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1.
Am J Surg ; 227: 57-62, 2024 Jan.
Article in English | MEDLINE | ID: mdl-37827870

ABSTRACT

BACKGROUND: Long-term follow-up (LTFU) following carotid revascularization is important for post-surgical care, stroke risk optimization and post-market surveillance of new technologies. METHODS: We instituted a quality improvement project to improve LTFU rates for carotid revascularizations (primary outcome) by scheduling perioperative and one-year follow-up appointments at time of surgery discharge. A temporal trends analysis (Q1 2019 through Q1 2022), multivariable regression, and interrupted time series (ITS) were performed to compare pre-post intervention LTFU rates. RESULTS: 269 consecutive patients were included (151 pre-intervention, 118 post-intervention; mean 71 â€‹± â€‹12 years-old, 39% female, 77% White). The overall LTFU rate improved (64.9%-78.8%; P â€‹= â€‹0.013) after the intervention. After controlling for patient factors, procedures performed after the intervention were associated with increased odds of being seen for 1-year follow-up (OR: 2.2 95%CI: 1.2-4.0). Quarterly ITS analysis corroborated this relationship (P â€‹= â€‹0.01). CONCLUSIONS: Time-of-surgery appointment creation and automated patient reminders can improve LTFU rates following carotid revascularizations.


Subject(s)
Carotid Stenosis , Endarterectomy, Carotid , Endovascular Procedures , Stroke , Humans , Female , Middle Aged , Aged , Aged, 80 and over , Male , Follow-Up Studies , Risk Factors , Risk Assessment , Stroke/complications , Treatment Outcome , Retrospective Studies , Carotid Stenosis/surgery , Stents
2.
Arterioscler Thromb Vasc Biol ; 41(3): 1229-1238, 2021 03.
Article in English | MEDLINE | ID: mdl-33504178

ABSTRACT

OBJECTIVE: The aim of this study was to comprehensively assess the association of multiple lipid measures with incident peripheral artery disease (PAD). Approach and Results: We used Cox proportional hazards models to characterize the associations of each of the fasting lipid measures (total cholesterol, LDL-C [low-density lipoprotein cholesterol], HDL-C [high-density lipoprotein cholesterol], triglycerides, RLP-C [remnant lipoprotein cholesterol], LDL-TG [LDL-triglycerides], sdLDL-C [small dense LDL-C], and Apo-E-HDL [Apo-E-containing HDL-C]) with incident PAD identified by pertinent International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM) hospital discharge codes (eg, 440.2) among 8330 Black and White ARIC (Atherosclerosis Risk in Communities) participants (mean age 62.8 [SD 5.6] years) free of PAD at baseline (1996-1998) through 2015. Since lipid traits are biologically correlated to each other, we also conducted principal component analysis to identify underlying components for PAD risk. There were 246 incident PAD cases with a median follow-up of 17 years. After accounting for potential confounders, the following lipid measures were significantly associated with PAD (hazard ratio per 1-SD increment [decrement for HDL-C and Apo-E-HDL]): triglycerides, 1.21 (95% CI, 1.08-1.36); RLP-C, 1.18 (1.08-1.29); LDL-TG, 1.18 (1.05-1.33); HDL-C, 1.39 (1.16-1.67); and Apo-E-HDL, 1.27 (1.07-1.51). The principal component analysis identified 3 components (1: mainly loaded by triglycerides, RLP-C, LDL-TG, and sdLDL-C; 2: by HDL-C and Apo-E-HDL; and 3: by LDL-C and RLP-C). Components 1 and 2 showed independent associations with incident PAD. CONCLUSIONS: Triglyceride-related and HDL-related lipids were independently associated with incident PAD, which has implications on preventive strategies for PAD. However, none of the novel lipid measures outperformed conventional ones. Graphic Abstract: A graphic abstract is available for this article.


Subject(s)
Lipids/blood , Peripheral Arterial Disease/blood , Aged , Aged, 80 and over , Apolipoproteins E/blood , Cholesterol/blood , Cholesterol, HDL/blood , Cholesterol, LDL/blood , Cohort Studies , Dyslipidemias/blood , Dyslipidemias/complications , Female , Humans , Lipoproteins/blood , Lipoproteins, HDL/blood , Lipoproteins, LDL/blood , Male , Peripheral Arterial Disease/etiology , Proportional Hazards Models , Prospective Studies , Risk Factors , Triglycerides/blood
3.
J Am Coll Cardiol ; 74(4): 498-507, 2019 07 30.
Article in English | MEDLINE | ID: mdl-31345423

ABSTRACT

BACKGROUND: Public statements about the effect of smoking on cardiovascular disease are predominantly based on investigations of coronary heart disease (CHD) and stroke, although smoking is recognized as a strong risk factor for peripheral artery disease (PAD). No study has comprehensively compared the long-term association of cigarette smoking and its cessation with the incidence of 3 major atherosclerotic diseases (PAD, CHD, and stroke). OBJECTIVES: The aim of this study was to quantify the long-term association of cigarette smoking and its cessation with the incidence of the 3 outcomes. METHODS: A total of 13,355 participants aged 45 to 64 years in the ARIC (Atherosclerosis Risk In Communities) study without PAD, CHD, or stroke at baseline (1987 to 1989) were included. The associations of smoking parameters (pack-years, duration, intensity, and cessation) with incident PAD were quantified and contrasted with CHD and stroke using Cox models. RESULTS: Over a median follow-up of 26 years, there were 492 PAD cases, 1,798 CHD cases, and 1,106 stroke cases. A dose-response relationship was identified between pack-years of smoking and 3 outcomes, with the strongest results for PAD. The pattern was consistent when investigating duration and intensity separately. A longer period of smoking cessation was consistently related to lower risk of PAD, CHD, and stroke, but a significantly elevated risk persisted up to 30 years following smoking cessation for PAD and up to 20 years for CHD. CONCLUSIONS: All smoking measures showed significant associations with 3 major atherosclerotic diseases, with the strongest effect size for incident PAD. The risk due to smoking lasted up to 30 years for PAD and 20 years for CHD. Our results further highlight the importance of smoking prevention and early smoking cessation, and indicate the need for public statements to take PAD into account when acknowledging the impact of smoking on overall cardiovascular health.


Subject(s)
Atherosclerosis/epidemiology , Atherosclerosis/etiology , Cigarette Smoking/adverse effects , Coronary Disease/epidemiology , Coronary Disease/etiology , Peripheral Arterial Disease/epidemiology , Peripheral Arterial Disease/etiology , Smoking Cessation , Stroke/epidemiology , Stroke/etiology , Female , Humans , Incidence , Male , Middle Aged , Prospective Studies , Risk Assessment , Risk Factors , Time Factors
5.
Vasc Med ; 21(6): 547-552, 2016 12.
Article in English | MEDLINE | ID: mdl-27126951

ABSTRACT

A type B dissection involves the aorta distal to the subclavian artery, and accounts for 25-40% of aortic dissections. Approximately 75% of these are uncomplicated with no malperfusion or ischemia. Multiple consensus statements recommend thoracic endovascular aortic repair (TEVAR) as the treatment of choice for acute complicated type B aortic dissections, while uncomplicated type B dissections are traditionally treated with medical management alone, including strict blood pressure control, as open repairs have a prohibitively high morbidity of up to 31%. However, with medical treatment alone, the morbidity, including aneurysm degeneration of the affected segment, is 30%, and mortality is 10% over 5 years. For both chronic and acute uncomplicated type B aortic dissections, emerging evidence supports the use of both best medical therapy and TEVAR. This paper reviews the current diagnosis and treatment of uncomplicated type B aortic dissections.


Subject(s)
Aortic Aneurysm, Thoracic/diagnostic imaging , Aortic Aneurysm, Thoracic/therapy , Aortic Dissection/diagnostic imaging , Aortic Dissection/therapy , Blood Vessel Prosthesis Implantation , Cardiovascular Agents/therapeutic use , Endovascular Procedures , Algorithms , Aortic Dissection/history , Aortic Dissection/mortality , Aortic Aneurysm, Thoracic/history , Aortic Aneurysm, Thoracic/mortality , Blood Vessel Prosthesis Implantation/adverse effects , Blood Vessel Prosthesis Implantation/history , Blood Vessel Prosthesis Implantation/mortality , Cardiovascular Agents/adverse effects , Cardiovascular Agents/history , Critical Pathways , Endovascular Procedures/adverse effects , Endovascular Procedures/history , Endovascular Procedures/mortality , History, 20th Century , History, 21st Century , Humans , Predictive Value of Tests , Risk Factors , Treatment Outcome
6.
Vasc Med ; 21(3): 276-80, 2016 06.
Article in English | MEDLINE | ID: mdl-26989169
9.
Phys Med Rehabil Clin N Am ; 20(4): 627-56, 2009 Nov.
Article in English | MEDLINE | ID: mdl-19781503

ABSTRACT

The prevalence of peripheral arterial disease is high and will continue to grow with our aging population. It is often under diagnosed and under treated due to a general lack of awareness on the part of the patient and the practitioner. The evidence-base is growing for the optimal medical management of the patient with peripheral arterial disease; in parallel, endovascular revascularization options continue to improve. Exercise training for claudication rehabilitation plays a critical role. Comprehensive care of the peripheral arterial disease patient focuses on the ultimate goals of improving quality of life and reducing cardiovascular morbidity and mortality.


Subject(s)
Cardiovascular Diseases/prevention & control , Exercise Therapy/methods , Intermittent Claudication/rehabilitation , Peripheral Vascular Diseases/complications , Female , Follow-Up Studies , Humans , Intermittent Claudication/diagnosis , Intermittent Claudication/etiology , Male , Peripheral Vascular Diseases/diagnosis , Peripheral Vascular Diseases/therapy , Quality of Life , Risk Assessment , Severity of Illness Index , Vasodilator Agents/therapeutic use
10.
Vascular ; 17(1): 51-4, 2009.
Article in English | MEDLINE | ID: mdl-19344584

ABSTRACT

Bradycardia may lead to an underestimation of carotid stenosis by duplex ultrasonography. An 83-year-old man with asymptomatic bradycardia was referred to our institution after magnetic resonance angiography revealed greater than 90% stenosis of the proximal left internal carotid artery (ICA). Two separate carotid duplex examinations were subsequently performed at different vascular laboratories within our institution. Both studies showed elevated (but borderline for the highest category of stenosis) peak systolic velocities with relatively low end-diastolic velocities (EDVs). Angiography demonstrated more than 90% stenosis of the left ICA. Carotid endarterectomy was then performed. In conclusion, interpreting physicians and vascular ultrasound technologists should be aware of the spurious decrease in EDV that accompanies bradycardia. Further imaging may be warranted when revascularization is a consideration for bradycardic patients with borderline results on carotid duplex ultrasonography.


Subject(s)
Bradycardia/etiology , Carotid Artery, Internal/diagnostic imaging , Carotid Stenosis/complications , Aged, 80 and over , Bradycardia/diagnostic imaging , Carotid Stenosis/diagnosis , Carotid Stenosis/diagnostic imaging , Humans , Magnetic Resonance Angiography , Male , Radiography , Sensitivity and Specificity , Ultrasonography, Doppler, Duplex
11.
Neurol Res ; 31(7): 748-52, 2009 Sep.
Article in English | MEDLINE | ID: mdl-19133168

ABSTRACT

OBJECTIVE: The prevalence of carotid bruits and the utility of auscultation for predicting carotid stenosis are not well known. We aimed to establish the prevalence of carotid bruits and the diagnostic accuracy of auscultation for detection of hemodynamically significant carotid stenosis, using carotid duplex as the gold standard. METHODS: The Northern Manhattan Study (NOMAS) is a prospective multiethnic community-based cohort designed to examine the incidence of stroke and other vascular events and the association between various vascular risk factors and subclinical atherosclerosis. Of the stroke-free cohort (n=3298), 686 were examined for carotid bruits and underwent carotid duplex. Main outcome measures included prevalence of carotid bruits and sensitivity, specificity, positive predictive value, negative predictive value and accuracy of auscultation for prediction of ipsilateral carotid stenosis. RESULTS: Among 686 subjects with a mean age of 68.2 +/- 9.4 years, the prevalence of >/=60% carotid stenosis as detected by ultrasound was 2.2% and the prevalence of carotid bruits was 4.1%. For detection of carotid stenosis, sensitivity of auscultation was 56%, specificity was 98%, positive predictive value was 25%, negative predictive value was 99% and overall accuracy was 97.5%. DISCUSSION: In this ethnically diverse cohort, the prevalence of carotid bruits and hemodynamically significant carotid stenosis was low. Sensitivity and positive predictive value were also low, and the 44% false-negative rate suggests that auscultation is not sufficient to exclude carotid stenosis. While the presence of a bruit may still warrant further evaluation with carotid duplex, ultrasonography may be considered in high-risk asymptomatic patients, irrespective of findings on auscultation.


Subject(s)
Auscultation/methods , Carotid Arteries/physiopathology , Carotid Stenosis , Hemodynamics/physiology , Adult , Aged , Aged, 80 and over , Carotid Arteries/diagnostic imaging , Carotid Stenosis/diagnosis , Carotid Stenosis/epidemiology , Carotid Stenosis/physiopathology , Echocardiography/methods , Female , Humans , Male , Middle Aged , New York City/epidemiology , Prevalence , Radiography , Ultrasonography, Doppler, Duplex/methods
12.
J Gen Intern Med ; 23(9): 1423-8, 2008 Sep.
Article in English | MEDLINE | ID: mdl-18581186

ABSTRACT

BACKGROUND: Lower extremity peripheral arterial disease (PAD) is highly prevalent and strongly associated with cardiovascular morbidity and mortality. The ankle-brachial index used to screen for PAD is not routinely performed in primary care settings. OBJECTIVE: To determine if self-reported PAD is an independent predictor of combined vascular events (myocardial infarction, ischemic stroke, and vascular death). DESIGN: Ongoing population-based prospective cohort (the Northern Manhattan Study). Subjects enrolled between July 1993 and June 2001 with a mean follow-up time of 7.1 years. PATIENTS: Subjects (n = 2,977), aged 40 years or older and free of prior stroke or myocardial infarction, were classified as having self-reported PAD if they answered affirmatively to one of two questions regarding exercise-induced leg pain or a prior diagnosis of PAD. MAIN OUTCOME MEASURES: Combined vascular outcome defined as incident myocardial infarction, incident ischemic stroke, or vascular death. RESULTS: The mean age of the cohort was 68.9 +/- 10.4 years; 64% were women; 54% Hispanic, 25% African-American, 21% Caucasian; 15% reported having PAD. After a mean follow-up of 7.1 years, self-reported PAD was significantly predictive of combined events (n = 484) in the univariate model (HR 1.5, 95% CI, 1.2-1.9) and after adjustment for traditional cardiovascular risk factors (HR 1.3, 95% CI, 1.0-1.7). CONCLUSION: Self-reported PAD is an independent risk factor for future vascular events in this predominantly non-white cohort. The addition of two simple PAD questions to the routine medical history in general medicine settings could identify high-risk patients who would benefit from further vascular evaluation and risk factor modification.


Subject(s)
Myocardial Infarction/complications , Peripheral Vascular Diseases/complications , Peripheral Vascular Diseases/diagnosis , Stroke/complications , Aged , Female , Health Surveys , Humans , Interviews as Topic , Male , Medical History Taking , Middle Aged , Prospective Studies , Risk Factors
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