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Biomedical subjects

Michael S Lauer

Publications and source records attributed to Michael S Lauer.

At least 55 records · Page 3Linked to original sources
PubMed2004

Impact of donor spontaneous intracranial hemorrhage on outcome after heart transplantation.

Donor cause of death has been suggested to have a significant impact on cardiac transplant morbidity and mortality. Our objective was to evaluate the impact of donor spontaneous intracranial bleeding on clinical outcome after heart transplantation. A group of 160 recipients underwent cardiac transplantation from donors with spontaneous intracranial bleeding (ICB group). These were compared with 197 recipients who were transplanted from trauma donors (Trauma group). A higher 4-year mortality rate was noted in the ICB group (24% vs. 14%, p=0.015). ICB as a cause of donor death was an independent predictor of recipient mortality (adjusted hazard ratio 2.02, 95% CI 1.27-3.40, p<0.0001). Compared with the Trauma group, the ICB group had an increased incidence of post-transplant graft dysfunction during the first week of transplant (10% vs. 3%, p=0.007), and higher incidence of interstitial myocardial fibrosis on their endomyocardial biopsies within 4 weeks of transplant (21% vs. 9%, p=0.0012). There was a trend towards an increased rate of allograft vasculopathy in the ICB group (competing risks adjusted hazard ratio 1.39, 95% CI 0.90-2.13, p = 0.14).

Adult↗
PubMed2004

Association of an abnormal exercise heart rate recovery with pulmonary function abnormalities.

BACKGROUND: Heart rate recovery (HRR) after exercise correlates with decreased vagal tone and mortality. Patients with COPD may have altered autonomic tone. We sought to determine the association of HRR with spirometry measures of pulmonary function. METHODS: We analyzed 627 patients (mean [+/- SD] age, 58 +/- 12 years; 65% men; mean FEV(1), 2.6 +/- 0.9 L, 80 +/- 20% predicted; patients receiving inhaled beta(2) agonist therapy, 10%; patients receiving inhaled anticholinergic therapy, 3%; patients receiving inhaled steroids, 5%; patients receiving oral prednisone, 4%) who had undergone maximal exercise testing and had undergone pulmonary function tests < 1 year apart. Patients with heart failure, pacemakers, and atrial fibrillation were excluded. Abnormal HRR was defined as a fall in heart rate during the first minute after exercise of <or= 12 beats/min (<or= 18 beats/min with stress echocardiography). Patients were divided into quartiles based on FEV(1) percent predicted. RESULTS: An abnormal HRR was seen in 229 patients (36%). The mean FEV(1) values broken into quartiles 1 to 4 were 54 +/- 11% predicted, 74 +/- 3% predicted, 87 +/- 4% predicted, and 106 +/- 10% predicted. In smokers and nonsmokers, a worsening FEV(1) percent predicted was associated with an abnormal HRR. In a multivariable model accounting for confounding factors including medications and functional capacity, the predictors of an abnormal HRR included FEV(1) percent predicted (adjusted odds ratio for 1 SD decrease, 1.32; 95% confidence interval, 1.07 to 1.65; p = 0.0004), impaired functional capacity, male gender, and age. CONCLUSIONS: Abnormalities found on spirometry are associated with abnormal HRR, which may reflect an altered autonomic tone associated with pulmonary dysfunction, either obstructive or restrictive in nature.

Autonomic Nervous System↗
PubMed2004

Association of triglyceride-to-HDL cholesterol ratio with heart rate recovery.

OBJECTIVE: Insulin resistance is associated with autonomic dysfunction. An attenuated decrease in heart rate after exercise (or heart rate recovery [HRR]) predicts all-cause mortality and is believed to reflect decreased parasympathetic activity. Utilizing triglyceride/HDL cholesterol concentration as a marker of insulin resistance, we sought to assess the association between insulin resistance and HRR. RESEARCH DESIGN AND METHODS: Our study population included 4,963 healthy adults who participated in the Lipid Research Clinics Prevalence Study and underwent exercise testing. HRR was considered abnormal if it did not drop > or = 42 bpm 2 min after completion of exercise. Fasting blood specimens were drawn. RESULTS: Individuals in the highest quartile of triglyceride/HDL cholesterol had a significantly higher prevalence of abnormal HRR (40 vs. 30%, multivariable-adjusted prevalence ratio 1.18, 95% CI 1.01-1.39; P = 0.04). As a continuous variable, an increase in 1 SD of triglyceride-to-HDL cholesterol ratio was associated with a greater likelihood of an abnormal HRR, even after adjusting for >20 covariates (adjusted OR 1.16, 95% CI 1.07-1.25; P < 0.001). During 12 years of follow-up, there were 284 deaths. In age- and sex-adjusted analysis, participants with an abnormal HRR and high triglyceride-to-HDL cholesterol ratio had significantly higher mortality than those with a normal HRR and high triglyceride-to-HDL cholesterol ratio (hazard ratio = 1.49, 95% CI 1.08-2.04; P = 0.015). CONCLUSIONS: HRR is associated with triglyceride-to-HDL cholesterol ratio and identifies patients with insulin resistance who are at increased risk of death.

Adult↗
PubMed2003

In-hospital initiation of lipid-lowering therapy after coronary intervention as a predictor of long-term utilization: a propensity analysis.

BACKGROUND: Despite multiple randomized trials demonstrating their efficacy for the secondary prevention of coronary disease, lipid-lowering agents remain underused. Few studies have examined the relationship between predischarge initiation of lipid-lowering therapy and long-term use. METHODS: Using data from patients at 69 centers from the United States and Canada enrolled in the Evaluation in PTCA to Improve Long-term Outcome With Abciximab GP IIb/IIIa Blockade (EPILOG) trial, we performed a retrospective propensity-analyzed cohort study. Patients underwent percutaneous coronary intervention for stable or recently unstable coronary disease and were older than 21 years, were not taking lipid-lowering therapy at the time of admission, and survived to hospital discharge; 175 were discharged taking lipid-lowering therapy and 1951 were not. RESULTS: After 6 months, 77% of patients who started taking lipid-lowering agents before hospital discharge continued taking therapy, compared with only 25% of those discharged without these agents (relative risk, 3.17; 95% confidence interval, 2.88-3.41; P<.001). After restricting the analysis to propensity-matched patients (n = 477) and adjusting for other potential confounders, initiation of a lipid-lowering agent during hospitalization was the strongest independent predictor of use at 6 months (relative risk, 2.50; 95% confidence interval, 2.29-2.65; P<.001). CONCLUSIONS: Inpatient initiation of lipid-lowering therapy is a strong and independent positive predictor of subsequent use, with patients who start taking lipid-lowering therapy before hospital discharge nearly 3 times as likely to be taking these agents 6 months later. Inpatient initiation of lipid-lowering therapy appears to be an effective strategy for bridging the gap between current medical knowledge and practice.

Abciximab↗
PubMed2003

Inflammation as a risk factor for atrial fibrillation.

BACKGROUND: The presence of systemic inflammation determined by elevations in C-reactive protein (CRP) has been associated with persistence of atrial fibrillation (AF). The relationship between CRP and prediction of AF has not been studied in a large population-based cohort. METHODS AND RESULTS: CRP measurement and cardiovascular assessment were performed at baseline in 5806 subjects enrolled in the Cardiovascular Health Study. Patients were followed up for a mean of 6.9+/-1.6 (median 7.8) years. AF was identified by self-reported history and ECGs at baseline and by ECGs and hospital discharge diagnoses at follow-up. Univariate and multivariate analyses were used to assess CRP as a predictor of baseline and future development of AF. At baseline, 315 subjects (5%) had AF. Compared with subjects in the first CRP quartile (<0.97 mg/L), subjects in the fourth quartile (>3.41 mg/L) had more AF (7.4% versus 3.7%, adjusted OR 1.8, 95% CI 1.2 to 2.5; P=0.002). Of 5491 subjects without AF at baseline, 897 (16%) developed AF during follow-up. Baseline CRP predicted higher risk for developing future AF (fourth versus first quartile adjusted hazard ratio 1.31, 95% CI 1.08 to 1.58; P=0.005). When treated as a continuous variable, elevated CRP predicted increased risk for developing future AF (adjusted hazard ratio for 1-SD increase, 1.24; 95% CI 1.11 to 1.40; P<0.001). CONCLUSIONS: CRP is not only associated with the presence of AF but may also predict patients at increased risk for future development of AF.

Aged↗
PubMed2003

Heart rate recovery after exercise is a predictor of mortality, independent of the angiographic severity of coronary disease.

OBJECTIVES: We sought to determine whether abnormal heart rate recovery predicts mortality independent of the angiographic severity of coronary disease. BACKGROUND: An attenuated decrease in heart rate after exercise, or heart rate recovery (HRR), has been shown to predict mortality. There are few data on its prognostic significance once the angiographic severity of coronary artery disease (CAD) is ascertained. METHODS: For six years we followed 2,935 consecutive patients who underwent symptom-limited exercise testing for suspected CAD and then had a coronary angiogram within 90 days. The HRR was abnormal if < or =12 beats/min during the first minute after exercise, except among patients undergoing stress echocardiography, in whom the cutoff was < or =18 beats/min. Angiographic CAD was considered severe if the Duke CAD Prognostic Severity Index was > or =42 (on a scale of 0 to 100), which corresponds to a level of CAD where revascularization is associated with better long-term survival. RESULTS: Severe CAD was present in 421 patients (14%), whereas abnormal HRR was noted in 838 patients (29%). There were 336 deaths (11%). Mortality was predicted by abnormal HRR (hazard ratio [HR] 2.5, 95% confidence interval [CI] 2.0 to 3.1; p < 0.0001) and by severe CAD (HR 2.0, 95% CI 1.6 to 2.6; p < 0.0001); both variables provided additive prognostic information. After adjusting for age, gender, standard risk factors, medications, exercise capacity, and left ventricular function, abnormal HRR remained predictive of death (adjusted HR 1.6, 95% CI 1.2 to 2.0; p < 0.0001); severe CAD was also predictive (adjusted HR 1.4, 95% CI 1.1 to 1.9; p = 0.008). CONCLUSIONS: Even after taking into account the angiographic severity of CAD, left ventricular function, and exercise capacity, HRR is independently predictive of mortality.

Aged↗
PubMed2003

Frequent ventricular ectopy after exercise as a predictor of death.

BACKGROUND: Exercise-induced ventricular ectopy predicts an increased risk of death in population-based cohorts. We sought to examine in a clinical cohort the prognostic importance of ventricular ectopy immediately after exercise, when reactivation of parasympathetic activity occurs. We hypothesized that ventricular ectopy after exercise (i.e., during the recovery phase) would predict an increased risk of death better than ventricular ectopy during exercise. METHODS: We studied 29,244 patients (mean [+/-SD] age, 56+/-11 years; 70 percent men) who had been referred for symptom-limited exercise testing without a history of heart failure, valve disease, or arrhythmia. Frequent ventricular ectopy was defined by the presence of seven or more ventricular premature beats per minute, ventricular bigeminy or trigeminy, ventricular couplets or triplets, ventricular tachycardia, ventricular flutter, torsade de pointes, or ventricular fibrillation. RESULTS: Frequent ventricular ectopy occurred only during exercise in 945 patients (3 percent), only during recovery in 589 (2 percent), and during both exercise and recovery in 491 (2 percent). There were 1862 deaths during a mean of 5.3 years of follow-up. Frequent ventricular ectopy during exercise predicted an increased risk of death (five-year death rate, 9 percent, vs. 5 percent among patients without frequent ventricular ectopy during exercise; hazard ratio, 1.8; 95 percent confidence interval, 1.5 to 2.1; P<0.001), but frequent ventricular ectopy during recovery was a stronger predictor (11 percent vs. 5 percent; hazard ratio, 2.4; 95 percent confidence interval, 2.0 to 2.9; P<0.001). After propensity matching for confounding variables, frequent ventricular ectopy during recovery predicted an increased risk of death (adjusted hazard ratio, 1.5; 95 percent confidence interval, 1.1 to 1.9; P=0.003), but frequent ventricular ectopy during exercise did not (adjusted hazard ratio, 1.1; 95 percent confidence interval, 0.9 to 1.3; P=0.53). CONCLUSIONS: Frequent ventricular ectopy during recovery after exercise is a better predictor of an increased risk of death than ventricular ectopy occurring only during exercise.

Aged↗
PubMed2003

Preprocedural white blood cell count and death after percutaneous coronary intervention.

BACKGROUND: Elevated inflammatory markers are associated with worse outcome after percutaneous coronary artery interventions (PCI). An elevation in the white blood cell (WBC) count is a nonspecific response to inflammation. We hypothesized that an elevated WBC count would be a predictor of death in patients undergoing PCI. METHODS: A total of 4450 patients undergoing percutaneous coronary artery intervention were divided into quintiles, based on their preprocedural WBC count (mean WBC count: quintile 1, 5.08 x 10(3)/muL; quintile 2, 6.58 x 10(3)/muL; quintile 3, 7.70 x 10(3)/muL; quintile 4, 9.14 x 10(3)/muL; and quintile 5, 13.4 x 10(3)/muL). Vital status was assessed through the use of the Social Security Death Index. RESULTS: There were a total of 504 deaths over a follow-up period of 48 months. The best survival was seen in quintile 2, with an increase in long-term mortality rates seen with both a higher or a lower WBC count (P <.001). This J-shaped curve was preserved after multivariate adjustment, with the adjusted hazard ratio of mortality relative to quintile 2 being 1.95 (95% CI, 1.40 to 2.73) in quintile 1, 1.66 (95% CI, 1.18 to 2.33) in quintile 3, 2.31 (95% CI, 1.67 to 3.17) in quintile 4, and 2.42 (95% CI, 1.76 to 3.34) in quintile 5. CONCLUSIONS: A low or an elevated preprocedural WBC count in patients undergoing PCI is associated with an increased risk of long-term death. Our result provides further evidence to support the important role of inflammation in coronary artery disease.

Angioplasty, Balloon, Coronary↗
PubMed2003

Screening for left ventricular systolic dysfunction among patients with risk factors for heart failure.

BACKGROUND: The prevalence of left ventricular systolic dysfunction (LVSD) among individuals at risk for heart failure (HF) and the feasibility of screening have not been clearly defined. This study determined the prevalence of LVSD with the use of a limited screening echocardiogram among patients with risk factors for HF but no prior HF. METHODS: General medicine patients > or =60 years of age with hypertension, diabetes, coronary artery disease, or previous myocardial infarction (MI) but no history of HF or reduced left ventricular ejection fraction (LVEF) were eligible. Medical history and symptoms of breathlessness were determined by interview and chart review; consenting patients underwent electrocardiography and echocardiography. The outcome was LVEF < or =45%, based on visual estimation from the echocardiogram. RESULTS: Of the 482 patients who completed the study, only 1 patient could not have the LVEF visually estimated. A total of 7.9% of patients had LVEF < or =45%. The prevalence was 15.4% among those with a prior MI and 6.7% among those without prior MI. In multivariate analysis, prior MI (adjusted odds ratio, 2.75; 95% CI, 1.14 to 6.64) and probable or definite left ventricular hypertrophy by electrocardiography (adjusted odds ratio, 3.57; 95% CI, 1.22 to 10.48) were the strongest predictors of LVEF < or =45%. CONCLUSIONS: Screening for LVSD among high-risk patients is feasible and has substantial yield, even among patients without prior MI. In light of the low cost of screening and the available therapies to prevent progression of LVSD to overt HF, controlled clinical trials of screening high-risk subgroups appear to be justified.

Aged↗