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Biomedical subjects

Kim A Eagle

Publications and source records attributed to Kim A Eagle.

At least 19 recordsLinked to original sources
PubMed2007

The duration of anticoagulation bridging therapy in clinical practice may significantly exceed that observed in clinical trials.

BACKGROUND: Clinical trials involving frequent, standardized monitoring of the international normalized ratio (INR) demonstrated that a short course of low-molecular-weight-heparin (LMWH) can successfully bridge patients to oral anticoagulation. However, rigidly performed INR testing is often not feasible in the outpatient setting in actual clinical practice. The purpose of this study was to determine if the anticoagulation results of clinical trials of LMWH bridging therapy are also achieved in a single-center clinical practice setting. METHODS: We conducted a retrospective analysis of 100 patients initiating warfarin while receiving LMWH under the care of a university-based anticoagulation management service. RESULTS: Mean patient age was 56.1 +/- 16.3 years. The commonest indications for anticoagulation were venous thrombosis (57%) and atrial fibrillation (25%). Mean initial warfarin dose was 5.1 +/- 1.8 mg/day; 30% of patients received antiplatelet therapy. The mean total duration of LMWH therapy was 12.0 +/- 8.2 days, of which 9.8 +/- 8.0 days (median 7.5 days; interquartile range 4.3-13.0 days) occurred in the outpatient setting. Forty-one percent of patients received outpatient LMWH for < 7 days, 40% for 7-14 days, and 19% for > 14 days. A mean of 3.9 +/- 2.0 INRs were performed during LMWH therapy. Complications included 11 minor and 1 major bleeding episodes and 1 thrombotic event. CONCLUSIONS: The duration of LMWH bridging therapy in practice may be significantly greater than previously reported in clinical trials, and the incidence of patients requiring prolonged (>14 days) LMWH therapy is relatively high. Outpatient LMWH as employed in clinical practice safely bridges patients to oral anticoagulation. Strategies to shorten the duration of LMWH therapy are needed and are likely to improve clinical outcomes and reduce health care expenses. In prospective clinical trials low-molecular-weight-heparin (LMWH) has proven effective in transitioning patients with venous thromboembolic disease to therapeutic warfarin anticoagulation. However, it is unknown if the anticoagulation results obtained in these trials, which involved rigidly performed anticoagulation monitoring, are achieved in standard clinical practice involving patients with a variety of indications for anticoagulation. We conducted a retrospective analysis of 100 patients initiating warfarin while receiving LMWH under the management of a university-based anticoagulation management service. The mean total duration of LMWH therapy was 12.0 +/- 8.2 days, of which 9.8 +/- 8.0 days (median 7.5 days; interquartile range 4.3-13.0 days) occurred in the outpatient setting. Forty-one percent of patients received outpatient LMWH for <7 days, 40% for 7-14 days, and 19% for >14 days. We conclude that the duration of LMWH bridging therapy in practice may be significantly greater than previously reported in clinical trials, and the incidence of patients requiring prolonged (>14 days) LMWH therapy is relatively high.

Adult↗
PubMed2007

A quality guarantee in acute coronary syndromes: the American College of Cardiology's Guidelines Applied in Practice program taken real-time.

BACKGROUND: Wide variation exists in the management of acute coronary syndromes (ACSs), which includes an apparent underutilization of evidence-based therapies. We have previously demonstrated that application of the American College of Cardiology Guidelines Applied in Practice (GAP) tools can improve quality indicator rates and outcomes of patients hospitalized with ACS. OBJECTIVE: To determine whether a real-time system for monitoring key quality-of-care indicators using GAP would improve both process indicators and outcomes beyond those of the initial implementation of GAP. DESIGN: Prospective patient identification, prospective chart coding, retrospective data abstraction. PATIENTS: All patients with ACS admitted (N = 3189) to our institution between January 1, 1999, and December 2004; 2019 studied before real-time implementation from January 1, 1999, to June 30, 2002, and 1170 studied during real-time implementation from July 1, 2002, to December 31, 2004. MAIN OUTCOME MEASURE: The effect of real-time monitoring of key quality indicators on inhospital therapy and outcomes, and 6-month outcomes in patients admitted with ACS. RESULTS: The real-time GAP implementation correlated with more frequent use of inhospital angiotensin-converting enzyme inhibitors (72.7% vs 63.7%, P < .0001), beta blockers (93.0% vs 89.7%, P = .0016), statins (81.2% vs 65.9%, P < .0001), antiplatelet agents (69.2% vs 22.5%, P < .0001), and glycoprotein IIb/IIIa inhibitors (35.5% vs 26.7%, P < .0001). There were fewer episodes of inhospital congestive heart failure (3.85% vs 8.77%, P < .0001) and major bleeding events (3.2% vs 7.9%, P < .0001) after the real-time system was adopted. Real-time GAP also resulted in higher discharge rates of aspirin (92.1% vs 86.5%, P < .0001), beta blockers (86.8% vs 79.1%, P < .0001), statins (81.2% vs 64.7%, P < .0001), and angiotensin-converting enzyme inhibitors (67.1% vs 55.5%, P < .0001). Real-time GAP implementation was associated with fewer rehospitalizations for heart disease (19.8% vs 25.2%, P = .0014), myocardial infarction (3.5% vs 5.4%, P = .0243), and combined death/cerebrovascular accident/myocardial infarction (9.5% vs 13.9%, P = .0009) during the first 6 months after discharge. CONCLUSION: The institution of a formal system to review and "guarantee" key quality-of-care indicators real time in the hospital is associated with improved outcomes in patients admitted with ACS. The combination of American College of Cardiology's GAP program and its real-time implementation leads to higher use of evidence-based therapies and correspondingly better outcomes than those associated with the initial GAP implementation.

Angina, Unstable↗
PubMed2007

Use of heparins in Non-ST-elevation acute coronary syndromes.

PURPOSE: We describe the use of antithrombotic therapy in the management of patients with acute coronary syndromes. METHODS: Patients from the Global Registry of Acute Coronary Events, a multinational coronary disease registry, were characterized according to the early and continued use of low-molecular-weight heparin, unfractionated heparin, any crossover of heparin therapy (change in early vs late heparin treatment), and no heparin treatment. Hospital outcomes were analyzed according to the heparin treatment and the timing of percutaneous coronary interventions. RESULTS: Data from 23,172 patients with non-ST-segment elevation myocardial infarction or unstable angina were analyzed. A total of 8791 patients were treated with low-molecular-weight heparin within the first 24 hours and continued thereafter; 4076 patients received unfractionated heparin; 2953 patients received neither heparin therapy; and 7352 patients received crossover heparin treatment. Concomitant treatment, including early or late percutaneous coronary intervention, varied according to the type of heparin therapy. Patients treated with a crossover therapy were more likely to undergo percutaneous coronary intervention. The rates of major bleeding and death were lower with low-molecular-weight heparin (1.4% and 1.8%, respectively) compared with unfractionated heparin (1.9% and 2.5%, respectively), crossover heparin (2.0% and 2.3%, respectively), or neither heparin (1.5% and 2.4%, respectively). CONCLUSIONS: There is significant variability in heparin use in patients with acute coronary syndromes. Heparin type and use seem to be related to the timing and use of percutaneous coronary interventions. The early use of low-molecular-weight heparin in the setting of an acute coronary syndrome is associated with better short-term outcomes.

Aged↗
PubMed2007

Simple risk models to predict surgical mortality in acute type A aortic dissection: the International Registry of Acute Aortic Dissection score.

BACKGROUND: Surgical mortality for acute type A aortic dissection is frequently related to preoperative clinical conditions. We report a predictive score to identify risk of death that may be helpful to assist surgeons who are considering whether to proceed with surgical correction in the case of patients in extreme clinical risk. METHODS: Surgical outcome of 682 patients enrolled in the International Registry of Acute Aortic Dissection from 1996 to 2003 was analyzed. Two different models were used. The initial model included only preoperative variables such as demographics, history, symptoms, signs, and diagnostic methods (model 1). The second model also tested intraoperative hemodynamic and surgical variables (model 2). A bedside risk prediction tool to predict operative mortality in individual patients was developed. RESULTS: The overall in-hospital surgical mortality was 23.9%. Independent preoperative predictors of mortality in model 1 were age greater than 70 years, prior cardiac surgery, hypotension (systolic blood pressure less than 100 mm Hg) or shock at presentation, migrating pain, cardiac tamponade, any pulse deficit, and electrocardiogram with findings of myocardial ischemia or infarction. In model 2, other predictors of surgical death were intraoperative hypotension, a right ventricle dysfunction at surgery, and a necessity to perform coronary revascularization. An independent predictor for favorable surgical outcome was right hemiarch replacement. CONCLUSIONS: Surgery in unstable patients with acute type A aortic dissection can be highly unsuccessful. The International Registry of Acute Aortic Dissection risk models predict in-hospital mortality using a multivariable risk prediction tool, useful for surgeons and patients as they consider their surgical risk and the pros and cons of embarking on high-risk surgery.

Acute Disease↗
PubMed2006

Long-term survival in patients presenting with type B acute aortic dissection: insights from the International Registry of Acute Aortic Dissection.

BACKGROUND: Follow-up survival studies in patients with acute type B aortic dissection have been restricted to a small number of patients in single centers. We used data from a contemporary registry of acute type B aortic dissection to better understand factors associated with adverse long-term survival. METHODS AND RESULTS: We examined 242 consecutive patients discharged alive with acute type B aortic dissection enrolled in the International Registry of Acute Aortic Dissection (IRAD) between 1996 and 2003. Kaplan-Meier survival curves were constructed, and Cox proportional hazards analysis was performed to identify independent predictors of follow-up mortality. Three-year survival for patients treated medically, surgically, or with endovascular therapy was 77.6+/-6.6%, 82.8+/-18.9%, and 76.2+/-25.2%, respectively (median follow-up 2.3 years, log-rank P=0.61). Independent predictors of follow-up mortality included female gender (hazard ratio [HR],1.99; 95% confidence interval [CI], 1.07 to 3.71; P=0.03), a history of prior aortic aneurysm (HR, 2.17; 95% CI, 1.03 to 4.59; P=0.04), a history of atherosclerosis (HR, 2.48; 95% CI, 1.32 to 4.66; P<0.01), in-hospital renal failure (HR, 2.55; 95% CI, 1.15 to 5.63; P=0.02), pleural effusion on chest radiograph (HR, 2.56; 95% CI, 1.18 to 5.58; P=0.02), and in-hospital hypotension/shock (HR, 12.5; 95% CI, 3.24 to 48.21; P<0.01). CONCLUSIONS: Contemporary follow-up mortality in patients who survive to hospital discharge with acute type B aortic dissection is high, approaching 1 in every 4 patients at 3 years. Current treatment and follow-up surveillance require further study to better understand and optimize care for patients with this complex disease.

Acute Disease↗
PubMed2006

Prediction of risk of death and myocardial infarction in the six months after presentation with acute coronary syndrome: prospective multinational observational study (GRACE).

OBJECTIVE: To develop a clinical risk prediction tool for estimating the cumulative six month risk of death and death or myocardial infarction to facilitate triage and management of patients with acute coronary syndrome. DESIGN: Prospective multinational observational study in which we used multivariable regression to develop a final predictive model, with prospective and external validation. SETTING: Ninety four hospitals in 14 countries in Europe, North and South America, Australia, and New Zealand. POPULATION: 43,810 patients (21,688 in derivation set; 22,122 in validation set) presenting with acute coronary syndrome with or without ST segment elevation enrolled in the global registry of acute coronary events (GRACE) study between April 1999 and September 2005. MAIN OUTCOME MEASURES: Death and myocardial infarction. RESULTS: 1989 patients died in hospital, 1466 died between discharge and six month follow-up, and 2793 sustained a new non-fatal myocardial infarction. Nine factors independently predicted death and the combined end point of death or myocardial infarction in the period from admission to six months after discharge: age, development (or history) of heart failure, peripheral vascular disease, systolic blood pressure, Killip class, initial serum creatinine concentration, elevated initial cardiac markers, cardiac arrest on admission, and ST segment deviation. The simplified model was robust, with prospectively validated C-statistics of 0.81 for predicting death and 0.73 for death or myocardial infarction from admission to six months after discharge. The external applicability of the model was validated in the dataset from GUSTO IIb (global use of strategies to open occluded coronary arteries). CONCLUSIONS: This risk prediction tool uses readily identifiable variables to provide robust prediction of the cumulative six month risk of death or myocardial infarction. It is a rapid and widely applicable method for assessing cardiovascular risk to complement clinical assessment and can guide patient triage and management across the spectrum of patients with acute coronary syndrome.

Epidemiologic Methods↗
PubMed2006

Symptoms of men and women presenting with acute coronary syndromes.

This study evaluated symptom similarities and differences between men and women presenting with acute coronary syndromes (ACSs) and determined whether differences in presentation are intrinsic to patient gender or to other factors. This study was a subgroup analysis of patients from an ACS registry. We compared differences in symptom presentation between men and women and analyzed them using binary logistic regression with all variables and 2 x 2 interactions. Patient gender was forced to remain in the models. Women comprised 35% of the 1,941 patients admitted with confirmed ACS. Men were more likely to present with chest pain, left arm pain, or diaphoresis. Nausea was more common in women. Dyspnea did not differ between groups. After binary logistic regression, gender remained a statistically significant predictor of diaphoresis and nausea, but not of chest or left arm pain. We found that differences in occurrence of chest pain and left arm pain between men and women are explainable by differences in co-morbidities and history; the higher occurrence of diaphoresis in men and of nausea in women is partly related to maleness or femaleness. In conclusion, gender should be considered when evaluating patients with symptoms of ACS.

Acute Disease↗
PubMed2006

Acute limb ischemia associated with type B aortic dissection: clinical relevance and therapy.

BACKGROUND: The goal of the current study is to characterize the presentation, therapy, and outcomes of acute limb ischemia (ALI) associated with type B aortic dissection (AoD). METHODS: The prospective/retrospective International Registry for Acute Aortic Dissection (IRAD) database and a single institutional database were queried for all patients with type B AoD from 1996 to 2002. Univariate and multivariate statistics were used to delineate factors associated with morbidity and mortality outcomes. RESULTS: According to the IRAD data (n = 458), the mean age of patients was 64 years, and 70% were men. The overall mortality was 12%; of these, 6% had ALI. Pulse (3-fold) and neurologic deficits (5-fold) were more common in those with ALI (P < .001). Endovascular, but not surgical therapy, was more commonly performed in patients with ALI compared with those without ALI (31% vs 10%, P = .004). No difference in age, race, gender, or origin of dissection was observed. ALI was associated with acute renal failure (odds ratio [OR] = 2.7; 95% confidence interval [CI] 1.1-7.1; P = .048) and acute mesenteric ischemia/infarction (OR = 6.9; 95% CI 2.5-20; P < .001). Adjusting for patient characteristics, ALI was associated with death (3.5; 95% CI 1.1-10; P = .02). The single institution analysis revealed similar patient demographics and mortality in 93 AoD patients, of whom 28 had ALI. Aortic fenestration or aorto-iliac stenting was the primary therapy in 93%; surgical bypass was used in 7%. Limb salvage was 93% in those with ALI at a mean of 18 months follow-up. The number of organ systems with malperfusion was 2-fold higher at aortography than suspected preprocedure (P = .002). By stepwise regression modeling, mortality was greater in those not taking a beta-blocker (OR = 19; 95% CI 3.1-111; P = .001). CONCLUSIONS: ALI secondary to AoD is predictive of death and visceral ischemia. Endovascular therapy confers excellent limb salvage and allows diagnosis of unsuspected visceral ischemia.

Acute Disease↗
PubMed2006

Long-term survival in patients presenting with type A acute aortic dissection: insights from the International Registry of Acute Aortic Dissection (IRAD).

BACKGROUND: Earlier studies evaluating long-term survival in type A acute aortic dissection (TA-AAD) have been restricted to a small number of patients in single center experiences. We used data from a contemporary, multi-center international registry of TA-AAD patients to better understand factors associated with long-term survival. METHODS AND RESULTS: We examined 303 consecutive patients with TA-AAD enrolled in the International Registry of Acute Aortic Dissection (IRAD) between 1996 and 2003. We included patients who were discharged alive and had documented clinical follow-up data. Kaplan-Meier survival curves were constructed to depict cumulative survival in patients from date of hospital discharge. Stepwise Cox proportional hazards analysis was performed to identify independent predictors of follow-up mortality. We found that 273 (90.1%) patients had been managed surgically and 30 (9.9%) were managed medically. Patients who were dead at follow-up were more likely to be older (63.9 versus 58.4 years, P=0.007) and to have had previous cardiac surgery (23.9% versus 10.6%, P=0.01). Survival for patients treated with surgery was 96.1%+/-2.4% and 90.5%+/-3.9% at 1 and 3 years versus 88.6%+/-12.2% and 68.7%+/-19.8% without surgery (mean follow-up overall, 2.8 years, log rank P=0.009). Multivariate analysis identified a history of atherosclerosis (relative risk (RR), 2.17; 95% confidence interval [CI], 1.08 to 4.37; P=0.03) and previous cardiac surgery (RR, 2.54; 95% CI, 1.16 to 5.57; P=0.02) as significant, independent predictors of follow-up mortality. CONCLUSIONS: Contemporary 1- and 3-year survival in patients with TA-AAD treated surgically are excellent. Independent predictors of survival during the follow-up period do not appear to be influenced by in-hospital risks but rather preexisting comorbidities.

Acute Disease↗
PubMed2006

Role and results of surgery in acute type B aortic dissection: insights from the International Registry of Acute Aortic Dissection (IRAD).

BACKGROUND: The clinical profiles and outcomes of patients treated surgically for acute type B aortic dissection (ABAD) are often reported for those in small series or for those cared for at a single institution over a long time period, during which a continuous evolution in techniques has occurred. Accordingly, we sought to evaluate the clinical features and surgical results of patients enrolled in the International Registry of Acute Aortic Dissection by identifying primary factors that influenced surgical outcome and estimating average surgical mortality for ABAD in the current era. METHODS AND RESULTS: A comprehensive analysis of 290 clinical variables and their relation to surgical outcomes for 82 patients who required surgery for ABAD (from a population of 1256 patients; mean+/-SD age, 60.6+/-15.0 years; 82.9% male) and who were enrolled in the International Registry of Acute Aortic Dissection was performed. The overall in-hospital mortality was 29.3%. Factors associated with increased surgical mortality based on univariate analysis were preoperative coma or altered consciousness, partial thrombosis of the false lumen, evidence of periaortic hematoma on diagnostic imaging, descending aortic diameter >6 cm, right ventricle dysfunction at surgery, and shorter time from the onset of symptoms to surgery. Factors associated with favorable outcomes included radiating pain, normotension at surgery (systolic blood pressure 100 to 149 mm Hg), and reduced hypothermic circulatory arrest time. The 2 independent predictors of surgical mortality were age >70 years (odds ratio, 4.32; 95% confidence interval, 1.30 to 14.34) and preoperative shock/hypotension (odds ratio, 6.05; 95% confidence interval, 1.12 to 32.49). CONCLUSIONS: The present study provides insights into current-day clinical profiles and surgical outcomes of ABAD. Knowledge about different preoperative clinical conditions may help surgeons in making treatment decisions among these high-risk patients.

Acute Disease↗
PubMed2006

Sex differences in the application of evidence-based therapies for the treatment of acute myocardial infarction: the American College of Cardiology's Guidelines Applied in Practice projects in Michigan.

BACKGROUND: Studies have shown that women with acute myocardial infarction (AMI) are less likely to receive evidence-based care compared with men. The American College of Cardiology's AMI Guidelines Applied in Practice (GAP) program has been shown to increase the rates of evidence-based medicine use and reduce mortality in patients with AMI. The objective of this study was to investigate the relative benefits of the GAP program in men and women. METHODS: By using a predesign-postdesign, standard orders, and a discharge tool to improve evidence-based indicator rates and long-term mortality in patients with AMI in Michigan, this study compared the success of GAP in men vs women. Logistic regression was used to develop predictive models for death at 30 days and 1 year in men and women. RESULTS: Use of evidence-based care, including use of beta-blockers and aspirin in men and women at hospital discharge and lipid-lowering agent use in men, was higher in the post-GAP sample (P<.01 for all). Use of the discharge tool promoted by the GAP program was independently protective against death at 1 year in women (adjusted odds ratio, 0.46; 95% confidence interval, 0.27-0.79), and a trend existed for similar results in men (adjusted odds ratio, 0.62; 95% confidence interval, 0.36-1.06). However, the tool was used slightly less often with women (27.9% vs 33.96%; P=.003). CONCLUSIONS: The GAP program increased the use of evidence-based therapies in male and female patients. In addition, the GAP discharge tool may decrease mortality rates at 1 year in patients with AMI; however, the tool was used less often with women. Greater use of the GAP discharge tool in women might narrow the post-MI sex mortality gap.

Aged↗
PubMed2006

Association of a continuous quality improvement initiative with practice and outcome variations of contemporary percutaneous coronary interventions.

BACKGROUND: The objective of this study was to evaluate the association of a continuous quality improvement program with practice and outcome variations of percutaneous coronary intervention (PCI). METHODS AND RESULTS: Data on consecutive PCI were collected in a consortium of 5 hospitals; 3731 PCIs reflected care provided at baseline (January 1, 1998, to December 31, 1998), and 5901 PCIs reflected care provided after implementation of a continuous quality improvement intervention (January 1, 2002, to December 31, 2002). The intervention included feedback on outcomes, working group meetings, site visits, selection of quality indicators, and use of bedside tools for quality improvement and risk assessment. Postintervention data were compared with baseline and with 10,287 PCIs from 7 hospitals added to the consortium in 2002. Quality indicators included use of preprocedural aspirin or clopidogrel, use of glycoprotein IIb/IIIa receptor blockers and postprocedural heparin, and amount of contrast media per case. Outcomes selected included emergency CABG, contrast nephropathy, myocardial infarction, stroke, transfusion, and in-hospital death. Compared with baseline and the control group, the intervention group at follow-up had higher use of preprocedural aspirin and glycoprotein IIb/IIIa blockers, lower use of postprocedural heparin, and a lower amount of contrast media per case (P<0.05). These changes were associated with lower rates of transfusions, vascular complications, contrast nephropathy, stroke, transient ischemic attack, and combined end points (all P<0.05). CONCLUSIONS: Our nonrandomized, observational data suggest that implementation of a regional continuous quality improvement program appears to be associated with enhanced adherence to quality indicators and improved outcomes of PCI. A randomized clinical trial is needed to determine whether this is a "causal" or a "casual" relationship.

Aged↗
PubMed2006

The impact of time and day on the presentation of acute coronary syndromes.

BACKGROUND: The frequency of acute myocardial infarction (AMI) peaks on Mondays and in the mornings. However, the distribution of the types of acute coronary syndromes (ACS), including unstable angina (UA), has not been systematically evaluated. HYPOTHESIS: The distribution of the types of ACS and clinical presentations varies by time and day of admission. METHODS: A retrospective cohort study was conducted in 1,946 consecutive nontransfer ACS admissions (1999-2004) to a tertiary-care academic center to assess presenting clinical variables in patients admitted on days versus nights (6 P.M.-6 A.M.) and weekdays versus weekends (Friday 6 P.M.-Monday 6 A.M.). RESULTS: There were fewer ACS admissions than expected on nights and weekends (p < 0.001), but the proportion of patients with ACS presenting with ST-elevation myocardial infarction (STEMI) is 64% higher on weekends (p < 0.001) and 31% higher on nights (p = 0.022). This increased proportion with STEMI results in a greater proportion of ACS with AMI on weekends (up arrow 10%, p = 0.006) and nights (up arrow 7%, p = 0.033). Using multivariate modeling, the increase in patients with AMI on weekends was not explained by conventional risk predictors. CONCLUSIONS: Although fewer patients with ACS presented on nights and weekends, patients at those times were more likely to have an AMI, driven largely by an increased proportion with STEMI at those times. Consideration should be given to these findings when developing clinical care paradigms, health care staffing needs, and when comparing new treatment outcomes in patients with ACS.

Aged↗