Biomedical subjects

Linda A Pape

Publications and source records attributed to Linda A Pape.

13 recordsLinked to original sources

PubMed2006

The use of enoxaparin compared with unfractionated heparin for short-term antithrombotic therapy in atrial fibrillation patients undergoing transoesophageal echocardiography-guided cardioversion: assessment of Cardioversion Using Transoesophageal Echocardiography (ACUTE) II randomized multicentre study.

AIMS: To compare the feasibility and safety of transoesophageal echocardiograpy-guided cardioversion (CV) with enoxaparin and unfractionated heparin (UFH) in patients with atrial fibrillation (AF). METHODS AND RESULTS: The Assessment of Cardioversion Using Transoesophageal Echocardiography (ACUTE) II pilot trial compared the safety and efficacy of enoxaparin with UFH in 155 patients with AF who were scheduled for transoesophageal echocardiography (TEE)-guided CV. Safety outcomes over a 5-week period were ischaemic stroke, major or minor bleeding, and death. Efficacy outcomes were length of stay (LOS) and return to normal sinus rhythm (NSR). Of the 76 patients assigned to the enoxaparin group, 72 (94.7%) had a transoesophageal echocardiogram and 63 (82.9%) had early CV, of which 59 (93.7%) were successful. Of the 79 UFH patients, 66 (83.5%) had a transoesophageal echocardiogram and 58 (73.4%) had early CV, of which 54 (98.2%) were successful. There were no significant differences in embolic events, bleeding, or deaths between groups. The enoxaparin group had shorter median LOS compared with the UFH group [3(2-4) vs. 4(3-5)] days; P<0.0001). There was also more NSR at 5 weeks in the enoxaparin group (76 vs. 57%; P=0.013). CONCLUSION: In the ACUTE II trial, there were no differences in safety outcomes between the two strategies. However, the enoxaparin group had a shorter LOS. Thus, the TEE-guided enoxaparin strategy may be considered a safe and effective alternative strategy for AF. The shorter LOS may translate to lower costs using the enoxaparin TEE-guided approach.

Atrial Fibrillation↗

PubMed2005

Implications of periaortic hematoma in patients with acute aortic dissection (from the International Registry of Acute Aortic Dissection).

The clinical profiles, presentation, and outcomes of patients with acute aortic dissections and associated periaortic hematomas on aortic imaging have not been described in a large cohort. This study sought to assess the prognostic implications of periaortic hematomas in patients with aortic dissections and to identify factors associated with in-hospital mortality in patients with periaortic hematomas. The study population was 971 patients with acute aortic dissections enrolled in the International Registry of Acute Aortic Dissection with available imaging data on presentation with the presence or absence of periaortic hematomas. Patients with periaortic hematomas (n = 227, 23.4%) were more likely to be women, to have a history of hypertension and atherosclerosis, and to present early to the hospital. At presentation, they had greater frequencies of shock, cardiac tamponade, coma, and/or altered consciousness. Clinical outcomes were significantly worse in patients with periaortic hematomas, including significantly greater mortality (33% vs 20.3%, p <0.001). A multivariate model demonstrated periaortic hematomas to be an independent predictor of mortality in patients with aortic dissections (odds ratio 1.71, 95% confidence interval 1.15 to 2.54, p = 0.007). In conclusion, this study provides insight into the profiles, presentation, and outcomes of patients with periaortic hematomas and acute aortic dissections. The early identification and aggressive management of patients with periaortic hematomas may potentially improve clinical outcomes.

Acute Disease↗

PubMed2005

Acute intramural hematoma of the aorta: a mystery in evolution.

BACKGROUND: The definition, prevalence, outcomes, and appropriate treatment strategies for acute intramural hematoma (IMH) continue to be debated. METHODS AND RESULTS: We studied 1010 patients with acute aortic syndromes who were enrolled in the International Registry of Aortic Dissection (IRAD) to delineate the prevalence, presentation, management, and outcomes of acute IMH by comparing these patients with those with classic aortic dissection (AD). Fifty-eight (5.7%) patients had IMH, and this cohort tended to be older (68.7 versus 61.7 years; P<0.001) and more likely to have distal aortic involvement (60.3% versus 35.3%; P<0.001) compared with 952 patients with AD. Patients with IMH described more severe initial pain than did those with AD but were less likely to have ischemic leg pain, pulse deficits, or aortic valve insufficiency; moreover, they required a longer time to diagnosis and more diagnostic tests. Overall mortality of IMH was similar to that of classic AD (20.7% versus 23.9%; P=0.57), as was mortality in patients with IMH of the descending aorta (8.3% versus 13.1%; P=0.60) and the ascending aorta (39.1% versus 29.9%; P=0.34) compared with AD. IMH limited to the aortic arch was seen in 7 patients, with no deaths, despite medical therapy in only 6 of the 7 individuals. Among the 51 patients whose initial diagnostic study showed IMH only, 8 (16%) progressed to AD on a serial imaging study. CONCLUSIONS: The IRAD data demonstrate a 5.7% prevalence of IMH in patients with acute aortic syndromes. Like classic AD, IMH is a highly lethal condition when it involves the ascending aorta and surgical therapy should be considered, but this condition is less critical when limited to the arch or descending aorta. Fully 16% of patients have evidence of evolution to dissection on serial imaging.

Acute Disease↗

PubMed2005

Impact of cardioversion strategy on functional capacity in patients with atrial fibrillation: the Assessment of Cardioversion Using Transesophageal Echocardiography (ACUTE) study.

BACKGROUND: The ACUTE Trial studied a transesophageal echocardiography (TEE)-guided strategy compared with a conventional strategy for management of patients with atrial fibrillation undergoing direct current cardioversion. The primary aim was to determine if patient functional capacity, measured by the Duke Activity Status Index (DASI), would differ between treatment strategies. METHODS: The DASI was self-administered at study enrollment and at 8-week follow-up in 1074 (88%) of 1222 total patients. Clinical outcomes associated with enrollment DASI scores and change in follow-up DASI scores were reviewed. RESULTS: There was no difference between the TEE-guided (n = 544) and conventional treatment (n = 530) groups for mean baseline and 8-week DASI scores, adjusting for baseline; however, patients who improved their DASI score were more likely to be in the TEE-guided group (P = .03). Pooled group data showed that the higher the enrollment DASI score, the more it tended to be positively related to maintenance of sinus rhythm (P = .06) at 8 weeks. The lower the enrollment DASI score, the more it was predictive of death (P = .03) and bleeding (P = .01) within 8 weeks. Patients with congestive heart failure (CHF) at enrollment showed greater improvement in DASI scores at 8 weeks compared with patients without CHF (DASI Delta 45.9% vs 31.6%, P < .001). CONCLUSIONS: There was no difference in DASI scores between treatment groups. However, TEE-guided treatment was a predictor of improved DASI at follow-up, and subgroup analysis showed that patients with CHF did show improvement in functional capacity with cardioversion.

Activities of Daily Living↗

PubMed2005

Does circadian and seasonal variation in occurrence of acute aortic dissection influence in-hospital outcomes?

The risk of acute aortic dissection (AAD) exhibits chronobiological variations with peak onset in the morning and in winter. However, it is not known whether the time of day or season of the year of the AAD affects clinical outcomes. We studied 1,032 patients enrolled in the International Registry of Acute Aortic Dissection from January 1997 to December 2001. For circadian and seasonal analysis, the time and date of symptom onset were available for 741 and 1,007 patients, respectively, and were grouped into four 6h periods (morning, afternoon, evening, and night) and four seasons (winter, spring, summer, and autumn). The chi2 test for goodness of fit was used to evaluate non-uniformity of the time of day and time of year for critical in-hospital clinical events, including death. While highest incidence of AAD occurred in the morning and winter, clinical events (including mortality) were similar during the four different periods of the 24 h (chi2 = 1.9, p = 0.60) and seasonal (chi2 = 1.2, p = 0.75) periods.

Aged↗

PubMed2004

Differences in clinical presentation, management, and outcomes of acute type a aortic dissection in patients with and without previous cardiac surgery.

BACKGROUND: There are less data on the clinical and diagnostic imaging characteristics, management, and outcomes of patients with previous cardiac surgery (PCS) presenting with acute type A aortic dissection (AAD). METHODS AND RESULTS: In 617 patients with AAD, we evaluated the differences in the clinical characteristics, management, and in-hospital outcomes of the cohorts with and without PCS. A history of PCS was present in 100 of 617 patients. Patients with PCS were more likely to be males (P=0.02), older (P=0.014), and to have a history of previous aortic dissection (P<0.001) or aneurysms (P<0.001). In contrast, PCS patients were less likely to have presenting chest pain (P<0.001). Cardiac tamponade was less common in PCS patients (P=0.007). Fewer AAD patients with PCS underwent surgical repair (P=0.001). Hospital mortality was not adversely influenced by PCS (odds ratio [OR], 1.46; 95% confidence interval [CI], 0.81 to 2.63), but a trend for increased death was seen in patients with previous aortic valve replacement (AVR) (OR, 2.31; 95% CI, 0.98 to 5.43). Age 70 years or older, previous AVR, shock, and renal failure identified PCS patients at risk for death. CONCLUSIONS: Our study highlights differences in clinical characteristics, management, and outcomes of AAD patients with PCS. Importantly, PCS, with the exception of previous AVR, does not adversely influence early outcomes of AAD patients, including those undergoing surgical repair. However, because of otherwise dismal outcomes with medical management of AAD, our data indicate that a history of PCS (even that of previous AVR) should not preclude physicians from recommending surgical correction of type A aortic dissection in appropriate patients.

Acute Kidney Injury↗

PubMed2004

Gender-related differences in acute aortic dissection.

BACKGROUND: Few data exist on gender-related differences in clinical presentation, diagnostic findings, management, and outcomes in acute aortic dissection (AAD). METHODS AND RESULTS: Accordingly, we evaluated 1078 patients enrolled in the International Registry of Acute Aortic Dissection (IRAD) to assess differences in clinical features, management, and in-hospital outcomes between men and women. Of the patients enrolled in IRAD (32.1%) with AAD, 346 were women. Although less frequently affected by AAD (32.1% of AAD), women were significantly older and had more often presented later than men (P=0.008); symptoms of coma/altered mental status were more common, whereas pulse deficit was less common. Diagnostic imaging suggestive of rupture, ie, periaortic hematoma, and pleural or pericardial effusion were more commonly observed in women. In-hospital complications of hypotension and tamponade occurred with greater frequency in women, resulting in higher in-hospital mortality compared with men. After adjustment for age and hypertension, women with aortic dissection die more frequently than men (OR, 1.4, P=0.04), predominantly in the 66- to 75-year age group. Moreover, surgical outcome was worse in women than men (P=0.013); type A dissection in women was associated with a higher surgical mortality of 32% versus 22% in men despite similar delay, surgical technique, and hemodynamics. CONCLUSIONS: Our analysis provides insights into gender-related differences in AAD with regard to clinical characteristics, management, and outcomes; important diagnostic and therapeutic implications may help shed light on aortic dissection in women to improve their outcomes.

Acute Disease↗

PubMed2004

Characterizing the young patient with aortic dissection: results from the International Registry of Aortic Dissection (IRAD).

OBJECTIVES: The goal of this study was to better characterize the young patient with aortic dissection (AoD). BACKGROUND: Aortic dissection is unusual in young patients, and frequently associated with unusual presentations. METHODS: Data were collected on 951 patients diagnosed with AoD between January 1996 and November 2001. Two categories of patients, <40 years and >or=40 years, were compared using chi-square cross tabulations for categorical and Student t test for continuous data. RESULTS: Sixty-eight patients (7%) with AoD were <40 years of age. Compared with patients >or=40 years, younger patients were less likely to have a prior history of hypertension (p < 0.05); however, younger patients were more likely to have Marfan syndrome, bicuspid aortic valve, and prior aortic surgery (all, p < 0.05). Clinical presentations in the two age groups were similar; however, younger patients were less likely to be hypertensive (25% vs. 45%, p = 0.003). The proximal aortas of young AoD patients were larger (all, p < 0.05) compared with older patients. These differences in aortic size between age groups were not entirely related to Marfan syndrome. Mortality among young patients was similar to patients >or=40 years of age (22% vs. 24%, p = NS), irrespective of the site of dissection. CONCLUSIONS: Compared with older patients with AoD, young patients have unique risk factors for dissection: Marfan syndrome, bicuspid aortic valves, and larger aortic dimensions. Surprisingly, the mortality risk for young AoD patients is not lower than older AoD patients.

Adult↗

PubMed2004

Acute type B aortic dissection in elderly patients: clinical features, outcomes, and simple risk stratification rule.

BACKGROUND: The clinical features and outcomes of elderly patients with acute type B aortic dissection (ABAD) are less well known. Accordingly, we sought to evaluate the clinical features and outcomes and derive a simple risk stratification rule for elderly with ABAD. METHODS: We categorized 383 patients with ABAD enrolled in the International Registry of Acute Aortic Dissection into two strata (aged less than 70 years and aged 70 years or more) and compared their clinical features and in-hospital outcomes. Further, we developed a clinical decision rule to risk-stratify elderly with ABAD. RESULTS: Forty-two percent (161 of 383) of patients with ABAD were aged 70 years or more. Hypertension, diabetes, history of prior aortic aneurysm, and arteriosclerosis were more common in the elderly patients, whereas Marfan syndrome and cocaine abuse were less common. The in-hospital complication of hypotension/shock was more common among elderly, and malperfusion of a visceral organ less frequent among elderly patients. In-hospital mortality was higher in the elderly cohort compared with the younger patients (16% versus 10%, p = 0.07). A classification tree identified that elderly patients with hypotension/shock had the highest risk of death (56%). In absence of this, any branch vessel involvement was associated with the next highest mortality rate (28.6%) followed by presence of periaortic hematoma (10.5%). In contrast, elderly patients without any of these three risk factors had an extremely low mortality rate (1.3%). CONCLUSIONS: Our study highlights important differences between older and younger patients with ABAD in their clinical characteristics, management, and outcomes. We also propose a simple decision rule that allows stepwise risk-stratification in elderly patients with ABAD.

Aged↗

PubMed2004

Branch vessel complications are increased in aortic dissection patients with renal insufficiency.

Morbidity and mortality from aortic dissection remain high despite advances in diagnosis and treatment. Simple markers to identify patients at high risk for non-aortic complications of dissection are lacking. We investigated the effect of renal insufficiency on the presentation, complications, and outcome of patients with acute aortic dissection. We evaluated 638 patients with type A and 365 patients with type B aortic dissection enrolled in the International Registry of Acute Aortic Dissection (IRAD) between January 1996 and December 2000. Chi-squared and Student's ttesting were performed to identify the effect of renal insufficiency on patient presentation, management, and outcome. Patients with renal insufficiency more often required nitroprusside for blood pressure control (type A: 40.7% vs 31.1%, p = 0.049; type B: 66.7% vs 37.3, p = 0.0001) and had a greater risk of mesenteric ischemia (type A: 10.7% vs 1.4%, p < 0.0001; type B: 17.7% vs 3.0%, p < 0.0001). In conclusion, aortic dissection patients with renal insufficiency are at increased risk for drug-resistant hypertension and aortic branch vessel compromise. Routine measurement of serum creatinine provides a readily accessible clinical marker for important complications. Upon recognition, renal impairment indicates a need for close monitoring, aggressive blood pressure control, and evaluation of aortic branch vessel circulations.

Acute Disease↗

PubMed2004

Association of painless acute aortic dissection with increased mortality.

OBJECTIVE: To evaluate the clinical characteristics and outcomes of patients with painless acute aortic dissection (AAD). PATIENTS AND METHODS: For this study conducted from 1997 to 2001, we searched the International Registry of Acute Aortic Dissection to identify patients with painless AAD (group 1). Their clinical features and in-hospital events were compared with patients who had painful AAD (group 2). RESULTS: Of the 977 patients in the database, 63 (6.4%) had painless AAD, and 914 (93.6%) had painful AAD. Patients in group 1 were older than those in group 2 (mean +/- SD age, 66.6 +/- 13.3 vs 61.9 +/- 14.1 years; P = .01). Type A dissection (involving the ascendIng aorta or the arch) was more frequent in group 1 (74.6% vs 60.9%; P = .03). Syncope (33.9% vs 11.7%; P < .001), congestive heart failure (19.7% vs 3.9%; P < .001), and stroke (11.3% vs 4.7%; P = .03) were more frequent presenting signs in group 1. Diabetes (10.2% vs 4.0%; P = .04), aortic aneurysm (29.5% vs 13.1%; P < .001), and prior cardiovascular surgery (48.1% vs 19.7%; P < .001) were also more common in group 1. In-hospital mortality was higher in group 1 (33.3% vs 23.2%; P = .05), especially due to type B dissection (limited to the descending aorta) (43.8% vs 10.4%; P < .001), and the prevalence of aortic rupture was higher among patients with type B dissection in group 1 (18.8% vs 5.9%; P = .04). CONCLUSION: Patients with painless AAD had syncope, congestive heart failure, or stroke. Compared with patients who have painful AAD, patients who have painless AAD have higher mortality, especially when AAD is type B.

Acute Disease↗

PubMed2003

Changes in size of ascending aorta and aortic valve function with time in patients with congenitally bicuspid aortic valves.

Bicuspid aortic valve (BAV) is associated with premature valve dysfunction and abnormalities of the ascending aorta. Limited data exist regarding serial changes of aortic dilation in patients with BAV. We studied paired transthoracic echocardiograms of 68 patients with BAV (mean age 44 years) and with at least 2 examinations >12 months apart (mean follow-up 47 months) to characterize the progression of aortic dilation and the natural history of valve function. We measured aortic root and ascending aortic diameters at baseline and follow-up. We measured aortic gradients and severity of aortic regurgitation (AR). During follow-up, aortic diameters increased at the sinuses of Valsalva by 1.9 mm (95% confidence interval [CI] 1.3 to 2.5), at the sinotubular junction by 1.6 mm (95% CI 0.8 to 2.3), and at the proximal ascending aorta by 2.7 mm (95% CI 1.9 to 3.6). Mean rate of diameter progression was 0.5 mm/year at the sinuses of Valsalva (95% CI 0.3 to 0.7), 0.5 mm/year at the sinotubular junction (95% CI 0.3 to 0.7), and 0.9 mm/year at the proximal ascending aorta (95% CI 0.6 to 1.2). Progression was observed regardless of hemodynamic function at baseline. Mean aortic valve gradient increased significantly from baseline to follow-up (17.6 mm Hg vs 25.7 mm Hg, p <0.001). The degree of AR increased during follow-up in 17 patients (25%). In addition, progression of aortic diameter dilation occurred irrespective of baseline valve function in adult patients with BAV. We also observed considerable progression of aortic gradients and AR over time.

Adult↗

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↗