Harmony R. Reynolds, M.D.

Effects of early and late re-infarction on mortality in patients with re-canalized or conservatively treated occluded coronary arteries in long term follow up of the Occluded Artery Trial (OAT)
Adlbrecht C.; Huber K.; Reynolds H.R.; Carvalho A.C.; White H.D.; Steg P.G.; Liu L.; Pearte C.A.; Marino P.; Hochman J.S.
2011 ;32:659-659, European heart journal
Background: The OAT trial demonstrated similar combined endpoint of death, re-infarction (Re-MI), and NYHA class IV heart failure either at 2.9 years mean or extended follow-up up to 9 years (n=2,201). OAT enrolled stable patients >24 hours (calendar days 3-28) post myocardial infarction (MI), with an angiographically confirmed occluded infarct-related artery (IRA). Patients were randomized either to receive percutaneous coronary intervention and optimal medical therapy (PCI), or to optimal medical therapy alone (MED). The study disclosed a trend towards more non-fatal Re-MIs in the PCI group, which was driven by excess type 4a or 4b MIs (i.e. PCI/stent-related) according to the universal MI definition. The current pre-specified analysis investigated the impact of Re-MIs, including time of occurrence (early (<=6 months) or late (>6 months) after randomization) and MI type on mortality. Methods: Cox regression models were used to analyze the effect of Re-MIs adjusted for baseline variables on mortality at a mean of 6 years of follow-up, and interaction with treatment assignment. Results: When the international universal definition of MI was applied, a total of 169 RE-MIs were detected (as compared to 142 Re-MIs based on the stricter MI criteria used in the OAT trial), of which 95 occurred in the PCI group and 74 in the MED group (p=0.08). After adjustment for baseline characteristics Re-MI patients had a 4.15-fold (95% CI 3.03-5.69, p<0.0001) increased risk of death compared to patients without Re-MI, whereby the risk was similar for both treatment groups (interaction p=0.26). Re-MI type 4a or 4b was associated with a similar impact on death (HR 3.29, 95% CI 1.80-6.02, p<0.0001) as spontaneous or secondary Re- MIs (i.e. MI types 1 or 2; HR 2.92, 95% CI 1.93-4.43, p<0.0001), (p=0.477 type 4a,b vs 1,2). Re-MIs occurring <=6 months after study entry (20/66 died) had similar impact on mortality as Re-MIs occurring >6 months after study entry (30/103 died) (p=0.60). Finally, there was no difference in the influence on mortality of Re-MIs by the qualifying IRA (HR 2.94, 95% CI 1.76-4.93, p<0.0001) or Re-MIs occurring in an epicardial coronary artery different from the IRA (HR 3.77, 95% CI 2.22-6.44, p<0.0001) (p=0.77 OAT IRA vs. nonIRA). Conclusions: For stable post-MI patients with totally occluded infarct arteries, the occurrence of a Re-MI had significant impact on mortality regardless of the initial management strategy (PCI vs. MED), early or late occurrence, location in the same or different IRA as the OAT qualifying MI and type of Re-MI based on the universal definition
— id: 137910, year: 2011, vol: 32, page: 659, stat: Journal Article,

Loss of short-term symptomatic benefit in patients with an occluded infarct artery is unrelated to non-protocol revascularization: results from the Occluded Artery Trial (OAT)
Devlin, Gerard; Reynolds, Harmony R; Mark, Daniel B; Rankin, James M; Carvalho, Antonio C; Vozzi, Carlos; Sopko, George; Caramori, Paulo; Dzavik, Vladimir; Ragosta, Michael; Forman, Sandra A; Lamas, Gervasio A; Hochman, Judith S
2011 Jan;161(1):84-90, American heart journal
BACKGROUND: the OAT found that routine late (3-28 days post-myocardial infarction) percutaneous coronary intervention (PCI) of an occluded infarct-related artery did not reduce death, reinfarction, or heart failure relative to medical treatment (MED). Angina rates were lower in PCI early, but the advantage over MED was lost by 3 years. METHODS: angina and revascularization status were collected at 4 months, then annually. We assessed whether non-protocol revascularization procedures in MED accounted for loss of the early symptomatic advantage of PCI. RESULTS: seven per 100 more PCI patients were angina-free at 4 months (P < .001) and 5 per 100 at 12 months (P = .005) with the difference narrowing to 1 per 100 at 3 years (P = .34). Non-protocol revascularization was more frequent in MED (5-year rate 22% vs 19% PCI, P = .05). Indications for revascularization included acute coronary syndromes (39% PCI vs 38% MED), stable angina/inducible ischemia (39% in each group), and physician preference (17% PCI vs 15% MED). Revascularization rates among patients with angina at any time during follow-up (35% of cohort) did not differ by treatment group (5-year rates 26% PCI vs 28% MED). Most symptomatic patients were treated without revascularization during follow-up (77%). CONCLUSIONS: in a large randomized clinical trial of stable post-myocardial infarction patients, the modest benefit on angina from PCI of an occluded infarct-related artery was lost by 3 years. Revascularization was slightly more common in MED during follow-up but was not driven by acute ischemia, and almost 1 in 5 procedures were attributed to physician preference alone
— id: 137106, year: 2011, vol: 161, page: 84, stat: Journal Article,

Long-term effects of percutaneous coronary intervention of the totally occluded infarct-related artery in the subacute phase after myocardial infarction
Hochman, Judith S; Reynolds, Harmony R; Dzavik, Vladimir; Buller, Christopher E; Ruzyllo, Witold; Sadowski, Zygmunt P; Maggioni, Aldo P; Carvalho, Antonio C; Rankin, James M; White, Harvey D; Goldberg, Suzanne; Forman, Sandra A; Mark, Daniel B; Lamas, Gervasio A
2011 Nov 22;124(21):2320-2328, Circulation
BACKGROUND: Despite observations suggesting a benefit for late opening of totally occluded infarct-related arteries after myocardial infarction, the Occluded Artery Trial (OAT) demonstrated no reduction in the composite of death, reinfarction, and class IV heart failure over a 2.9-year mean follow-up. Follow-up was extended to determine whether late trends would favor either treatment group. METHODS AND RESULTS: OAT randomized 2201 stable patients with infarct-related artery total occlusion >24 hours (calendar days 3-28) after myocardial infarction. Patients with severe inducible ischemia, rest angina, class III-IV heart failure, and 3-vessel/left main disease were excluded. We conducted extended follow-up of enrolled patients for an additional 3 years for the primary end point and angina (6-year median survivor follow-up; longest, 9 years; 12 234 patient-years). Rates of the primary end point (hazard ratio, 1.06; 95% confidence interval, 0.88-1.28), fatal and nonfatal myocardial infarction (hazard ratio, 1.25; 95% confidence interval, 0.89-1.75), death, and class IV heart failure were similar for the percutaneous coronary intervention (PCI) and medical therapy alone groups. No interactions between baseline characteristics and treatment group on outcomes were observed. The vast majority of patients at each follow-up visit did not report angina. There was less angina in the PCI group through early in follow-up; by 3 years, the between group difference was consistently <4 patients per 100 treated and not significantly different, although there was a trend toward less angina in the PCI group at 3 and 5 years. The 7-year rate of PCI of the infarct-related artery during follow-up was 11.1% for the PCI group compared with 14.7% for the medical therapy alone group (hazard ratio, 0.79; 95% confidence interval, 0.61-1.01; P=0.06). CONCLUSIONS: Extended follow-up of the OAT cohort provides robust evidence for no reduction of long-term rates of clinical events after routine PCI in stable patients with a totally occluded infarct-related artery and without severe inducible ischemia in the subacute phase after myocardial infarction
— id: 148728, year: 2011, vol: 124, page: 2320, stat: Journal Article,

Cardiovascular disease in young women: a population at risk
Levit, Rebecca D; Reynolds, Harmony R; Hochman, Judith S
2011 Mar-Apr;19(2):60-65, Cardiology in review
Ischemic heart disease (IHD) is a leading cause of morbidity in the United States and worldwide. In women, it is the leading cause of death in all age groups except young women who rarely have clinically evident disease. However, when young women less than age 50 develop IHD, they are at high risk for mortality. This may be due in part to delay in diagnosis or less aggressive treatment. Young women may be less aggressively treated with medical therapies and percutaneous or surgical interventions despite studies that have shown benefit in women as well as men. Young women are an especially important population to target for treatment and study since prevention of IHD during this stage of life can have great personal and societal health consequences. Epidemiological studies, including the INTERHEART study, have identified risk factors including hypertension, diabetes, metabolic syndrome, smoking, and sedentary lifestyle that explain much of IHD in women. Several factors, including diabetes, metabolic syndrome, and tobacco use, are stronger predictors of IHD in young women as compared with older women. Healthcare practitioners who encounter young women should aggressively treat risk factors, maintain an appropriate index of suspicion for IHD, and treat acute coronary syndromes promptly and intensively to reduce the burden of IHD in young women
— id: 122545, year: 2011, vol: 19, page: 60, stat: Journal Article,

Afferent baroreflex failure and tako-tsubo cardiomyopathy
Norcliffe-Kaufmann, Lucy J; Reynolds, Harmony R
2011 Feb;21(1):1-2, Clinical autonomic research
— id: 122536, year: 2011, vol: 21, page: 1, stat: Journal Article,

Mechanisms of Myocardial Infarction in Women Without Angiographically Obstructive Coronary Artery Disease
Reynolds HR; Srichai MB; Iqbal SN; Slater JN; Mancini GB; Feit F; Pena-Sing I; Axel L; Attubato MJ; Yatskar L; Kalhorn RT; Wood DA; Lobach IV; Hochman JS
2011 Sep 27;124(13):1414-1425, Circulation
BACKGROUND: . Unique identifier: NCT00798122
— id: 137093, year: 2011, vol: 124, page: 1414, stat: Journal Article,

Comparison of Late Results of Percutaneous Coronary Intervention Among Stable Patients </=65 Versus >65 Years of Age With an Occluded Infarct Related Artery (from the Occluded Artery Trial)
Skolnick AH; Reynolds HR; White HD; Menon V; Carvalho AC; Maggioni AP; Pearte CA; Gruberg L; Azevedo RE; Schroeder E; Forman SA; Lamas GA; Hochman JS; Dzavik V
2011 Dec 13;:?-? #, American journal of cardiology
Although opening an occluded infarct-related artery >24 hours after myocardial infarction in stable patients in the Occluded Artery Trial (OAT) did not reduce events over 7 years, there was a suggestion that the effect of treatment might differ by patient age. Baseline characteristics and outcomes by treatment with percutaneous coronary intervention (PCI) versus optimal medical therapy alone were compared by prespecified stratification at age 65 years. A p value <0.01 was prespecified as significant for OAT secondary analyses. The primary outcome was death, myocardial infarction, or New York Heart Association class IV heart failure. Patients aged >65 years (n = 641) were more likely to be female, to be nonsmokers, and to have hypertension, lower estimated glomerular filtration rates, and multivessel disease compared to younger patients (aged </=65 years, n = 1,560) (p <0.001). There was no significant observed interaction between treatment assignment and age for the primary outcome after adjustment (p = 0.10), and there was no difference between PCI and optimal medical therapy observed in either age group. At 7-year follow-up, younger patients tended to have angina more often compared to the older group (hazard ratio 1.21, 99% confidence interval 1.00 to 1.46, p = 0.01). The 7-year composite primary outcome was more common in older patients (p <0.001), and age remained significant after covariate adjustment (hazard ratio 1.42, 99% confidence interval 1.09 to 1.84). The rate of early PCI complications was low in the 2 age groups. The trend toward a differential effect of PCI in the young versus the old for the primary outcome was likely driven by measured and unmeasured confounders and by chance. PCI reduces angina to a similar degree in the young and old. In conclusion, there is no indication for routine PCI to open a persistently occluded infarct-related artery in stable patients after myocardial infarction, regardless of age
— id: 147671, year: 2011, vol: , page: ?, stat: Journal Article,

Women have less severe and extensive coronary atherosclerosis in fatal cases of ischemic heart disease: An autopsy study
Smilowitz, Nathaniel R; Sampson, Barbara A; Abrecht, Christopher R; Siegfried, Jonathan S; Hochman, Judith S; Reynolds, Harmony R
2011 Apr;161(4):681-688, American heart journal
OBJECTIVE: The study aims to evaluate sex differences in extent and severity of coronary artery disease (CAD) and myocardial findings at autopsy among young people with fatal ischemic heart disease (IHD). BACKGROUND: Women with acute coronary syndrome are less likely than men to display obstructive CAD at angiography. This suggests unique mechanisms of acute coronary syndrome exist in women or may reflect prehospital death of women with the most severe CAD. METHODS: Reports of autopsies by the Office of the Chief Medical Examiner of New York City on people aged 21 to 54 years who died between January 1, 2006, and December 31, 2008, were reviewed. A total of 639 cases of death due to atherosclerotic or arteriosclerotic cardiovascular disease according to the medical examiner were analyzed. Significant CAD was defined as >/=75% cross-sectional area stenosis in an epicardial vessel or >/=50% left main. RESULTS: Women were less likely to have obstructive CAD (63% vs 77% of men, P = .002). There was pathologic evidence of myocardial infarction (MI) in 43% of cases, 17% of which had nonobstructive CAD. Frequency of MI did not vary by sex overall (38% of women vs 45% of men, P = .18) or among those without significant CAD (23% vs 29%, P = .45). CONCLUSIONS: Among young people determined at autopsy to have died of IHD, fewer women had obstructive CAD, consistent with angiographic data in other IHD syndromes. Pathologic evidence of MI may exist in the absence of obstructive CAD
— id: 130911, year: 2011, vol: 161, page: 681, stat: Journal Article,

Reply to Letter Regarding Article, "The Impact of Collateral Flow to the Occluded Infarct-Related Artery on Clinical Outcomes in Patients With Recent Myocardial Infarction: A Report From the Randomized Occluded Artery Trial"
Steg, Ph Gabriel; Kerner, Arthur; Mancini, G. B. John; Buller, Christopher E.; Carvalho, Antonio C.; Forman, Sandra A.; Fridrich, Viliam; Reynolds, Harmony R.; Hochman, Judith S.; Lamas, Gervasio A.; White, Harvey D.
2011 MAR 1 ;123(8):E257-E258, Circulation
— id: 126457, year: 2011, vol: 123, page: E257, stat: Journal Article,

Predictors of reinfarction following PCI or medical management using the universal definition in patients with total occlusion after myocardial infarction: Results from OAT long term follow up
White H.D.; Reynolds H.R.; Carvalho A.C.; Liu L.; Pearte C.A.; Dzavik V.; Kruk M.; Steg P.G.; Lamas G.A.; Hochman J.S.
2011 ;32:738-739, European heart journal
Purpose: The Occluded Artery Trial (OAT) randomized 2201 patients with an occluded infarct-related artery on days 3-28 (>24 hours) following MI to either percutaneous coronary intervention (PCI) or medical treatment (MED). There was no difference in the primary endpoint of death, reinfarction (reMI) or heart failure either at 2.9 years (mean) or follow up to 9 years. However in patients randomized to PCI there was a trend for an increase in adjudicated reMI. This analysis sought to determine the independent predictors of reMI over mean 6 years follow up. Methods: reMIs were adjudicated blinded to randomization and according to the universal definition, for a type 1 (spontaneous) or type 2 Infarction (supplydemand mismatch) and after PCI (type 4), biomarkers 3x upper limit of normal (ULN) and after bypass surgery (type 5), biomarkers 5x ULN. Cox multivariable regression models were developed including baseline demographics and angiographic data, p<0.01 was considered significant. Results: There were 169 reMIs; (9.4% PCI vs. 8.0% MED, HR 1.31, 95% CI 0.97 - 1.77, p=0.08). The most common type of reMI was type 1 (62.7%) with no difference between the groups; 4.9% PCI vs 6.7% MED, HR 0.78, 95% CI 0.53 - 1.15, p=0.21. There were more type 4 reMIs in the PCI group; 3.5% vs 0.7%, HR 5.22, 95% CI 2.32 - 11.74, p<0.001, with an increase in type 4a reMI (related to protocol or repeat PCI); 0.8% PCI vs 0.1% MED, HR 9.03, 95% CI 1.14 - 71.3, p=0.01, and an increase in type 4b reMI (stent thrombosis); 2.7% PCI vs 0.6% MED, HR 4.59, 95% CI 1.89 - 11.1, p<0.001. Most reMIs in the PCI group were in the OAT qualifying territory (when assessed n=135); 59.5% vs 37.7% MED, p=0.01. There were 11/95 (11.6%) fatal reMIs in the PCI group and 8/74 (10.8%) in the MED group. Multivariate predictors of reMI for the overall group were: prior history of PCI, p=0.001, diabetes, p=0.005, and no new Q waves with the index infarction, p=0.011. There were no angiographic predictors of reMI. Among the PCI group multivariate predictors of reMI were prior history of MI, p=0.011, and lower ejection fraction, p=0.004. For the MED group the only predictor was a prior history of PCI, p=0.0001. Conclusions: There was a trend for more reMIs in patients randomized to PCI as compared with MED. There were significantly more type 4 reMIs in the PCI group largely driven by excess stent thrombosis. No modifiable predictors of reMI were identified. Opening an occluded infarct-related artery in stable patients late post MI creates a substrate exposing them to a risk of reMI related to reocclusion and stent thrombosis
— id: 137909, year: 2011, vol: 32, page: 738, stat: Journal Article,

Sex and race are associated with the absence of epicardial coronary artery obstructive disease at angiography in patients with acute coronary syndromes
Chokshi, Neel P; Iqbal, Sohah N; Berger, Rachel L; Hochman, Judith S; Feit, Frederick; Slater, James N; Pena-Sing, Ivan; Yatskar, Leonid; Keller, Norma M; Babaev, Anvar; Attubato, Michael J; Reynolds, Harmony R
2010 Aug;33(8):495-501, Clinical cardiology
BACKGROUND: A substantial minority of patients with acute coronary syndromes (ACS) do not have a diameter stenosis of any major epicardial coronary artery on angiography ('no obstruction at angiography') of >/= 50%. We examined the frequency of this finding and its relationship to race and sex. HYPOTHESIS: Among patients with myocardial infarction, younger age, female sex and non-white race are associated with the absence of obstructive coronary artery disease at angiography. METHODS: We reviewed the results of all angiograms performed from May 19, 2006 to September 29, 2006 at 1 private (n = 793) and 1 public (n = 578) urban academic medical center. Charts were reviewed for indication and results of angiography, and for demographics. RESULTS: The cohort included 518 patients with ACS. There was no obstruction at angiography in 106 patients (21%), including 48 (18%) of 258 patients with myocardial infarction. Women were more likely to have no obstruction at angiography than men, both in the overall cohort (55/170 women [32%] vs 51/348 men [15%], P < 0.001) and in the subset with MI (29/90 women [32%] vs 19/168 men [11%], P < 0.001). Black patients were more likely to have no obstruction at angiography relative to any other subgroup (24/66 [36%] vs 41/229 [18%] Whites, 31/150 [21%] Hispanics, and 5/58 [9%] Asians, P = 0.001). Among women, Black patients more frequently had no obstruction at angiography compared with other ethnic groups (16/27 [59%] vs 17/59 [29%] Whites, 17/60 [28%] Hispanics, and 3/19 [6%] Asians, P = 0.001). CONCLUSIONS: A high proportion of a multiethnic sample of patients with ACS were found to have no stenosis >/= 50% in diameter at coronary angiography. This was particularly common among women and Black patients.
— id: 111980, year: 2010, vol: 33, page: 495, stat: Journal Article,

Renal impairment and heart failure with preserved ejection fraction early post-myocardial infarction
Jorapur, Vinod; Lamas, Gervasio A; Sadowski, Zygmunt P; Reynolds, Harmony R; Carvalho, Antonio C; Buller, Christopher E; Rankin, James M; Renkin, Jean; Steg, Philippe Gabriel; White, Harvey D; Vozzi, Carlos; Balcells, Eduardo; Ragosta, Michael; Martin, C Edwin; Srinivas, Vankeepuram S; Wharton Iii, William W; Abramsky, Staci; Mon, Ana C; Kronsberg, Shari S; Hochman, Judith S
2010 Jan 26;2(1):13-18, World journal of cardiology
AIM: To study if impaired renal function is associated with increased risk of peri-infarct heart failure (HF) in patients with preserved ejection fraction (EF). METHODS: Patients with occluded infarct-related arteries (IRAs) between 1 to 28 d after myocardial infarction (MI) were grouped into chronic kidney disease (CKD) stages based on estimated glomerular filtration rate (eGFR). Rates of early post-MI HF were compared among eGFR groups. Logistic regression was used to explore independent predictors of HF. RESULTS: Reduced eGFR was present in 71.1% of 2160 patients, with significant renal impairment (eGFR < 60 mL/min every 1.73 m(2)) in 14.8%. The prevalence of HF was higher with worsening renal function: 15.5%, 17.8% and 29.4% in patients with CKD stages 1, 2 and 3 or 4, respectively (P < 0.0001), despite a small absolute difference in mean EF across eGFR groups: 48.2 +/- 10.0, 47.9 +/- 11.3 and 46.2 +/- 12.1, respectively (P = 0.02). The prevalence of HF was again higher with worsening renal function among patients with preserved EF: 10.1%, 13.6% and 23.6% (P < 0.0001), but this relationship was not significant among patients with depressed EF: 27.1%, 26.2% and 37.9% (P = 0.071). Moreover, eGFR was an independent correlate of HF in patients with preserved EF (P = 0.003) but not in patients with depressed EF (P = 0.181). CONCLUSION: A significant proportion of post-MI patients with occluded IRAs have impaired renal function. Impaired renal function was associated with an increased rate of early post-MI HF, the association being strongest in patients with preserved EF. These findings have implications for management of peri-infarct HF
— id: 137113, year: 2010, vol: 2, page: 13, stat: Journal Article,

A Review of Current Guidelines and Data Supporting the Use of an Intra-Aortic Balloon Pump in Cardiogenic Shock
Reynolds, Harmony R.; Toklu, Bora
2010 DEC ;22(12):3C-5C, Journal of invasive cardiology
— id: 121340, year: 2010, vol: 22, page: 3C, stat: Journal Article,

Association of plasma soluble E-selectin and adiponectin with carotid plaque in patients with systemic lupus erythematosus
Reynolds, Harmony R; Buyon, Jill; Kim, Mimi; Rivera, Tania L; Izmirly, Peter; Tunick, Paul; Clancy, Robert M
2010 Jun;210(2):569-574, Atherosclerosis
BACKGROUND: Systemic lupus erythematosus (SLE) is associated with premature atherosclerosis but the mechanisms underlying this association are not understood. The role of endothelial dysfunction is hypothesized. METHODS: In predominantly non-Caucasian patients with SLE (N=119) and controls (N=71), carotid ultrasonography was performed and circulating endothelial cells (CECs), soluble endothelial protein C receptor and gene polymorphism at A6936G, soluble E-selectin (sE-selectin), and adiponectin were assessed. RESULTS: Carotid plaque was more prevalent among patients than controls (43% vs 17%, p=0.0002). Mean CCA IMT was greater in patients compared to controls (0.59+/-0.19 mm vs 0.54+/-0.11 mm, p=0.03). Among SLE patients, plaque was not associated with smoking, body-mass index, LDL, triglycerides, homocysteine, C-reactive protein, anti-ds DNA antibody, C3, C4, SLE activity, or medications. Age and levels of soluble E-selectin and adiponectin were significantly higher in the SLE patients with plaque compared to those without plaque in univariate and multivariate analyses. sE-selectin and adiponectin were found to serve as independent predictors of carotid plaque and that elevations were persistent over more than one visit. Unexpectedly, these biomarkers were present despite clinical quiescence. CONCLUSION: Premature atherosclerosis is a consistent feature of SLE and extends across ethnicities. Higher levels of adiponectin may represent a physiological attempt to limit further endothelial damage already reflected by the elevation in sE-selectin and the observed increase in plaque represents overwhelming of this reparative process by atherogenic stimuli
— id: 109844, year: 2010, vol: 210, page: 569, stat: Journal Article,

Heartbreak
Reynolds, Harmony R; Hochman, Judith S
2010 Jun;31(12):1433-1435, European heart journal
— id: 134366, year: 2010, vol: 31, page: 1433, stat: Journal Article,

Normal intima-media thickness on carotid ultrasound reliably excludes an ischemic cause of cardiomyopathy
Reynolds, Harmony R; Steckman, David A; Tunick, Paul A; Kronzon, Itzhak; Lobach, Iryna; Rosenzweig, Barry P
2010 Jun;159(6):1059-1066, American heart journal
BACKGROUND: Coronary artery disease (CAD) is the most common cause of left ventricular systolic dysfunction (LVSD). Patients with ischemia as the cause of LVSD may warrant revascularization. Angiography is the most accurate method of CAD diagnosis but is invasive, expensive, and associated with some risk. Noninvasive imaging for CAD often involves expensive equipment, radiation exposure, medication, and/or contrast administration. Carotid ultrasound with measurement of intima-media thickness (IMT) is safe and inexpensive. Carotid IMT is well correlated with the presence of CAD. We assessed the accuracy of carotid ultrasound for identification of CAD as a potential etiology of LVSD. METHODS: Patients with LVSD (ejection fraction < or =40%) of uncertain etiology referred for angiography underwent carotid ultrasound. Patients with history of myocardial infarction were excluded. Two experienced cardiologists blinded to CAD status determined common carotid artery (CCA) IMT and plaque. Significant CAD was defined as > or =50% stenosis of any major artery. Ischemic LVSD was defined as (1) left main and/or proximal left anterior descending coronary artery > or =75% or (2) > or =2 major arteries with > or =75% stenosis. RESULTS: Mean ejection fraction was 27% +/- 10% in 150 patients. Significant CAD was found in 64 (42.7%) and ischemic LVSD in 40 (26.7%). Carotid plaque was seen in 95 (63.3%). Mean CCA IMT was > or =0.9 mm in 69 (46.0%). The combination of mean CCA IMT <0.9 mm and no plaque had negative predictive value for ischemic LVSD of 98%. CONCLUSIONS: Carotid ultrasound with IMT measurement is a valuable screening tool for excluding an ischemic etiology of LVSD when CAD is suspected
— id: 110089, year: 2010, vol: 159, page: 1059, stat: Journal Article,

A severity scoring system for risk assessment of patients with cardiogenic shock: a report from the SHOCK Trial and Registry
Sleeper, Lynn A; Reynolds, Harmony R; White, Harvey D; Webb, John G; Dzavik, Vladimir; Hochman, Judith S
2010 Sep;160(3):443-450, American heart journal
BACKGROUND: Early revascularization (ERV) is beneficial in the management of cardiogenic shock (CS) complicating myocardial infarction. The severity of CS varies widely, and identification of independent risk factors for outcome is needed. The effect of ERV on mortality in different risk strata is also unknown. We created a severity scoring system for CS and used it to examine the potential benefit of ERV in different risk strata using data from the SHOCK Trial and Registry. METHODS: Data from 1,217 patients (294 from the randomized trial and 923 from the registry) with CS due to pump failure were included in a Stage 1 severity scoring system using clinical variables. A Stage 2 scoring system was developed using data from 872 patients who had invasive hemodynamic measurements. The outcome was in-hospital mortality at 30 days. RESULTS: In-hospital mortality at 30 days was 57%. Multivariable modeling identified 8 risk factors (Stage 1): age, shock on admission, clinical evidence of end-organ hypoperfusion, anoxic brain damage, systolic blood pressure, prior coronary artery bypass grafting, noninferior myocardial infarction, and creatinine > or = 1.9 mg/dL (c-statistic = 0.74). Mortality ranged from 22% to 88% by score category. The ERV benefit was greatest in moderate- to high-risk patients (P = .02). The Stage 2 model based on patients with pulmonary artery catheterization included age, end-organ hypoperfusion, anoxic brain damage, stroke work, and left ventricular ejection fraction <28% (c-statistic = 0.76). In this cohort, the effect of ERV did not vary by risk stratum. CONCLUSIONS: Simple clinical predictors provide good discrimination of mortality risk in CS complicating myocardial infarction. Early revascularization is associated with improved survival across a broad range of risk strata
— id: 137110, year: 2010, vol: 160, page: 443, stat: Journal Article,

Impact of collateral flow to the occluded infarct-related artery on clinical outcomes in patients with recent myocardial infarction: a report from the randomized occluded artery trial
Steg, Ph Gabriel; Kerner, Arthur; Mancini, G B John; Reynolds, Harmony R; Carvalho, Antonio C; Fridrich, Viliam; White, Harvey D; Forman, Sandra A; Lamas, Gervasio A; Hochman, Judith S; Buller, Christopher E
2010 Jun 29;121(25):2724-2730, Circulation
BACKGROUND: Collateral flow to the infarct artery territory after acute myocardial infarction may be associated with improved clinical outcomes and may also impact the benefit of subsequent recanalization of an occluded infarct-related artery. METHODS AND RESULTS: To understand the association between baseline collateral flow to the infarct territory on clinical outcomes and its interaction with percutaneous coronary intervention of an occluded infarct artery, long-term outcomes in 2173 patients with total occlusion of the infarct artery 3 to 28 days after myocardial infarction from the randomized Occluded Artery Trial were analyzed according to angiographic collaterals documented at study entry. There were important differences in baseline clinical and angiographic characteristics as a function of collateral grade, with generally lower-risk characteristics associated with higher collateral grade. Higher collateral grade was associated with lower rates of death (P=0.009), class III and IV heart failure (P<0.0001) or either (P=0.0002) but had no association with the risk of reinfarction. However, by multivariate analysis, collateral flow was neither an independent predictor of death nor of the primary end point of the trial (composite of death, reinfarction, or class IV heart failure). There was no interaction between angiographic collateral grade and the results of randomized treatment assignment (percutaneous coronary intervention or medical therapy alone) on clinical outcomes. CONCLUSIONS: In recent myocardial infarction, angiographic collaterals to the occluded infarct artery are correlates but not independent predictors of major clinical outcomes. Late recanalization of the infarct artery in addition to medical therapy shows no benefit compared with medical therapy alone, regardless of the presence or absence of collaterals. Therefore, revascularization decisions in patients with recent myocardial infarction should not be based on the presence or grade of angiographic collaterals. Clinical Trial Registration- URL: http://www.clinicaltrials.gov. Unique identifier: NCT00004562
— id: 137111, year: 2010, vol: 121, page: 2724, stat: Journal Article,

Characterization and outcomes of women and men with non-ST-segment elevation myocardial infarction and nonobstructive coronary artery disease: results from the Can Rapid Risk Stratification of Unstable Angina Patients Suppress Adverse Outcomes with Early Implementation of the ACC/AHA Guidelines (CRUSADE) quality improvement initiative
Gehrie, Erika R; Reynolds, Harmony R; Chen, Anita Y; Neelon, Brian H; Roe, Matthew T; Gibler, W Brian; Ohman, E Magnus; Newby, L Kristin; Peterson, Eric D; Hochman, Judith S
2009 Oct;158(4):688-694, American heart journal
BACKGROUND: Women with non-ST-segment elevation myocardial infarction (NSTEMI) who undergo coronary angiography have no obstructive coronary lesions more often than men. Sex-specific characteristics and outcomes of patients without obstructive coronary artery disease (CAD) have not been described previously. METHODS: Using data from NSTEMI patients enrolled in CRUSADE from 2001 to 2005, we evaluated differences in clinical features and in-hospital outcomes between men and women with no obstructive CAD. RESULTS: After excluding patients with missing catheterization and sex data (n = 1,494), previous coronary artery bypass grafting or percutaneous coronary intervention (47,907), catheterization contraindications (n = 6,588), and missing obstructive CAD status (n = 1,565), there were 55,514 patients (68.4%) with NSTE acute coronary syndromes (ACS) who underwent angiography (among women, 62.1% [21,294/34,290], and among men, 73% [34,220/46,875]; P < .001). Among these, a total of 5,538 patients (10.0%) had nonnonobstructive CAD-15.1% (3,221/21,294) of women and 6.8% (2,317/34,220) of men (P < .0001). In patients without obstructive CAD, women were as likely as men to have MI (troponin elevation in 89% vs 87%, P = .37). Women and men were equally likely to have larger troponin elevations (58.9% vs 58.6% with troponin >5x upper limit of normal, P = .69, respectively). In NSTEMI patients without obstructive CAD, in-hospital death (0.6% women vs 0.7% men) and cardiogenic shock (1.0% women vs 0.7% men) were infrequent. CONCLUSIONS: Among NSTE ACS patients undergoing coronary angiography, absence of obstructive CAD is more common in women than men. Although nonobstructive CAD was twice as common among women with NSTEMI, sex differences in characteristics and outcomes were similar to those found with obstructive CAD. Unadjusted in-hospital outcomes of NSTEMI patients with nonobstructive CAD are favorable in both sexes. Whether the underlying pathophysiology of NSTE ACS without documentation of obstructive CAD is different between women and men requires further study
— id: 102938, year: 2009, vol: 158, page: 688, stat: Journal Article,

Association of soluble E-selectin and adiponectin with carotid plaque, independent of clinical activity, in patients with systemic lupus erythematosus
Izmirly P.M.; Reynolds H.R.; Rivera T.L.; Kim M.Y.; Tunick P.A.; Buyon J.P.; Clancy R.M.
2009 ;60:1562-1562, Arthritis & rheumatism
Purpose: The mechanisms underlying premature atherosclerosis in SLE are not understood. The endothelium merits focus since it provides the physiologic boundary which limits extravasation and diapedesis of inflammatory cells. Methods: One hundred and nineteen patients with SLE, predominantly non-Caucasian, and 71 healthy controls matched for age, sex and race, underwent carotid ultrasonography and donated blood for evaluation of circulating endothelial cells (CEC), soluble endothelial protein C receptor (sEPCR) and gene polymorphism at A6936G, soluble E-selectin, and adiponectin. Results: Carotid plaque was more prevalent among patients than controls (43% vs 17%, p=0.0002). Mean CCA IMT was greater in patients compared to controls (0.59mm+/-0.19 vs 0.54mm+/-0.11, p=0.03). Levels of CEC (19 vs 3 CECs/mL, p<0.0001) and sE-selectin (64 vs 36 ng/ml, p<0.0001) were significantly elevated in patients compared to controls. Unexpectedly, adiponectin was also significantly higher in patients compared to controls (16 ug/mL versus 11 ug/mL, p=0.0001) but no differences were seen in the levels of sEPCR or the distribution of genotype. Independent predictors of plaque status using logistic regression models included: age (p<0.0001; OR=2.1 per 10 year increase; 95% CI: 1.5-3.0), SLE status (p=0.015; OR=3.4 for SLE vs control; 95% CI: 1.3-9.1), sE-selectin (p=0.016; OR=1.2 per 10 unit increase; 95% CI: 1.0-1.4) and adiponectin (p=0.050; OR=1.5 per 10 unit increase; 95% CI: 1.0-2.4). Comparing SLE patients with and without plaque, there were no differences in cardiac CRP, complement, anti-dsDNA ab, CEC, sEPCR levels and EPCR SNP. However, sE-selectin and adiponectin levels were significantly higher in SLE with plaque compared to those without (sE-selectin 78 vs 52 ng/ml; p=0.006; adiponectin 18 vs 14 ug/ml; p=0.033). The estimated odds ratios for plaque in the final logistic regression model were: OR_selectin= 1.3 per 10 ng/ml increase (95% CI: 1.1-1.5) and OR_adiponectin=1.8 per 10 ug/ml increase (95% CI: 1.1-3.0). SELENA-SLEDAI scores were similar between groups, and the proportion of patients with SLEDAI<= 4 did not segregate with the absence of plaque. Neither past nor current medications significantly associated with plaque. In the stable subjects (SLEDAI <=4), age (p=0.007), sE-selectin (p=0.02) and adiponectin (p=0.02) remained associated with plaque. The prevalence of plaque was greatest in the stable patients with high sE-selectin plus high adiponectin (55%; p =0.0009) confirming the multivariable analyses. Sixty-two patients donated blood at a second visit. High sE-selectin and adiponectin were sustained in plaque patients compared to non-plaque patients (p=0.0009 and p=0.0011 respectively). Conclusion: These results confirm that SLE patients, irrespective of race, are at increased risk for premature atherosclerosis and support the hypothesis that endothelial perturbation is contributory even in the absence of clinically measurable disease activity
— id: 130319, year: 2009, vol: 60, page: 1562, stat: Journal Article,

Predictors of 30-day mortality in patients with refractory cardiogenic shock following acute myocardial infarction despite a patent infarct artery
Katz, Jason N; Stebbins, Amanda L; Alexander, John H; Reynolds, Harmony R; Pieper, Karen S; Ruzyllo, Witold; Werdan, Karl; Geppert, Alexander; Dzavik, Vladimir; Van de Werf, Frans; Hochman, Judith S
2009 Oct;158(4):680-687, American heart journal
BACKGROUND: Little is known about predictors of survival in patients with persistent shock following acute myocardial infarction (MI) despite a patent infarct artery. METHODS: We examined data from TRIUMPH, a multicenter randomized clinical trial of the nitric oxide synthase inhibitor, L-N(G)-monomethyl-arginine, in patients with persistent vasopressor-dependent cardiogenic shock complicating acute MI at least 1 hour after established infarct-related artery patency. Patients who died within 30 days were compared with those who survived. Continuous variables were assessed using the Wilcoxon rank sum and categorical variables using the chi(2) test. Prespecified baseline variables were included in a multivariable logistic regression model to predict mortality. A second model incorporating baseline vasopressors and dosages and a third model including change in systolic blood pressure at 2 hours were also developed. Bootstrapping was used to assess the stability of model variables. RESULTS: Of 396 patients, 180 (45.5%) died within 30 days. Systolic blood pressure (SBP), measured on vasopressor support, and creatinine clearance were significant predictors of mortality in all models. The number of vasopressors and norepinephrine dose were also predictors of mortality in the second model, but the latter was no longer significant when change in SBP at 2 hours was added as a covariate in the third model. CONCLUSIONS: The SBP, creatinine clearance, and number of vasopressors are significant predictors of mortality in patients with persistent vasopressor-dependent cardiogenic shock following acute MI despite a patent infarct artery. These prognostic variables may be useful for risk-stratification and in selecting patients for investigation of additional therapies
— id: 137116, year: 2009, vol: 158, page: 680, stat: Journal Article,

Late coronary intervention for totally occluded left anterior descending coronary arteries in stable patients after myocardial infarction: Results from the Occluded Artery Trial (OAT)
Malek, Lukasz A; Reynolds, Harmony R; Forman, Sandra A; Vozzi, Carlos; Mancini, G B John; French, John K; Dziarmaga, Mieczyslaw; Renkin, Jean P; Kochman, Janusz; Lamas, Gervasio A; Hochman, Judith S
2009 Apr;157(4):724-732, American heart journal
BACKGROUND: We analyzed a prespecified hypothesis of the Occluded Artery Trial (OAT) that late percutaneous coronary intervention (PCI) of the infarct-related artery (IRA) would be most beneficial for patients with anterior myocardial infarction (MI). METHODS: Two thousand two hundred one stable, high-risk patients with total occlusion of the IRA (793 left anterior descending [LAD]) on days 3 to 28 (minimum of 24 hours) after MI were randomized to PCI and stenting with optimal medical therapy (1,101 patients) or to optimal medical therapy alone (1,100 patients). The primary end point was a composite of death, recurrent MI, or hospitalization for class IV heart failure. RESULTS: The 5-year cumulative primary end point rate was more frequent in the LAD group (19.5%) than in the non-LAD group (16.4%) (HR 1.34, 99% CI 1.00-1.81, P = .01). Within the LAD group, the HR for the primary end point in the PCI group (22.7%) compared with the medical therapy group (16.4%) was 1.35 (99% CI 0.86-2.13, P = .09), whereas in the non-LAD group the HR for the primary end point in PCI (16.9%) compared with medical therapy (15.8%) was 1.03 (99% CI 0.70-1.52, P = .83) (interaction P = .24). The results were similar when the effect of PCI was assessed in patients with proximal LAD occlusion. CONCLUSIONS: In stable patients, persistent total occlusion of the LAD post MI is associated with a worse prognosis compared with occlusion of the other IRAs. A strategy of PCI of occluded LAD IRA >24 hours post MI in stable patients is not beneficial and may increase risk of adverse events in comparison to optimal medical treatment alone
— id: 101571, year: 2009, vol: 157, page: 724, stat: Journal Article,

Extent and Severity of Coronary Stenosis at Autopsy Varies by Sex in Fatal Cases of Coronary Heart Disease
Smilowitz, N; Hochman, JS; Sampson, BA; Mangalmurti, S; Siegfried, J; Reynolds, HR
2009 NOV 3 ;120(18):S1049-S1049, Circulation
— id: 106982, year: 2009, vol: 120, page: S1049, stat: Journal Article,

A case of apical ballooning cardiomyopathy associated with duloxetine
Bergman, Benjamin R; Reynolds, Harmony R; Skolnick, Adam H; Castillo, Demetrio
2008 Aug 5;149(3):218-219, Annals of internal medicine
— id: 94438, year: 2008, vol: 149, page: 218, stat: Journal Article,

Sex and race are associated with the finding of non-obstructive coronary artery disease in patients with acute coronary syndromes
Chokshi, NP; Berger, RL; Hochman, JS; Keller, NM; Feit, F; Attubato, MJ; Slater, JN; Pena-Sing, I; Babaev, A; Reynolds, HR
2008 MAR 11 ;51(10):A217-A217, Journal of the American College of Cardiology
— id: 78384, year: 2008, vol: 51, page: A217, stat: Journal Article,

The effect of transvenous pacemaker and implantable cardioverter defibrillator lead placement on tricuspid valve function: an observational study
Kim, Juyong B; Spevack, Daniel M; Tunick, Paul A; Bullinga, John R; Kronzon, Itzhak; Chinitz, Larry A; Reynolds, Harmony R
2008 Mar;21(3):284-287, Journal of the American Society of Echocardiography
This study assessed the effect of transtricuspid placement of permanent pacemaker (PPM) and implantable cardioverter defibrillator (ICD) leads on tricuspid regurgitation (TR) in 248 patients with echocardiograms before and after placement. Some 21.2% of patients with baseline mild TR or less developed abnormal TR (3.4% mild-moderate, 12.8% moderate, 1.1% moderate-severe, 3.9% severe) after implant. TR worsened by 1 grade or more after implant in 24.2% (20.7% of PPMs vs. 32.4% of ICDs; P < .05). TR worsening was more common with ICDs than PPMs in patients with baseline mild TR or less. After lead implantation, abnormal TR developed in 21.2% and severe TR developed in 3.9% of patients with initially normal TR. TR worsened by at least 1 grade in 24.2%. Patients with ICDs had a higher rate of TR worsening compared with patients with PPMs (32.4% vs. 20.1%; P < .05)
— id: 76454, year: 2008, vol: 21, page: 284, stat: Journal Article,

Predictors of Outcome and the Lack of Effect of Percutaneous Coronary Intervention Across the Risk Strata in Patients With Persistent Total Occlusion After Myocardial Infarction. Results From the Occluded Artery Trial (OAT)
Kruk, Mariusz; Kadziela, Jacek; Reynolds, Harmony R; Forman, Sandra A; Sadowski, Zygmunt; Barton, Bruce A; Mark, Daniel B; Maggioni, Aldo P; Leor, Jonathan; Webb, John G; Kapeliovich, Michael; Marin-Neto, Jose A; White, Harvey D; Lamas, Gervasio A; Hochman, Judith S
2008 ;1:511-520, JACC: Cardiovascular Interventions
OBJECTIVES: To determine predictors of outcome and examine the influence of baseline risk on therapeutic impact of late mechanical opening of a persistently occluded infarct related artery (IRA) after myocardial infarction (MI) in stable patients. BACKGROUND: Previous studies in patients with acute coronary syndromes suggest that the impact of IRA recanalization on clinical outcome is greatest in patients at highest risk. METHODS: Of 2201 patients (age 58.6+/-11.0) with IRA occlusion on days 3 to 28 after MI in the Occluded Artery Trial (OAT), 1101 were assigned to PCI and 1100 to medical therapy alone, and followed for a mean of 3.2 years. The primary end point was a composite of death, reinfarction, or NYHA class IV heart failure. Interaction of treatment effect with tertiles of predicted survival were examined using the Cox survival model. RESULTS: The 5-year rate for the primary endpoint was 18.9% versus 16.1% for patients assigned PCI and medical treatment alone (MED) respectively (HR=1.14;95% CI:0.92-1.43, p=0.23). Lack of benefit of PCI was consistent across the risk spectrum for both the primary endpoint and total mortality, including for the highest tertile (33.9% PCI versus 27.3 % MED, HR=1.27;99% CI:0.87-1.85 primary endpoint and 23.5% PCI versus 21.7% MED, HR=1.16,99% CI: 0.73-1.85 mortality). The independent predictors of the composite outcome were: history of heart failure (HR=2.06,p<0.001), peripheral vascular disease (HR=1.93,p=0.001), diabetes (HR=1.49,p=0.002), rales (HR=1.88,p<0.001), decreasing: ejection fraction (HR=1.48 per 10%,p<0.001), days from MI to randomization (HR=1.04 per day,p<0.001), and glomerular filtration rate (HR=1.11 per 10mL/min/1.73m(2),p<0.001). CONCLUSIONS: In OAT, there was no variation in the effect of PCI on clinical outcomes at different levels of patient risk, including the subset with very high event rates
— id: 94437, year: 2008, vol: 1, page: 511, stat: Journal Article,

Cardiogenic shock: current concepts and improving outcomes
Reynolds, Harmony R; Hochman, Judith S
2008 Feb 5;117(5):686-697, Circulation
— id: 76106, year: 2008, vol: 117, page: 686, stat: Journal Article,

Collateral flow to the occluded infarct-related artery is associated with a lower rate of heart failure in the occluded artery trial (OAT)
Steg, PG; Kerner, A; Buller, CE; Forman, SA; White, HD; Carvalho, AC; Reynolds, HR; Fricrich, V; Cohen, EA; Mancini, GBJ; Lamas, GA; Hochman, JS
2008 MAR 11 ;51(10):A215-A215, Journal of the American College of Cardiology
— id: 78383, year: 2008, vol: 51, page: A215, stat: Journal Article,

Effect of tilarginine acetate in patients with acute myocardial infarction and cardiogenic shock: the TRIUMPH randomized controlled trial
Alexander, John H; Reynolds, Harmony R; Stebbins, Amanda L; Dzavik, Vladimir; Harrington, Robert A; Van de Werf, Frans; Hochman, Judith S
2007 Apr 18;297(15):1657-1666, JAMA
CONTEXT: Cardiogenic shock complicating acute myocardial infarction (MI) remains a common and lethal disorder despite aggressive use of early revascularization. Systemic inflammation, including expression of inducible nitric oxide synthase (NOS) and generation of excess nitric oxide, is believed to contribute to the pathogenesis and inappropriate vasodilatation of persistent cardiogenic shock. Preliminary, single-center studies suggested a beneficial effect of NOS inhibition on hemodynamics, renal function, and survival in patients with cardiogenic shock. OBJECTIVE: To examine the effects of an isoform-nonselective NOS inhibitor in patients with MI and refractory cardiogenic shock despite establishment of an open infarct artery. DESIGN, SETTING, AND PATIENTS: International, multicenter, randomized, double-blind, placebo-controlled trial (Tilarginine Acetate Injection in a Randomized International Study in Unstable MI Patients With Cardiogenic Shock [TRIUMPH]) with planned enrollment of 658 patients at 130 centers. Participants were enrolled between January 2005 and August 2006 when the study was terminated early. INTERVENTION: Tilarginine (L-N(G)-monomethylarginine [L-NMMA]), 1-mg/kg bolus and 1-mg/kg per hour 5-hour infusion, vs matching placebo. MAIN OUTCOME MEASURES: The primary outcome was 30-day all-cause mortality among patients who received study medication. Secondary outcomes included shock resolution and duration, New York Heart Association (NYHA) functional class at 30 days, and 6-month mortality. RESULTS: Enrollment was terminated at 398 patients based on a prespecified futility analysis. Six-month follow-up was completed in February 2007. There was no difference in 30-day all-cause mortality between patients who received tilarginine (97/201 [48%]) vs placebo (76/180 [42%]) (risk ratio, 1.14; 95% confidence interval, 0.92-1.41; P = .24). Resolution of shock (133/201 [66%] tilarginine vs 110/180 [61%] placebo; P = .31) and duration of shock (median, 156 [interquartile range, 78-759] hours tilarginine vs 190 [100-759] placebo; P = .16) were similar. At 30 days a similar percentage of patients had heart failure (48% tilarginine vs 51% placebo; P = .51) with a similar percentage of those patients in NYHA class I/II (73% tilarginine vs 75% placebo; P = .27). After 6 months mortality rates were similar in the 2 groups (58% tilarginine vs 59% placebo; hazard ratio, 1.04; 95% confidence interval, 0.79-1.36; P = .80). CONCLUSIONS: Tilarginine, 1-mg/kg bolus and 5-hour infusion, did not reduce mortality rates in patients with refractory cardiogenic shock complicating MI despite an open infarct artery. Early mortality rates in this patient group are high. Further research is needed to develop effective therapies for patients with cardiogenic shock following acute MI. TRIAL REGISTRATION: clinicaltrials.gov Identifier: NCT00112281
— id: 71980, year: 2007, vol: 297, page: 1657, stat: Journal Article,

Effect of nitric oxide synthase inhibition on haemodynamics and outcome of patients with persistent cardiogenic shock complicating acute myocardial infarction: a phase II dose-ranging study
Dzavik, Vladimir; Cotter, Gad; Reynolds, Harmony R; Alexander, John H; Ramanathan, Krishnan; Stebbins, Amanda L; Hathaway, David; Farkouh, Michael E; Ohman, E Magnus; Baran, David A; Prondzinsky, Roland; Panza, Julio A; Cantor, Warren J; Vered, Zvi; Buller, Christopher E; Kleiman, Neal S; Webb, John G; Holmes, David R; Parrillo, Joseph E; Hazen, Stanley L; Gross, Steven S; Harrington, Robert A; Hochman, Judith S
2007 May;28(9):1109-1116, European heart journal
Aims Previous studies suggested haemodynamic benefits and, possibly, mortality reduction with the use of nitric oxide synthase (NOS) inhibition in patients with acute myocardial infarction (AMI) complicated by cardiogenic shock (CS). We assessed preliminary efficacy and safety of four doses of l-n-monomethyl-arginine (l-NMMA), a non-selective NOS inhibitor, in patients with AMI complicated by CS despite an open infarct-related artery. Methods and results Patients (n = 79) were randomly assigned to a bolus and 5 h infusion of placebo or 0.15, 0.5, 1.0, or 1.5 mg/kg of l-NMMA. The primary outcome measure was absolute change in mean arterial pressure (MAP) at 2 h. Fifteen minutes after study drug initiation, mean change in MAP was -4.0 mmHg in the placebo group and 5.8 (P = 0.02), 4.8 (P = 0.02), 5.1 (P = 0.07), and 11.6 (P < 0.001) mmHg in the four l-NMMA groups, respectively (all vs. placebo). Mean change in MAP at 2 h was -0.4, 4.4, 1.8, -4.1, and 6.8 mmHg in the placebo and four l-NMMA groups, respectively (all P = NS). Conclusion l-NMMA resulted in modest increases in MAP at 15 min compared with placebo but there were no differences at 2 h
— id: 71977, year: 2007, vol: 28, page: 1109, stat: Journal Article,

Persistent coronary occlusion after myocardial infarction
Hochman, JS; Forman, S; Reynolds, HR
2007 APR 19 ;356(16):1683-1684, New England journal of medicine
— id: 71613, year: 2007, vol: 356, page: 1683, stat: Journal Article,

Predictors of outcome and the lack of effect of PCI across the risk strata in patients with persistent total occlusion after myocardial infarction: Results from the occluded artery trial (OAT)
Kruk, M; Kadziela, J; Sadowski, ZP; Barton, BA; Mark, DB; Forman, SA; Reynolds, HR; Maggioni, AP; Leor, J; Webb, JG; Kapeliovich, M; Marin-Neto, JA; Preto, R; White, HD; Lamas, GA; Hochman, JS
2007 OCT 16 ;116(16):625-625, Circulation
— id: 75977, year: 2007, vol: 116, page: 625, stat: Journal Article,

Impact of female sex on death and bleeding after fibrinolytic treatment of myocardial infarction in GUSTO V
Reynolds, Harmony R; Farkouh, Michael E; Lincoff, A Michael; Hsu, Amy; Swahn, Eva; Sadowski, Zygmunt P; White, Jennifer A; Topol, Eric J; Hochman, Judith S
2007 Oct 22;167(19):2054-2060, Archives of internal medicine
BACKGROUND: Women with acute myocardial infarction are more likely than men to experience reinfarction, bleeding, or death. This difference has been hypothesized to be due to older age, treatment delay, and comorbidities in women. Use of diagnostic and therapeutic modalities may also differ. There is controversy regarding whether female sex is an independent risk factor for death and/or bleeding. METHODS: The GUSTO (Global Use of Strategies to Open Occluded Arteries in Acute Coronary Syndromes) V Investigators studied standard-dose reteplase vs standard-dose abciximab plus half-dose reteplase in patients with myocardial infarction. RESULTS: Women were older and more often had diabetes mellitus and hypertension. Angiography and percutaneous coronary intervention were less frequent in women. Death (9.8% vs 4.4% at 30 days; odds ratio [OR], 2.00; 95% confidence interval, 1.59-2.53; P < .001) and bleeding (6.4% vs 2.5%; OR, 1.31; 95% confidence interval, 1.18-1.45; P < .01) were more common in women. There was no association between treatment assignment and death in either sex; bleeding was more common in both sexes receiving combination therapy. Female sex was independently associated with mortality. After Killip class greater than 1 (OR, 4.7), female sex (OR, 2.0) was the strongest correlate of death. Female sex was independently associated with bleeding for both treatments. CONCLUSIONS: Female sex is independently associated with death and bleeding complications among fibrinolytic-treated patients with myocardial infarction. There remains a sex differential in the use of angiography and, therefore, percutaneous coronary intervention after fibrinolysis. Further research will determine what mediates excess risk in women
— id: 75395, year: 2007, vol: 167, page: 2054, stat: Journal Article,

Paradoxical septal motion after cardiac surgery: a review of 3,292 cases
Reynolds, Harmony R; Tunick, Paul A; Grossi, Eugene A; Dilmanian, Hajir; Colvin, Stephen B; Kronzon, Itzhak
2007 Dec;30(12):621-623, Clinical cardiology
BACKGROUND: Paradoxical septal motion (PSM) is the systolic movement of the interventricular septum toward the right ventricle despite normal thickening. The PSM is a frequent echocardiographic finding after cardiac surgery. Although it is universally recognized, there has been no large-scale study to correlate PSM with the type of surgical procedure. The cause of PSM is unknown; prevailing theories include: (1) operation on the heart alters the degree to which it is restrained by the pericardium and the chest wall and (2) transient ischemia alters septal motion. HYPOTHESIS: The PSM is related to type of surgery and surgical approach. METHODS: Between 1996 and 2002, 3,292 patients underwent a first cardiac operation and had a postoperative echocardiogram; 313 were excluded due to other explanations for PSM (severe tricuspid regurgitation [TR] cardiac pacing), leaving a study group of 2,979 patients. Univariate and multivariate analyses were performed to determine which surgical characteristics were correlated with postoperative PSM. Septal thickening was assessed in a subset. RESULTS: On multivariate analysis, aortic (p = 0.02) and mitral valve surgery (p < 0.001) and longer cardiopulmonary bypass time (p < 0.001) were independently associated with PSM. Coronary artery bypass grafting (CABG) was less likely to cause PSM than non-CABG surgery (p = 0.003) and off-pump coronary artery bypass (OPCAB) caused less PSM than did on-pump CABG. CONCLUSIONS: 1. Valve surgery is more likely to cause PSM than CABG. 2. Among patients with CABG, OPCAB causes less PSM. 3. Cardiopulmonary bypass time is associated with the development of PSM. 4. The cause of PSM is likely to be multifactorial
— id: 75772, year: 2007, vol: 30, page: 621, stat: Journal Article,

Predictors of reinfarction following PCI or medical management in patients with persistent total occlusion after myocardial infarction: Results from the occluded artery trial (OAT)
White, HD; Steg, PG; Dzavik, V; Menon, V; Reynolds, HR; Carvalho, AC; Barton, BA; Cantor, WJ; Kruk, M; Martin, CE; Pearle, CA; Knatterud, GL; Lamas, GA; Hochman, JS
2007 OCT 16 ;116(16):625-625, Circulation
— id: 75978, year: 2007, vol: 116, page: 625, stat: Journal Article,

Sex-related differences in non-obstructive coronary artery disease among patients with non-ST-segment elevation acute coronary syndromes: Results from the CRUSADE quality improvement initiative
Gehrie, ER; Reynolds, HR; Neelon, BH; Roe, MT; Gibler, WB; Ohman, EM; Newby, LK; Peterson, ED; Hochman, JS
2006 FEB 21 ;47(4):172A-172A, Journal of the American College of Cardiology
— id: 63304, year: 2006, vol: 47, page: 172A, stat: Journal Article,

Coronary intervention for persistent occlusion after myocardial infarction
Hochman, Judith S; Lamas, Gervasio A; Buller, Christopher E; Dzavik, Vladimir; Reynolds, Harmony R; Abramsky, Staci J; Forman, Sandra; Ruzyllo, Witold; Maggioni, Aldo P; White, Harvey; Sadowski, Zygmunt; Carvalho, Antonio C; Rankin, Jamie M; Renkin, Jean P; Steg, P Gabriel; Mascette, Alice M; Sopko, George; Pfisterer, Matthias E; Leor, Jonathan; Fridrich, Viliam; Mark, Daniel B; Knatterud, Genell L
2006 Dec 7;355(23):2395-2407, New England journal of medicine
BACKGROUND: It is unclear whether stable, high-risk patients with persistent total occlusion of the infarct-related coronary artery identified after the currently accepted period for myocardial salvage has passed should undergo percutaneous coronary intervention (PCI) in addition to receiving optimal medical therapy to reduce the risk of subsequent events. METHODS: We conducted a randomized study involving 2166 stable patients who had total occlusion of the infarct-related artery 3 to 28 days after myocardial infarction and who met a high-risk criterion (an ejection fraction of <50% or proximal occlusion). Of these patients, 1082 were assigned to routine PCI and stenting with optimal medical therapy, and 1084 were assigned to optimal medical therapy alone. The primary end point was a composite of death, myocardial reinfarction, or New York Heart Association (NYHA) class IV heart failure. RESULTS: The 4-year cumulative primary event rate was 17.2% in the PCI group and 15.6% in the medical therapy group (hazard ratio for death, reinfarction, or heart failure in the PCI group as compared with the medical therapy group, 1.16; 95% confidence interval [CI], 0.92 to 1.45; P=0.20). Rates of myocardial reinfarction (fatal and nonfatal) were 7.0% and 5.3% in the two groups, respectively (hazard ratio, 1.36; 95% CI, 0.92 to 2.00; P=0.13). Rates of nonfatal reinfarction were 6.9% and 5.0%, respectively (hazard ratio, 1.44; 95% CI, 0.96 to 2.16; P=0.08); only six reinfarctions (0.6%) were related to assigned PCI procedures. Rates of NYHA class IV heart failure (4.4% vs. 4.5%) and death (9.1% vs. 9.4%) were similar. There was no interaction between treatment effect and any subgroup variable (age, sex, race or ethnic group, infarct-related artery, ejection fraction, diabetes, Killip class, and the time from myocardial infarction to randomization). CONCLUSIONS: PCI did not reduce the occurrence of death, reinfarction, or heart failure, and there was a trend toward excess reinfarction during 4 years of follow-up in stable patients with occlusion of the infarct-related artery 3 to 28 days after myocardial infarction. (ClinicalTrials.gov number, NCT00004562 [ClinicalTrials.gov].)
— id: 69605, year: 2006, vol: 355, page: 2395, stat: Journal Article,

Chronic kidney disease, ejection fraction and heart failure in patients with occluded infarct-related arteries post-myocardial infarction: Data from the occluded artery trial
Jorapur, V; Sadowski, Z; Reynolds, HR; Carvalho, AC; Buller, CE; Rankin, J; Renkin, J; Steg, PG; White, H; Vozzi, C; Balcells, E; Ragosta, M; Martin, CE; Tamis-Holland, JE; Srinivas, V; Wharton, W; Abramsky, S; Mon, AC; Barton, B; Lamas, GA; Hochman, JS
2006 OCT 31 ;114(18):404-404, Circulation
— id: 69553, year: 2006, vol: 114, page: 404, stat: Journal Article,

Restrictive physiology in cardiogenic shock: observations from echocardiography
Reynolds, Harmony R; Anand, Sumeet K; Fox, Justin M; Harkness, Shannon; Dzavik, Vladimir; White, Harvey D; Webb, John G; Gin, Kenneth; Hochman, Judith S; Picard, Michael H
2006 Apr;151(4):890.e9-890.15, American heart journal
BACKGROUND: Left ventricular diastolic abnormalities are associated with adverse outcome in myocardial infarction. Intra-aortic balloon pump (IABP) support is associated with improved diastolic filling. In the SHOCK trial and registry, average left ventricular ejection fraction (LVEF) was approximately 30%, higher than expected based on the classic paradigm. We hypothesized that restrictive physiology plays a role in cardiogenic shock (CS). METHODS: Echocardiograms obtained during the SHOCK trial within 24 hours of randomization were centrally interpreted. Patients with quantifiable mitral E-wave deceleration time were included (n = 64). The restrictive filling pattern was defined as deceleration time < 140 milliseconds. RESULTS: The restrictive pattern was seen in 60.9% of patients studied. Patients with this pattern had lower LVEF (31.1% vs 39.0%, P = .02) and higher wall motion score index (2.1 vs 1.8, P = .05). Patients with restriction were more likely to have IABP support during echocardiography (73.7% vs 43.5%, P = .03). There was no difference with and without restriction in demographic and hemodynamic variables or in mitral regurgitation degree or extent of coronary disease. The restrictive pattern had positive predictive value of 80% for pulmonary capillary wedge pressure > or = 20 mm Hg. Thirty-day survival was 53.9% with restriction versus 68.0% without restriction, P = .31. There was no difference in New York Heart Association class at 1 year between groups. CONCLUSIONS: The restrictive filling pattern is common in patients with CS, which may suggest that diastolic dysfunction contributes to CS pathogenesis. Patients with the restrictive pattern had lower LVEF despite IABP support. An association between the restrictive pattern and mortality was not demonstrated; power was limited by sample size
— id: 63840, year: 2006, vol: 151, page: 890.e9, stat: Journal Article,

Serial echocardiograms in patients with cardiogenic shock: Analysis of the SHOCK trial
Yehudai, L; Reynolds, HR; Schwarz, SA; Harkness, SM; Picard, MH; Davidoff, R; Hochman, JS
2006 FEB 21 ;47(4):111A-111A, Journal of the American College of Cardiology
— id: 63301, year: 2006, vol: 47, page: 111A, stat: Journal Article,

Circulating endothelial cells and soluble endothelial protein C receptor predict the presence of carotid plaque in minority SLE patients
Gehrie, ER; Reynolds, HR; Buyon, JP; Clancy, R
2005 SEP ;52(9):S606-S606, Arthritis & rheumatism
— id: 59293, year: 2005, vol: 52, page: S606, stat: Journal Article,

Design and methodology of the Occluded Artery Trial (OAT)
Hochman, Judith S; Lamas, Gervasio A; Knatterud, Genell L; Buller, Christopher E; Dzavik, Vladimir; Mark, Daniel B; Reynolds, Harmony R; White, Harvey D
2005 Oct;150(4):627-642, American heart journal
Experimental and clinical studies have suggested that late opening of an infarct-related artery (IRA) after myocardial infarction (MI) could improve clinical outcome. However, the suggestive observational data are limited by selection biases. Indeed, most small randomized studies have not demonstrated benefit. Thus, there is no recommendation for routine late opening of the IRA in current national guidelines for management of stable post-MI patients. The OAT is designed to test the hypothesis that opening a totally occluded IRA 3 to 28 days after MI in high-risk asymptomatic patients will improve clinical outcome and be cost-effective. The primary end point is the first occurrence of recurrent MI, hospitalization/treatment of New York Heart Association class IV congestive heart failure, or death. Trial background, design, and preliminary baseline characteristics of 2027 randomized patients are presented. Eligible patients are randomly assigned in equal proportions to optimal evidence-based medical care or optimal care plus late opening of the IRA using percutaneous coronary intervention of the occluded IRA. Treatment groups will be compared using intent-to-treat analysis. The results of OAT should have broad clinical impact by defining an evidence-based approach to the asymptomatic, high-risk, post-MI patient with an occluded IRA. If the efficacy and cost-effectiveness of percutaneous coronary intervention are established, then a policy of routinely seeking and opening persistently occluded IRAs could be advocated. If not, this strategy should be avoided in this large subgroup of post-MI patients
— id: 66474, year: 2005, vol: 150, page: 627, stat: Journal Article,

Sex differences in presentation with persistent total occlusion after acute
Ramanathan, K; Atchison, D; Abramsky, S; Mon, A; Tunesi, AM; Forman, SA; Hochman, JS; Reynolds, H
2005 SEP ;26(3):245-246, European heart journal
— id: 69535, year: 2005, vol: 26, page: 245, stat: Journal Article,

Usefulness of myocardial perfusion echocardiography to identify obstructive coronary artery disease in patients with abnormal ventricular septal motion
Spevack, Daniel M; Shoyeb, Abu; Yoon, Andrew J; Gordon, Garet M; Matros, Todd; Reynolds, Harmony A; Shah, Alan; Tunick, Paul A; Kronzon, Itzhak
2005 Apr 1;95(7):852-855, American journal of cardiology
Twenty-three patients who had septal wall motion abnormalities and who underwent angiography within 2 weeks were evaluated by myocardial perfusion echocardiography. Mean perfusion score (plateau video intensity times the wash-in rate) was lower in segments that were supplied by obstructed coronary arteries in real time (7.5 vs 22.6 dB/s, p <0.005) and with end-systolic triggering (8.6 vs 20.9 dB/s, p <0.001). Lower mean septal perfusion scores (<12 dB/s) were seen in 14 of 16 patients who had obstructive septal coronary artery disease, and normal mean septal perfusion scores were seen in 6 of 7 patients who did not have obstructive septal coronary artery disease
— id: 58970, year: 2005, vol: 95, page: 852, stat: Journal Article,

Left ventricular thrombus formation in patients with acute myocardial infarction complicated by cardiogenic shock: Incidence, predictors, and 1-year outcome
Ramanathan, K; Anand, SK; Jeger, RV; Harkness, SM; Reynolds, HR; Thompson, C; Farkouh, ME; Sleeper, LA; Davidoff, R
2004 OCT 26 ;110(17):713-713, Circulation
— id: 55948, year: 2004, vol: 110, page: 713, stat: Journal Article,

Comparison of image quality between a narrow caliber transesophageal echocardiographic probe and the standard size probe during intraoperative evaluation
Reynolds, Harmony R; Spevack, Daniel M; Shah, Alan; Applebaum, Robert M; Kanchuger, Mark; Tunick, Paul A; Kronzon, Itzhak
2004 Oct;17(10):1050-1052, Journal of the American Society of Echocardiography
BACKGROUND: Transesophageal echocardiography (TEE) has become an integral part of the evaluation and monitoring of patients during cardiac operation. Until recently, the smallest TEE probe with multiplane imaging measured 13 mm in diameter. This size is now standard for adult TEE probes. Recently, a new TEE probe has become available (MiniMulti TEE probe, Philips Medical Systems, Andover, Mass), which has a diameter of 8 mm. Although using a smaller probe is attractive, the quality of images it generates when used in adults has not yet been examined. OBJECTIVE: The purpose of this study was to compare TEE studies done with both probes. METHODS: After informed consent was obtained, full intraoperative TEE studies were performed in 20 patients with a small pediatric probe. The study was then repeated using a standard adult probe. The studies were read in random order by two experienced echocardiographers blinded to probe used. For each study, 18 anatomic cardiac structures and 5 Doppler patterns were subjectively graded as excellent (1), good (2), fair (3), or poor (4) in quality. The average score for each structure or Doppler profile was computed for each probe. RESULTS: The average score for all findings was lower (better) for the adult TEE probe (1.4 +/- 0.4 vs 1.7 +/- 0.4; P =.003). When each finding was compared separately, several cardiac structures (left ventricle [LV], pericardium, right ventricle [RV], interatrial septum, left atrium, left atrial appendage, mitral valve, aortic valve) had better scores with the adult probe, and the differences for the LV and RV were larger than those for the other findings (LV scores differed by 0.7, P =.0004; RV scores differed by 0.5, P =.01). There was no significant difference between probes when evaluating venous structures (coronary sinus, superior vena cava, pulmonary vein), the thoracic aorta, or the right atrium or tricuspid valve. In addition, Doppler patterns were not significantly different with the two probes. There were two findings that were missed with the small probe and seen with the adult probe (one aortic plaque and one left atrial appendage thrombus). CONCLUSIONS: In the adult, the larger probe provides better images, particularly of the RV and LV. In addition, important findings may be missed with the smaller probe. However, if the adult probe cannot be passed, the pediatric probe is a reasonable alternative
— id: 45390, year: 2004, vol: 17, page: 1050, stat: Journal Article,

Frequency of severe renal artery stenosis in patients with severe thoracic aortic plaque
Reynolds, Harmony R; Tunick, Paul A; Benenstein, Ricardo J; Nakra, Navin C; Shah, Alan; Spevack, Daniel M; Kronzon, Itzhak
2004 Sep 15;94(6):844-846, American journal of cardiology
Atherosclerotic renal artery stenosis (RAS) is an underdiagnosed disorder and a treatable etiology of hypertension and renal insufficiency. All patients were referred for a transesophageal echocardiogram for various indications. Abdominal ultrasound was performed in 69 patients, 43 with severe thoracic aortic plaque (> or =4 mm) and 26 controls with no or mild plaque (< or =2 mm). Severe RAS (> or =60%) was defined as flow velocity > or =1.8 m/s and a renal:aortic ratio of > or =3.5. There were 8 cases of RAS (all severe) in the 43 patients with severe aortic plaque (19% vs 0% of controls; p = 0.02). Severe plaque (p = 0.02) and hypertension (p = 0.03) were correlated with RAS. On multivariate analysis, severe plaque (p = 0.017) and hypertension (p = 0.002) remained independently correlated with RAS. In a paired analysis, matched for age and gender (McNemar), severe plaque was significantly associated with RAS (p = 0.008). Severe thoracic aortic plaque is strongly associated with RAS, which is found in 19% of patients with severe plaque. Patients found to have severe aortic plaque on transesophageal echocardiography should be screened for RAS
— id: 45391, year: 2004, vol: 94, page: 844, stat: Journal Article,

Severe renal artery stenosis is common in patients with severe thoracic aortic plaque
Reynolds, HR; Benenstein, RJ; Nakra, NC; Shah, A; Spevack, DM; Kronzon, I; Tunick, PA
2004 MAR 3 ;43(5):461A-461A, Journal of the American College of Cardiology
— id: 42454, year: 2004, vol: 43, page: 461A, stat: Journal Article,

Female sex: A more important prognostic marker than treatment assignment or comorbid conditions among patients with acute myocardial infarction in the GUSTO V Trial
Reynolds, HR; Farkouh, ME; Swahn, E; White, JA; Sadowski, ZP; Lincoff, AM; Topol, EJ; Hochman, JS
2004 MAR 3 ;43(5):261A-261A, Journal of the American College of Cardiology
— id: 42450, year: 2004, vol: 43, page: 261A, stat: Journal Article,

LV geometry and mitral regurgitation in patients with persistent total occlusion of the infarct artery in OAT
Reynolds, HR; Ramanathan, K; Lamas, GA; Forman, S; Anagnostopoulos, CE; Rankin, JM; Carere, RG; Hochman, JS; Buller, CE
2004 OCT 26 ;110(17):659-659, Circulation
— id: 55947, year: 2004, vol: 110, page: 659, stat: Journal Article,

Comparison of a small (pediatric) transesophageal echocardiography probe with a standard (adult) probe
Reynolds, HR; Spevack, DM; Shah, A; Applebaum, RM; Kanchuger, M; Tunick, PA; Kronzon, I
2004 MAR 3 ;43(5):350A-350A, Journal of the American College of Cardiology
— id: 42452, year: 2004, vol: 43, page: 350A, stat: Journal Article,

Sensitivity of transthoracic versus transesophageal echocardiography for the detection of native valve vegetations in the modern era
Reynolds, Harmony R; Jagen, Michael A; Tunick, Paul A; Kronzon, Itzhak
2003 Jan;16(1):67-70, Journal of the American Society of Echocardiography
BACKGROUND: Thirteen years ago, transthoracic echocardiography (TTE) was found to be less sensitive than transesophageal echocardiography (TEE) for native valve vegetations. Since then, harmonic imaging and other advances have improved TTE. How this affects the sensitivity of TTE is unknown. METHODS: Fifty patients with echocardiography-diagnosed endocarditis had TTE and TEE examinations on high-end machines. These were matched for date of study with 50 patients who had TTE and TEE examinations that were negative for vegetations. RESULTS: A total of 51 vegetations were seen on TEE. The sensitivity of TTE for vegetations was only 55% (aortic 50% [12/24]; mitral 62% [16/26]; tricuspid 0% [0/1]). Anatomic valvular abnormalities did not alter the sensitivity of TTE (P =.42 for mitral; P =.97 for aortic valves). However, larger vegetations were more likely to be found by TTE. CONCLUSION: Despite advances in imaging during 12 years, TTE is still insensitive compared with TEE for the detection of native valve vegetations, and fails to demonstrate nearly half of them
— id: 39334, year: 2003, vol: 16, page: 67, stat: Journal Article,

Substernal epicardial echocardiography: review of a new technique
Reynolds, Harmony R; Nayar, Ambika C; McAleer, Eileen P; Schwartz, Jesse D; Tunick, Paul A; Applebaum, Robert M; Colvin, Stephen B; Culliford, Alfred T; Galloway, Aubrey C; Grossi, Eugene A; Ribakove, Gregory H; Kronzon, Itzhak
2003 Nov;16(11):1204-1210, Journal of the American Society of Echocardiography
BACKGROUND: Patients after cardiac operation pose a challenge to the treating physician-these patients may become critically ill and are among the most difficult to image using transthoracic echocardiography. Several factors contribute to this, including difficulties in positioning the patient, inability of the patient to cooperate with instructions, surgical dressings, and hyperinflated lungs. Transesophageal echocardiography may be performed when transthoracic echocardiography is not diagnostic; however, transesophageal echocardiography is semi-invasive and does not lend itself to prolonged or repeated monitoring. METHODS: Recently, a new approach to echocardiography for use in the patient after operation has been introduced with the modification of the standard mediastinal drainage tube to allow for substernal epicardial echocardiography (SEE). The SEE tube has 2 lumens. The first allows for routine mediastinal drainage and the second has a blind end that permits the insertion of a standard transesophageal echocardiographic probe for high-resolution imaging as often as is desired over the period during which the mediastinal tube is in place. CONCLUSION: This article reviews the technique of SEE including a description of the method of performance of SEE (with representative images), a review of the published literature on this new modality, examples of clinical use, and a discussion of the advantages, indications, and limitations of SEE with an eye toward future directions for research
— id: 42051, year: 2003, vol: 16, page: 1204, stat: Journal Article,

Role of transesophageal echocardiography in the evaluation of patients with stroke
Reynolds, Harmony R; Tunick, Paul A; Kronzon, Itzhak
2003 Sep;18(5):340-345, Current opinion in cardiology
This review article summarizes recent advances in the care of patients presenting with neurologic events, in which transesophageal echocardiography plays an important role in diagnosis, prognosis, and treatment. New research on the use of transesophageal echocardiography in patients with stroke and atrial fibrillation is discussed, including left atrial clot formation, maintenance of sinus rhythm after cardioversion, and techniques of left atrial appendage occlusion. A discussion of developments in the diagnosis and management of thoracic aortic plaque follows. The association of patent foramen ovale and atrial septal aneurysm with stroke is outlined, and possible reasons for this association are discussed. Recent literature on the use of percutaneous closure devices for patent foramen ovale is reviewed
— id: 39086, year: 2003, vol: 18, page: 340, stat: Journal Article,

Substernal epicardial echocardiography may be a critical diagnostic tool in the postoperative cardiac surgery patient
Reynolds, HR; Applebaum, RM; Spevack, DM; Shah, A; Mcaleer, EP; Nayar, AC; Tunick, PA; Lapietra, A; Patel, S; Bizekis, CS; Wood, MG; Grossi, EA; Ribakove, GH; Colvin, SB; Kronzon, I
2003 MAR 19 ;41(6):449A-449A, Journal of the American College of Cardiology
— id: 37102, year: 2003, vol: 41, page: 449A, stat: Journal Article,

Paradoxically normal septal motion in Ebstein's anomaly
Reynolds, Harmony R; Tunick, Paul A; Freedberg, Robin S; Rutkowski, Monika; Kaplan, Kenneth C; Kronzon, Itzhak
2002 Aug;15(8):841-842, Journal of the American Society of Echocardiography
Paradoxical septal motion has been reported as characteristic of Ebstein's anomaly. The patient reported here has the characteristic apical displacement of the tricuspid value, but septal motion is uncharacteristically normal. Because there is only mild tricuspid regurgitation, it is likely that the absence of right ventricular volume overload accounts for the normal septal motion in this patient
— id: 32260, year: 2002, vol: 15, page: 841, stat: Journal Article,

Abdominal aortic aneurysms and thoracic aortic atheromas
Reynolds HR; Tunick PA; Kort S; Rosenzweig BP; Freedberg RS; Katz ES; Applebaum RM; Portnay EL; Adelman MA; Attubato MJ; Kronzon I
2001 Nov;14(11):1127-1131, Journal of the American Society of Echocardiography
BACKGROUND: Abdominal aortic aneurysm (AAA) is associated with atherosclerosis elsewhere. Thoracic aortic atheromas (ATHs) seen on transesophageal echocardiography (TEE) are an important cause of stroke and peripheral embolization. The purposes of this study were to determine whether an association exists between AAA and ATHs and to assess the importance of screening patients with ATHs for AAA. METHODS: For the retrospective analysis, 109 patients with AAA and 109 matched controls were compared for the prevalence of ATHs on TEE and for historical variables. For the prospective analysis, screening for AAA on ultrasonography was performed in 364 patients at the time of TEE. RESULTS: Results of the retrospective analysis showed that ATHs were present in 52% of patients with AAA and in 25% of controls (odds ratio [OR] = 3.3; P =.00003). There was a significantly higher prevalence of hypertension, myocardial infarction, heart failure, smoking, and carotid or peripheral arterial disease in patients with AAA. However, only ATHs were independently associated with AAA on multivariate analysis (P =.001). Results of the prospective analysis showed that screening at the time of TEE in 364 patients revealed AAA in 13.9% of those with ATHs and in 1.4% of those without ATHs (P <.0001; OR = 11.4). CONCLUSIONS: (1) There is a strong, highly significant association between abdominal aneurysm and thoracic atheromas. (2) Patients with AAA may be at high risk for stroke because of the concomitance of thoracic aortic atheromas. (3) The high prevalence of abdominal aneurysm in patients with thoracic atheromas suggests that screening for abdominal aneurysm should be carried out in all patients with thoracic atheromas identified by TEE
— id: 26574, year: 2001, vol: 14, page: 1127, stat: Journal Article,

Abdominal aortic aneurysms are strongly associated with thoracic aortic atheromas seen on TEE
Reynolds, HR; Tunick, PA; Adelman, MA; Attubato, MJ; Kronzon, I
1999 NOV 2 ;100(18):168-169, Circulation
— id: 53788, year: 1999, vol: 100, page: 168, stat: Journal Article,