Coronary Artery Disease: Douglas PS

Patel MR, Dehmer GJ, Hirshfeld JW, Smith PK, Spertus JA, Masoudi FA, Brindis RG, Beckman KJ, Chambers CE, Ferguson TB, Garcia MJ, Grover FL, Holmes DR, Klein LW, Limacher M, Mack MJ, Malenka DJ, Park MH, Ragosta M, Ritchie JL, Rose GA, Rosenberg AB, Shemin RJ, Weintraub WS, Wolk MJ, Allen JM, Douglas PS, Hendel RC, Peterson ED. · Division of Cardiology, Duke University Medical Center, Durham, NC, USA. · Catheter Cardiovasc Interv. · Pubmed #19127535 No free full text.

Abstract: The American College of Cardiology Foundation (ACCF), Society for Cardiovascular Angiography and Interventions, Society of Thoracic Surgeons, and the American Association for Thoracic Surgery, along with key specialty and subspecialty societies, conducted an appropriateness review of common clinical scenarios in which coronary revascularization is frequently considered. The clinical scenarios were developed to mimic common situations encountered in everyday practice and included information on symptom status, extent of medical therapy, risk level as assessed by noninvasive testing, and coronary anatomy. Approximately 180 clinical scenarios were developed by a writing committee and scored by a separate technical panel on a scale of 1 to 9. Scores of 7 to 9 indicate that revascularization was considered appropriate and likely to improve health outcomes or survival. Scores of 1 to 3 indicate revascularization was considered inappropriate and unlikely to improve health outcomes or survival. The mid range (4 to 6) indicates a clinical scenario for which the likelihood that coronary revascularization would improve health outcomes or survival was considered uncertain. For the majority of the clinical scenarios, the panel only considered the appropriateness of revascularization irrespective of whether this was accomplished by percutaneous coronary intervention (PCI) or coronary artery bypass graft surgery (CABG). In a select subgroup of clinical scenarios in which revascularization is generally considered appropriate, the appropriateness of PCI and CABG individually as the primary mode of revascularization was considered. In general, the use of coronary revascularization for patients with acute coronary syndromes and combinations of significant symptoms and/or ischemia was viewed favorably. In contrast, revascularization of asymptomatic patients or patients with low-risk findings on noninvasive testing and minimal medical therapy were viewed less favorably. It is anticipated that these results will have an impact on physician decision making and patient education regarding expected benefits from revascularization and will help guide future research.

Douglas PS, Khandheria B, Stainback RF, Weissman NJ, Peterson ED, Hendel RC, Stainback RF, Blaivas M, Des Prez RD, Gillam LD, Golash T, Hiratzka LF, Kussmaul WG, Labovitz AJ, Lindenfeld J, Masoudi FA, Mayo PH, Porembka D, Spertus JA, Wann LS, Wiegers SE, Brindis RG, Douglas PS, Hendel RC, Patel MR, Peterson ED, Wolk MJ, Allen JM, Anonymous00094, Anonymous00095, Anonymous00096, Anonymous00097, Anonymous00098, Anonymous00099, Anonymous00100, Anonymous00101. · No affiliation provided · J Am Coll Cardiol. · Pubmed #18342240 No free full text.

Abstract: The American College of Cardiology Foundation (ACCF) and the American Society of Echocardiography (ASE) together with key specialty and subspecialty societies, conducted an appropriateness review for stress echocardiography. The review assessed the risks and benefits of stress echocardiography for several indications or clinical scenarios and scored them on a scale of 1 to 9 (based upon methodology developed by the ACCF to assess imaging appropriateness). The upper range (7 to 9) implies that the test is generally acceptable and is a reasonable approach, and the lower range (1 to 3) implies that the test is generally not acceptable and is not a reasonable approach. The midrange (4 to 6) indicates a clinical scenario for which the indication for a stress echocardiogram is uncertain. The indications for this review were drawn from common applications or anticipated uses, as well as from current clinical practice guidelines. Use of stress echocardiography for risk assessment in patients with coronary artery disease (CAD) was viewed favorably, while routine repeat testing and general screening in certain clinical scenarios were viewed less favorably. It is anticipated that these results will have a significant impact on physician decision making and performance, reimbursement policy, and will help guide future research.

Douglas PS, Khandheria B, Stainback RF, Weissman NJ, Peterson ED, Hendel RC, Stainback RF, Blaivas M, Des Prez RD, Gillam LD, Golash T, Hiratzka LF, Kussmaul WG, Labovitz AJ, Lindenfeld J, Masoudi FA, Mayo PH, Porembka D, Spertus JA, Wann LS, Wiegers SE, Brindis RG, Douglas PS, Hendel RC, Patel MR, Peterson ED, Wolk MJ, Allen JM, Anonymous00094, Anonymous00095, Anonymous00096, Anonymous00097, Anonymous00098, Anonymous00099, Anonymous00100, Anonymous00101. · No affiliation provided · J Am Coll Cardiol. · Pubmed #18342240 No free full text.

Abstract: The American College of Cardiology Foundation (ACCF) and the American Society of Echocardiography (ASE) together with key specialty and subspecialty societies, conducted an appropriateness review for stress echocardiography. The review assessed the risks and benefits of stress echocardiography for several indications or clinical scenarios and scored them on a scale of 1 to 9 (based upon methodology developed by the ACCF to assess imaging appropriateness). The upper range (7 to 9) implies that the test is generally acceptable and is a reasonable approach, and the lower range (1 to 3) implies that the test is generally not acceptable and is not a reasonable approach. The midrange (4 to 6) indicates a clinical scenario for which the indication for a stress echocardiogram is uncertain. The indications for this review were drawn from common applications or anticipated uses, as well as from current clinical practice guidelines. Use of stress echocardiography for risk assessment in patients with coronary artery disease (CAD) was viewed favorably, while routine repeat testing and general screening in certain clinical scenarios were viewed less favorably. It is anticipated that these results will have a significant impact on physician decision making and performance, reimbursement policy, and will help guide future research.

Douglas PS, Khandheria B, Stainback RF, Weissman NJ, Peterson ED, Hendel RC, Stainback RF, Blaivas M, Des Prez RD, Gillam LD, Golash T, Hiratzka LF, Kussmaul WG, Labovitz AJ, Lindenfeld J, Masoudi FA, Mayo PH, Porembka D, Spertus JA, Wann LS, Wiegers SE, Brindis RG, Douglas PS, Patel MR, Wolk MJ, Allen JM, Anonymous00125, Anonymous00126, Anonymous00127, Anonymous00128, Anonymous00129, Anonymous00130, Anonymous00131, Anonymous00132. · Duke University Medical Center, Durham, NC, USA. · Circulation. · Pubmed #18316491 links to  free full text

Abstract: The American College of Cardiology Foundation (ACCF) and the American Society of Echocardiography (ASE) together with key specialty and subspecialty societies, conducted an appropriateness review for stress echocardiography. The review assessed the risks and benefits of stress echocardiography for several indications or clinical scenarios and scored them on a scale of 1 to 9 (based upon methodology developed by the ACCF to assess imaging appropriateness). The upper range (7 to 9) implies that the test is generally acceptable and is a reasonable approach, and the lower range (1 to 3) implies that the test is generally not acceptable and is not a reasonable approach. The midrange (4 to 6) indicates a clinical scenario for which the indication for a stress echocardiogram is uncertain. The indications for this review were drawn from common applications or anticipated uses, as well as from current clinical practice guidelines. Use of stress echocardiography for risk assessment in patients with coronary artery disease (CAD) was viewed favorably, while routine repeat testing and general screening in certain clinical scenarios were viewed less favorably. It is anticipated that these results will have a significant impact on physician decision making and performance, reimbursement policy, and will help guide future research.

Douglas PS, Khandheria B, Stainback RF, Weissman NJ, Peterson ED, Hendel RC, Stainback RF, Blaivas M, Des Prez RD, Gillam LD, Golash T, Hiratzka LF, Kussmaul WG, Labovitz AJ, Lindenfeld J, Masoudi FA, Mayo PH, Porembka D, Spertus JA, Wann LS, Wiegers SE, Brindis RG, Douglas PS, Patel MR, Wolk MJ, Allen JM, Anonymous00125, Anonymous00126, Anonymous00127, Anonymous00128, Anonymous00129, Anonymous00130, Anonymous00131, Anonymous00132. · Duke University Medical Center, Durham, NC, USA. · Circulation. · Pubmed #18316491 links to  free full text

Abstract: The American College of Cardiology Foundation (ACCF) and the American Society of Echocardiography (ASE) together with key specialty and subspecialty societies, conducted an appropriateness review for stress echocardiography. The review assessed the risks and benefits of stress echocardiography for several indications or clinical scenarios and scored them on a scale of 1 to 9 (based upon methodology developed by the ACCF to assess imaging appropriateness). The upper range (7 to 9) implies that the test is generally acceptable and is a reasonable approach, and the lower range (1 to 3) implies that the test is generally not acceptable and is not a reasonable approach. The midrange (4 to 6) indicates a clinical scenario for which the indication for a stress echocardiogram is uncertain. The indications for this review were drawn from common applications or anticipated uses, as well as from current clinical practice guidelines. Use of stress echocardiography for risk assessment in patients with coronary artery disease (CAD) was viewed favorably, while routine repeat testing and general screening in certain clinical scenarios were viewed less favorably. It is anticipated that these results will have a significant impact on physician decision making and performance, reimbursement policy, and will help guide future research.

Douglas PS, Khandheria B, Stainback RF, Weissman NJ, Peterson ED, Hendel RC, Stainback RF, Blaivas M, Des Prez RD, Gillam LD, Golash T, Hiratzka LF, Kussmaul WG, Labovitz AJ, Lindenfeld J, Masoudi FA, Mayo PH, Porembka D, Spertus JA, Wann LS, Wiegers SE, Brindis RG, Douglas PS, Hendel RC, Patel MR, Peterson ED, Wolk MJ, Allen JM, Anonymous00137, Anonymous00138, Anonymous00139, Anonymous00140, Anonymous00141, Anonymous00142, Anonymous00143, Anonymous00144, Anonymous00145, Anonymous00146. · Duke University Medical Center, Durham, NC, USA. · Catheter Cardiovasc Interv. · Pubmed #18314889 No free full text.

Abstract: The American College of Cardiology Foundation (ACCF) and the American Society of Echocardiography (ASE) together with key specialty and subspecialty societies, conducted an appropriateness review for stress echocardiography. The review assessed the risks and benefits of stress echocardiography for several indications or clinical scenarios and scored them on a scale of 1 to 9 (based upon methodology developed by the ACCF to assess imaging appropriateness). The upper range (7 to 9) implies that the test is generally acceptable and is a reasonable approach, and the lower range (1 to 3) implies that the test is generally not acceptable and is not a reasonable approach. The midrange (4 to 6) indicates a clinical scenario for which the indication for a stress echocardiogram is uncertain.The indications for this review were drawn from common applications or anticipated uses, as well as from current clinical practice guidelines. Use of stress echocardiography for risk assessment in patients with coronary artery disease (CAD) was viewed favorably, while routine repeat testing and general screening in certain clinical scenarios were viewed less favorably. It is anticipated that these results will have a significant impact on physician decision making and performance, reimbursement policy, and will help guide future research.

Douglas PS, Khandheria B, Stainback RF, Weissman NJ, Peterson ED, Hendel RC, Stainback RF, Blaivas M, Des Prez RD, Gillam LD, Golash T, Hiratzka LF, Kussmaul WG, Labovitz AJ, Lindenfeld J, Masoudi FA, Mayo PH, Porembka D, Spertus JA, Wann LS, Wiegers SE, Brindis RG, Douglas PS, Hendel RC, Patel MR, Peterson ED, Wolk MJ, Allen JM, Anonymous00137, Anonymous00138, Anonymous00139, Anonymous00140, Anonymous00141, Anonymous00142, Anonymous00143, Anonymous00144, Anonymous00145, Anonymous00146. · Duke University Medical Center, Durham, NC, USA. · Catheter Cardiovasc Interv. · Pubmed #18314889 No free full text.

Abstract: The American College of Cardiology Foundation (ACCF) and the American Society of Echocardiography (ASE) together with key specialty and subspecialty societies, conducted an appropriateness review for stress echocardiography. The review assessed the risks and benefits of stress echocardiography for several indications or clinical scenarios and scored them on a scale of 1 to 9 (based upon methodology developed by the ACCF to assess imaging appropriateness). The upper range (7 to 9) implies that the test is generally acceptable and is a reasonable approach, and the lower range (1 to 3) implies that the test is generally not acceptable and is not a reasonable approach. The midrange (4 to 6) indicates a clinical scenario for which the indication for a stress echocardiogram is uncertain.The indications for this review were drawn from common applications or anticipated uses, as well as from current clinical practice guidelines. Use of stress echocardiography for risk assessment in patients with coronary artery disease (CAD) was viewed favorably, while routine repeat testing and general screening in certain clinical scenarios were viewed less favorably. It is anticipated that these results will have a significant impact on physician decision making and performance, reimbursement policy, and will help guide future research.

O'Rourke RA, Brundage BH, Froelicher VF, Greenland P, Grundy SM, Hachamovitch R, Pohost GM, Shaw LJ, Weintraub WS, Winters WL, Forrester JS, Douglas PS, Faxon DP, Fisher JD, Gregoratos G, Hochman JS, Hutter AM, Kaul S, Wolk MJ. · No affiliation provided · Circulation. · Pubmed #10880426 links to  free full text

This publication has no abstract.

Chuang ML, Douglas PS, Bisinov EA, Stein JH. · University of Wisconsin Atherosclerosis Imaging Research Program, University of Wisconsin Medical School, Madison 53792, USA. · Vasc Med. · Pubmed #12402990 No free full text.

Abstract: To investigate the effects of non-ECG-triggered imaging during ultrasound studies of endothelial function, brachial artery diameters were measured throughout the cardiac cycle at rest, during reactive hyperemia, and after administration of nitroglycerin. R-wave-triggered imaging using a 7.5-MHz ultrasound transducer with acquisition every 41.7-66.7 ms was performed in 24 subjects. Cardiac cycle-related variation was computed as the maximum per cent change from the end-diastolic diameter. The range of possible errors in flow-mediated dilation (FMD) and nitroglycerin-mediated vasodilation that may result from ignoring cyclic variations in diameter was determined for each condition. True FMD, true nitroglycerin-mediated vasodilation, and the maximum and minimum values that could be erroneously calculated for FMD if timing was ignored all differed dramatically (p < 0.05). The range of apparent FMD values that could be measured was nearly three times the true FMD value. Ignoring temporal position within the cardiac cycle artifactually increased calculated FMD into the normal range, despite truly impaired FMD. Peak arterial dilation occurred before end-systole and greater baseline vessel compliance was associated with greater FMD. Brachial arterial diameters vary significantly throughout the cardiac cycle. The magnitude of this variation is similar to the arterial dilation induced by reactive hyperemia and nitroglycerin, making ECG-triggered imaging mandatory for accurate and reproducible clinical and research measurements of artery diameters and FMD. Measurement of diameters at end-diastole may be preferred to other time-points in the cardiac cycle.

Douglas PS, Taylor A, Bild D, Bonow R, Greenland P, Lauer M, Peacock F, Udelson J. · Division of Cardiovascular Medicine, Duke University Medical Center, Durham, North Carolina 27715, USA. · JACC Cardiovasc Imaging. · Pubmed #19608141 No free full text.

Abstract: In July of 2008, the National Heart, Lung, and Blood Institute convened experts in noninvasive cardiovascular imaging, outcomes research, statistics, and clinical trials to develop recommendations for future randomized controlled trials of the use of imaging in: 1) screening the asymptomatic patient for coronary artery disease; 2) assessment of patients with stable angina; 3) identification of acute coronary syndromes in the emergency room; and 4) assessment of heart failure patients with chronic coronary artery disease with reduced left ventricular ejection fraction. This study highlights several possible trial designs for each clinical situation.

Douglas PS, Taylor A, Bild D, Bonow R, Greenland P, Lauer M, Peacock F, Udelson J. · Division of Cardiovascular Medicine, Duke University Medical Center, 7022 North Pavilion DUMC, PO Box 17969, Durham, North Carolina 27715, USA. · J Cardiovasc Comput Tomogr. · Pubmed #19577208 No free full text.

Abstract: In July of 2008, the National Heart, Lung, and Blood Institute convened experts in noninvasive cardiovascular imaging, outcomes research, statistics, and clinical trials to develop recommendations for future randomized controlled trials of the use of imaging in: 1) screening the asymptomatic patient for coronary artery disease; 2) assessment of patients with stable angina; 3) identification of acute coronary syndromes in the emergency room; and 4) assessment of heart failure patients with chronic coronary artery disease with reduced left ventricular ejection fraction. This study highlights several possible trial designs for each clinical situation.

Douglas PS, Taylor A, Bild D, Bonow R, Greenland P, Lauer M, Peacock F, Udelson J. · Division of Cardiovascular Medicine, Duke University Medical Center, Durham, North Carolina 27715, USA. · J Am Soc Echocardiogr. · Pubmed #19560655 No free full text.

Abstract: In July of 2008, the National Heart, Lung, and Blood Institute convened experts in noninvasive cardiovascular imaging, outcomes research, statistics, and clinical trials to develop recommendations for future randomized controlled trials of the use of imaging in: 1) screening the asymptomatic patient for coronary artery disease; 2) assessment of patients with stable angina; 3) identification of acute coronary syndromes in the emergency room; and 4) assessment of heart failure patients with chronic coronary artery disease with reduced left ventricular ejection fraction. This study highlights several possible trial designs for each clinical situation.

Hendel RC, Berman DS, Di Carli MF, Heidenreich PA, Henkin RE, Pellikka PA, Pohost GM, Williams KA, Wolk MJ, Alagona P, Bateman TM, Cerqueira MD, Corbett JR, Dean AJ, Dehmer GJ, Goldbach P, Gordon L, Kushner FG, Kwong RY, Min J, Quinones MA, Ward RP, Yang SH, Allen J, Brindis RG, Douglas PS, Patel M, Peterson E. · Appropriate Use Criteria for Radionuclide Imaging Writing Group-Midwest Heart Specialists, Winfield, IL, USA. · Circulation. · Pubmed #19451357 No free full text.

Abstract: The American College of Cardiology Foundation (ACCF), along with key specialty and subspecialty societies, conducted an appropriate use review of common clinical scenarios where cardiac radionuclide imaging (RNI) is frequently considered. This document is a revision of the original Single-Photon Emission Computed Tomography Myocardial Perfusion Imaging (SPECT MPI) Appropriateness Criteria, published 4 years earlier, written to reflect changes in test utilization and new clinical data, and to clarify RNI use where omissions or lack of clarity existed in the original criteria. This is in keeping with the commitment to revise and refine appropriate use criteria (AUC) on a frequent basis. The indications for this review were drawn from common applications or anticipated uses, as well as from current clinical practice guidelines. Sixty-seven clinical scenarios were developed by a writing group and scored by a separate technical panel on a scale of 1 to 9 to designate appropriate use, inappropriate use, or uncertain use. In general, use of cardiac RNI for diagnosis and risk assessment in intermediate- and high-risk patients with coronary artery disease (CAD) was viewed favorably, while testing in low-risk patients, routine repeat testing, and general screening in certain clinical scenarios were viewed less favorably. Additionally, use for perioperative testing was found to be inappropriate except for high selected groups of patients. It is anticipated that these results will have a significant impact on physician decision making, test performance, and reimbursement policy, and will help guide future research.

Douglas PS, Budoff M, Tunis S, Woodard PK, Justman RA, Honigberg R. · Duke University Medical Center, Durham, NC, USA. · JACC Cardiovasc Imaging. · Pubmed #19356455 No free full text.

This publication has no abstract.

Douglas PS, Redberg RF, Blumenthal RS, Ambrose M. · Duke University, USA. · JACC Cardiovasc Imaging. · Pubmed #19356436 No free full text.

This publication has no abstract.

Shaw LJ, Shaw RE, Merz CN, Brindis RG, Klein LW, Nallamothu B, Douglas PS, Krone RJ, McKay CR, Block PC, Hewitt K, Weintraub WS, Peterson ED, Anonymous00293. · Emory Program in Cardiovascular Outcomes Research and Epidemiology, 1256 Briarcliff Rd NE, Suite 1-N, Emory University School of Medicine, Atlanta, GA 30306, USA. · Circulation. · Pubmed #18378615 links to  free full text

Abstract: BACKGROUND: Although populations referred for coronary angiography are increasingly diverse, there is limited information on coronary artery disease (CAD) prevalence and in-hospital mortality other than for predominately white male patients. METHODS AND RESULTS: We examined gender and ethnic differences in CAD prevalence and in-hospital mortality in a prospective cohort of patients referred for angiographic evaluation of stable angina (n=375,886) or acute coronary syndromes (ACS; unstable angina or myocardial infarction, n=450,329) at 388 US hospitals participating in the American College of Cardiology-National Cardiovascular Data Registry, an angiographic registry. Univariable and multivariable (with covariates that included risk factors, symptoms, and comorbidities) logistic regression models were used to estimate significant CAD, defined as > or = 70% stenosis, and in-hospital mortality. Within stable angina and ACS cohorts, 7% of patients were black, 2% were Hispanic, 0.3% were Native American, 1% were Asian, and 90% were white, respectively. In stable angina, the risk-adjusted OR for significant CAD was 0.34 for women compared with men (P<0.0001), with black women having the lowest risk-adjusted odds (P<0.0001) compared with other females. Among ACS patients, the risk-adjusted OR of significant CAD was 0.47 for women compared with men (P<0.0001); similarly, black women had the lowest risk-adjusted odds (P<0.0001) compared with other females. Higher in-hospital mortality was reported for white women presenting with stable angina (P<0.00001). White women had a 1.34-fold (95% CI 1.21 to 1.48) higher risk-adjusted odds ratio for mortality than white men with stable angina (P<0.0001), with higher rates noted for white women who were older or had significant CAD (both P<0.0001). Lower utilization of elective coronary revascularization, aspirin, and glycoprotein IIb/IIIa inhibitors (all P<0.0001) may have contributed to higher in-hospital mortality for white women. In ACS, higher in-hospital mortality was reported for Hispanic (P=0.015) and white (P<0.0001) women; however, neither white (P=0.51) or Hispanic (P=0.13) women had higher in-hospital risk-adjusted mortality. CONCLUSIONS: The likelihood for significant CAD at coronary angiography and for in-hospital mortality varied significantly by ethnicity and gender. Future clinical practice guidelines should be tailored to gender subsets of the population, in particular for black women, to improve the efficient use of angiographic laboratories and to target at-risk populations of women and men.

Kumar D, Hacker TA, Buck J, Whitesell LF, Kaji EH, Douglas PS, Kamp TJ. · Department of Medicine, University of Vermont, Burlington, Vermont, USA. · Coron Artery Dis. · Pubmed #15654199 No free full text.

Abstract: This study describes the coronary anatomy of C57BL/6 mice and the functional impact of that anatomy on myocardial infarctions induced by ligation of the left coronary artery. In contrast to humans, a distinct septal coronary artery was observed in all mice arising either from a separate ostium from the right sinus of Valsalva or as a branch of the right coronary artery. Ligation of the left coronary artery at the site of its emergence from under the left atrium resulted in reproducible large myocardial infarctions involving the anterolateral, posterior, and apical regions of the heart as evidenced by histology and echocardiography. Interestingly, the septum was spared from infarction as predicted by the presence of the distinct septal branch found in mice. Thus, the distinct mouse coronary artery anatomy results in different regionality of infarction compared with man and large laboratory animals, and this may affect on the associated pathological remodeling of the heart. BACKGROUND: The objective of this study was to describe the coronary anatomy of C57BL/6 mice and determine the functional impact of that anatomy on myocardial infarctions induced by ligation of the left coronary artery. METHODS: C57BL/6 mice were used to visualize mouse coronary anatomy and to generate myocardial infarction. Mouse coronary artery visualization was performed on isolated hearts using injection of Silastic sealant into the aortic arch. After left thoracotomy myocardial infarction was produced by ligating the left coronary artery at the site of the vessels' emergence past the tip of the left atrium. Echocardiography was performed to analyze heart function, and histology was performed to delineate myocardial infarction. RESULTS: The different septal coronary artery was observed in all mice arising either from a separate ostium from the right sinus of Valsalva or as a branch of the right coronary artery. The mouse left coronary artery passed obliquely across the left ventricular free wall similar to the ramus intermedius coronary artery variant in man. Ligation of the left coronary artery as it emerged from under the left atrium resulted in reproducible large infarctions involving the anterolateral, posterior, and apical regions of the heart as demonstrated by histology and echocardiography. Notably, the septum was spared from infarction as predicted by the presence of the distinct septal coronary artery found in mice. CONCLUSIONS: Mouse coronary anatomy is distinct compared to man or large laboratory animals, and myocardial infarctions resulting from ligation of the mouse left coronary artery spare the septum, which may affect the pathological remodeling of the heart.

Stein JH, Fraizer MC, Aeschlimann SE, Nelson-Worel J, McBride PE, Douglas PS. · University of Wisconsin Atherosclerosis Imaging Research Program, Section of Cardiovascular Medicine, University of Wisconsin Medical School, Madison, Wisconsin 53792, USA. · Clin Cardiol. · Pubmed #15298037 No free full text.

Abstract: BACKGROUND: An imaging test that quantifies atherosclerotic burden and that can be integrated with existing risk stratification paradigms would be a very useful clinical tool. HYPOTHESIS: Measurement of carotid intima-media thickness (CIMT) is feasible in a clinical setting. Such measurements can be integrated into coronary risk assessment models. METHODS: Carotid intima-media thickness was measured by B-mode ultrasound in 82 consecutive patients without manifest atherosclerotic vascular disease. The values were used to determine "vascular age" (VA) based on nomograms from the Atherosclerosis Risk in Communities study. Vascular age was substituted for chronological age and standard and vascular age-adjusted 10-year coronary heart disease (CHD) risk estimates were compared. RESULTS: The mean chronological age was 55.8 +/- 9.0 years. The mean VA using CIMT was 65.5 +/- 18.9 years (p < 0.001). The Framingham 10-year hard CHD risk estimate was 6.5 +/- 4.9%. Substituting CIMT-derived VA for chronological age increased the 10-year CHD risk estimate to 8.0 +/- 6.8% (p < 0.001). Of 14 subjects initially at intermediate risk, 5 (35.7%) were reclassified as higher risk and 2 (14.3%) were reclassified as lower risk. Significant predictors of reclassification were tobacco use, high-density lipoprotein cholesterol, systolic blood pressure, and low-density lipoprotein cholesterol. CONCLUSIONS: Measurement of CIMT, a noninvasive estimate of current atherosclerotic burden, is feasible in a clinical setting and can be integrated into CHD risk assessment models. Determining VA using CIMT values may help individualize the age component of population-based CHD risk estimates. This strategy should be tested in a large trial with hard clinical endpoints.

Vallis KA, Pintilie M, Chong N, Holowaty E, Douglas PS, Kirkbride P, Wielgosz A. · Department of Radiation Oncology, Princess Margaret Hospital/University Health Network and University of Toronto, Canada. · J Clin Oncol. · Pubmed #11844827 No free full text.

Abstract: PURPOSE: To assess the risk of fatal and nonfatal myocardial infarction (MI) after breast-conserving surgery (BCS) and radiation therapy (RT) for left-sided breast cancer. PATIENTS AND METHODS: A hospital-based retrospective cohort linkage study of all breast cancer patients registered at the Princess Margaret Hospital (PMH), Toronto, Canada, between 1982 and 1988 who were treated with postlumpectomy RT was performed. Available identifiers for the study cohort were linked to two province-wide health files: the Canadian Institute for Health Information Hospitalization File and the Ontario Mortality Database. Admissions to hospital for MI and deaths attributable to MI were identified. The relevant original health records were abstracted to verify the diagnosis of MI according to diagnostic criteria used in the World Health Organization multinational monitoring of trends and determinants in cardiovascular disease (MONICA) project. We compared incidence of MI in the study cohort with the general population and incidence of MI after therapy for left- versus right-sided breast cancer. RESULTS: A cohort of 2,128 patients was identified. The median length of follow-up was 10.2 years. The incidence of MI in the study cohort was comparable to that in an age-matched general population of women in Ontario. There were 70 coronary events among 56 patients after breast irradiation. According to MONICA criteria, 53 and six events were characterized as definite and possible MIs, respectively. Eleven events did not satisfy MONICA criteria for MI. Twenty-six patients treated for left-sided and 23 patients treated for right-sided breast cancer experienced at least one definite or possible MI (log-rank test, P =.66). There were eight fatal MIs among the left-sided group and six among the right-sided group. There was no excess of other cardiac diseases among patients who received left-sided radiotherapy compared to the right-sided group. CONCLUSION: We have found no evidence for excess morbidity and mortality from coronary artery disease among women treated with RT to the left breast after BCS at 10.2 years of follow-up. Longer follow-up is required to confirm that excess cardiac disease has been completely avoided.

Harris DJ, Douglas PS. · Yale College, New Haven, Conn, USA. · N Engl J Med. · Pubmed #10944565 links to  free full text

Abstract: BACKGROUND: With the recognition that certain aspects of cardiovascular disease are specific to sex, the government has sought to ensure that federally funded clinical research yields adequate high-quality information about heart disease in women. METHODS: We tabulated the numbers of men and women in cardiovascular clinical trials funded by the National Heart, Lung, and Blood Institute (NHLBI) between 1965 and 1998, recording both total numbers and the numbers for each type of cardiovascular disease. We analyzed the data according to the sex-specific prevalence of disease and assessed changes in enrollment over time. We performed a similar analysis after excluding all single-sex trials. RESULTS: A total of 398,801 subjects (215,796 women and 183,005 men) were enrolled in NHLBI-funded studies of cardiovascular disease. The overall enrollment rate for women (54 percent) exceeded the prevalence of cardiovascular disease in women in the general population (49 percent) and increased over time (P=0.002). With single-sex trials excluded, the enrollment rate for women was 38 percent, which did not change significantly over time. In studies of coronary artery disease and hypertension the rates of enrollment of women were similar to or exceeded the prevalence of these disorders in women. The enrollment rate increased significantly over time in studies of coronary artery disease (P<0.001) but not in studies of hypertension or arrhythmia. Women were under-enrolled in studies of heart failure, and the rate of enrollment did not change significantly over time. When single-sex trials were excluded from the analysis of enrollment rates according to the prevalence of disease, the results were similar. There was no change in enrollment rates overtime for any category of disease. CONCLUSIONS: Federal efforts to increase the representation of women in clinical trials have been moderately successful primarily because of the institution of a small number of large, single-sex trials involving coronary artery disease. There has been no change in the sex composition of cohorts in the majority of studies of cardiovascular disease.

Kuntz KM, Fleischmann KE, Hunink MG, Douglas PS. · Brigham and Women's Hospital, and Harvard Medical School, Boston, Massachusetts, USA. · Ann Intern Med. · Pubmed #10357689 links to  free full text

Abstract: BACKGROUND: Many noninvasive tests exist to determine whether patients should undergo coronary angiography. The routine use of coronary angiography without previous noninvasive testing is typically not advocated. OBJECTIVE: To determine the cost-effectiveness of diagnostic strategies for patients with chest pain. DESIGN: Cost-effectiveness analysis. DATA SOURCES: Published data. TARGET POPULATION: Patients who present with chest pain, have no history of myocardial infarction, and are able to perform an exercise stress test. TIME HORIZON: Lifetime. PERSPECTIVE: Societal. INTERVENTIONS: No testing, exercise electrocardiography, exercise echocardiography, exercise single-photon emission computed tomography (SPECT), and coronary angiography alone. OUTCOME MEASURES: Quality-adjusted life expectancy, lifetime cost, and incremental cost-effectiveness. RESULTS OF BASE-CASE ANALYSIS: The incremental cost-effectiveness ratio of routine coronary angiography compared with exercise echocardiography was $36,400 per quality-adjusted life-year (QALY) saved for 55-year-old men with typical angina. For 55-year-old men with atypical angina, exercise echocardiography compared with exercise electrocardiography cost $41,900 per QALY saved. If adequate exercise echocardiography was not available, exercise SPECT cost $54,800 per QALY saved compared with exercise electrocardiography for these patients. For 55-year-old men with nonspecific chest pain, the incremental cost-effectiveness ratio of exercise electrocardiography compared with no testing was $57,700 per QALY saved. RESULTS OF SENSITIVITY ANALYSIS: On the basis of a probabilistic sensitivity analysis, there is a 75% chance that exercise echocardiography costs less than $50,900 per QALY saved for 55-year-old men with atypical angina. CONCLUSIONS: Exercise electrocardiography or exercise echocardiography resulted in reasonable cost-effectiveness ratios for patients at mild to moderate risk for coronary artery disease in terms of age, sex, and type of chest pain. Coronary angiography without previous noninvasive testing resulted in reasonable cost-effectiveness ratios for patients with a high pretest probability of coronary artery disease.