risk of death independently.

Acute Disease↗
PubMed2002

Missed opportunities to treat atherosclerosis in patients undergoing peripheral vascular interventions: insights from the University of Michigan Peripheral Vascular Disease Quality Improvement Initiative (PVD-QI2).

BACKGROUND: Peripheral vascular disease is a manifestation of systemic atherosclerosis and is associated with an increased risk of cardiovascular morbidity and mortality. METHODS AND RESULTS: We examined clinical outcomes in 66 consecutive patients undergoing peripheral vascular interventions at our institution between January 2001 and October 2001. At hospital discharge and at 6 months, lifestyle modifications and use of evidence-based therapy was suboptimal. At 6 months, a significant proportion continued to smoke (22.7%) and only half of the patients exercised, controlled their weight, or modified their diet for lipid control. The use of antiplatelet therapy was 77.2%; of angiotensin-converting enzyme, 35.9%; of beta-blockers, 42.5%; and of statins, 50%. Twelve of the 66 patients (18.2%) had a clinical event of death, myocardial infarction, or stroke. An appropriateness algorithm for use of secondary prevention measures was created with the use of evidence-based therapy guidelines, and a composite appropriateness variable was also created. The use of evidence-based therapy was associated with a significant reduction of the composite of death, myocardial infarction, and stroke at 6 months (OR 0.02, 95% CI 0.01 to 0.44, P=0.01). CONCLUSIONS: Atherosclerosis risk factors are very prevalent in patients with peripheral vascular disease, but these patients receive less than optimal treatment after a predominantly technical vascular intervention. Effective secondary prevention with appropriate lifestyle interventions and evidence-based medical therapy needs to be strongly encouraged and implemented in these patients.

Algorithms↗
PubMed2002

Chronobiological patterns of acute aortic dissection.

BACKGROUND: Chronobiological rhythms have been shown to influence the occurrence of a variety of cardiovascular disorders. However, the effects of the time of the day, the day of the week, or monthly/seasonal changes on acute aortic dissection (AAD) have not been well studied. METHODS AND RESULTS: Accordingly, we evaluated 957 patients enrolled in the International Registry of Acute Aortic Dissection (IRAD) between 1996 and 2000 (mean age 62+/-14 years, type A 61%). A chi2 test for goodness of fit and partial Fourier analysis were used to evaluate nonuniformity and rhythmicity of AAD during circadian, weekly, and monthly periods. A significantly higher frequency of AAD occurred from 6:00 AM to 12:00 noon compared with other time periods (12:00 noon to 6:00 PM, 6:00 PM to 12:00 midnight, and 12:00 midnight to 6:00 AM; P<0.001 by chi2 test). Fourier analysis showed a highly significant circadian variation (P<0.001) with a peak between 8:00 AM and 9:00 AM. Although no significant variation was found for the day of the week, the frequency of AAD was significantly higher during winter (P=0.008 versus other seasons by chi2 test). Fourier analysis confirmed this monthly variation with a peak in January (P<0.001). Subgroup analysis identified a significant association for all subgroups with circadian rhythmicity. However, seasonal/monthly variations were observed only among patients aged <70 years, those with type B AAD, and those without hypertension or diabetes. CONCLUSIONS: Similar to other cardiovascular conditions, AAD exhibits significant circadian and seasonal/monthly variations. Our findings may have important implications for the prevention of AAD by tailoring treatment strategies to ensure maximal benefits during the vulnerable periods.

Aged↗
PubMed2002

Acute type A aortic dissection in the elderly: clinical characteristics, management, and outcomes in the current era.

OBJECTIVES: We sought to evaluate the clinical characteristics, management, and outcomes of elderly patients with acute type A aortic dissection. BACKGROUND: Few data exist on the clinical manifestations and outcomes of acute type A aortic dissection in an elderly patient cohort. METHODS: We categorized 550 patients with type A aortic dissection enrolled in the International Registry of Acute Aortic Dissection into two age strata (<70 and >or=70 years) and compared their clinical features, management, and in-hospital events. RESULTS: Thirty-two percent of patients with type A dissection were aged >or=70 years. Marfan syndrome was exclusively associated with dissection in the young, whereas hypertension, atherosclerosis and iatrogenic dissection predominated in older patients. Typical symptoms (abrupt onset of chest or back pain) and signs (aortic regurgitation murmur or pulse deficits) of dissection were less common among the elderly. Fewer elderly patients were managed surgically than younger patients (64% vs. 86%, p < 0.0001). Hypotension occurred more frequently (46% vs. 32%, p = 0.002) and focal neurologic deficits less frequently (18% vs. 26%, p = 0.04) among the elderly. In-hospital mortality was higher among older patients (43% vs. 28%, p = 0.0006). Logistic regression analysis identified age >or=70 years as an independent predictor of hospital death for acute type A aortic dissection (odds ratio 1.7, 95% confidence interval 1.1-2.8; p = 0.03). CONCLUSIONS: Our study shows significant differences between older (age >or=70 years) and younger (age <70 years) patients with acute type A aortic dissection in their clinical characteristics, management, and hospital outcomes. Future research should evaluate strategies to improve outcomes in this high-risk elderly cohort.

Acute Disease↗