Harlan Krumholz

Paradoxical low-flow, low-gradient severe aortic stenosis (PLFLG AS) is frequently underrecognized and undertreated. 1–4 Though PLFLG AS can be identified on transthoracic echocardiogram (TTE), 5 it is unknown how reader characteristics may impact TTE reporting. We hypothesized that reader volume, years of experience and quaternary-care-based site of interpretation would be positively associated with reporting severe AS on TTEs meeting criteria for PLFLG AS.We retrospectively reviewed data from all TTE reports for adults with aortic stenosis between 9/14/2015 and 3/31/22 within Yale New Haven Health (YNHH) system, which includes a quaternary referral center and 27 inpatient and outpatient echocardiography sites. All TTEs in this study met the following criteria for PLFLG AS: peak aortic jet velocity< 4.0 m/s, mean aortic valve gradient< 40 mmHg, aortic valve area [AVA]< 1.0 cm2, indexed AVA< 0.6 …

BackgroundWe previously showed sex differences in risk factors and co-morbidities of older adults (≥ 65 years) with pulmonary embolism (PE). Some investigators hypothesize that female patients may receive a shorter duration of anticoagulation or less frequently receive fibrinolysis for PE.MethodsUsing data from RIETE-a global PE registry with greatest participation from Europe-and US Medicare beneficiaries, we assessed sex difference in anticoagulation, and PE advanced therapies in older adults. A standardized difference (STD)> 0.1 indicated a clinically-relevant sex difference.ResultsRIETE included 33,462 (57.7% female) and Medicare included 102,391 (55.0% female) older adults with PE. In RIETE, there were no sex differences in use of anticoagulation, thrombectomy, or IVC filters. However, fibrinolysis (systemic and catheter-based) was less often used in women with intermediate-risk PE (STD: 0.14 …

The practice of medicine initially leaned heavily on an understanding, albeit incomplete, of physiology, with a predominant focus on the mechanism of disease. Clinicians were taught to reason from basic principles. The tradition of moving from the laboratory to the bedside assumed that results of care would naturally follow

BackgroundWhile factors associated with long COVID (LC) continue to be illuminated, little is known about recovery. This study used national survey data to assess differences between adults in the United States with LC and those who recovered.MethodsWe used COVID-19 and LC data from the 2022 National Health Interview Survey, a cross-sectional sample of non-institutionalized US adults. Survey analysis was used to account for oversampling and nonresponse bias and to obtain nationally representative estimates. A multivariable logistic regression model was used to identify potential predictors of LC recovery.ResultsAmong the study sample, 17.7% or an estimated 17.5 American adults reported ever having LC, and among those with LC, 48.5% or an estimated 8.5 million reported having recovered. Multivariable logistic regression analysis showed that Hispanic adults were significantly more likely than …

Fibrinolytic agents catalyze the conversion of the inactive proenzyme plasminogen into the active protease plasmin, degrading fibrin within the thrombus and recanalizing occluded vessels. The history of these medications dates to the discovery of the first fibrinolytic compound, streptokinase, from bacterial cultures in 1933. Over time, researchers identified two other plasminogen activators in human samples, namely urokinase and tissue plasminogen activator (tPA). Subsequently, tPA was cloned using recombinant DNA methods to produce alteplase. Several additional derivatives of tPA, such as tenecteplase and reteplase, were developed to extend the plasma half-life of tPA. Over the past decades, fibrinolytic medications have been widely used to manage patients with venous and arterial thromboembolic events. Currently, alteplase is approved by the U.S. Food and Drug Administration (FDA) for use in patients …

The inferior vena cava (IVC) and superior vena cava are the main conduits of the systemic venous circulation into the right atrium. Developmental or procedural interruptions of vena cava might predispose to stasis and deep vein thrombosis (DVT) distal to the anomaly and may impact the subsequent rate of pulmonary embolism (PE). This study aimed to review the various etiologies of developmental or procedural vena cava interruption and their impact on venous thromboembolism. A systematic search was performed in PubMed according to Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines per each clinical question. For management questions with no high-quality evidence and no mutual agreements between authors, Delphi methods were used. IVC agenesis is the most common form of congenital vena cava interruption, is associated with an increased risk of DVT, and …

Background Incarceration is a social determinant of cardiovascular health but is rarely addressed in clinical settings or public health prevention efforts. People who have been incarcerated are more likely to develop cardiovascular disease (CVD) at younger ages and have worse cardiovascular outcomes compared with the general population, even after controlling for traditional risk factors. This study aims to identify incarceration-specific factors that are associated with uncontrolled CVD risk factors to identify potential targets for prevention. Methods Using data from Justice-Involved Individuals Cardiovascular Disease Epidemiology (JUSTICE), a prospective cohort study of individuals released from incarceration with CVD risk factors, we examine the unique association between incarceration-specific factors and CVD risk factor control, including systolic blood pressure (SBP≥140 mmHg, diastolic blood pressure (DBP)≥90, body mass index (BMI)≥40, glycosylated hemoglobin (HbA1c) ≥8%, and low-density lipoprotein cholesterol (LDL-c)≥ 160). Incarceration-specific factors include the conditions of confinement (jail vs. prison, time in solitary confinement), and collateral sanctions following release (barriers to housing, food, employment due to criminal record). Variables associated with uncontrolled CVD risk factors were included in the multivariate model to examine the unique contribution of each risk factor with uncontrolled CVD risk factors. Results Participants (N=471), mean age of 45.0 ±SD 10.8 years were disproportionately men (89%), from racially minoritized groups (79%), and poor (91% below the 100% federal poverty level). Over half …

Artificial intelligence–enhanced electrocardiography (AI–ECG) interpretation can identify hypertrophic cardiomyopathy (HCM) on 12–lead ECGs and is a novel way to monitor response to treatment. While initial therapies were procedural – i.e. the surgical or percutaneous reduction of the interventricular septum (SRT), medical therapy with mavacamten offers an oral alternative. To evaluate biological response to SRT, we applied an AI–ECG model for HCM detection to ECG images obtained from the same patients before and after SRT across three sites: Yale New Haven Health System (YNHHS), Cleveland Clinic Foundation (CCF), and Atlantic Health System (AHS). We also applied the model in ECGs from patients who had received mavacamten at YNHHS over the past year since its approval. A total of 70 patients underwent SRT at YNHHS, 100 patients at CCF, and 145 at AHS. Among patients at YNHHS, there was no significant change in the AI–ECG score before versus after SRT (pre–SRT: 0.55 [IQR 0.24–0.77] vs post–SRT: 0.59 [IQR 0.40–0.75], p = 0.42 by Wilcoxon signed–rank test). The AI–ECG HCM scores were higher post SRT at CCF (0.61 [IQR 0.32–0.79] vs 0.69 [IQR 0.52–0.79], p = 0.003) and AHS (0.52 [IQR 0.35–0.69] vs 0.61 [IQR 0.49–0.70], p < 0.001). At YNHHS, among 17 patients undergoing treatment with Mavacamten, the median AI–ECG score prior to starting mavacamten was 0.61 (IQR 0.27–0.77). At the end of a median follow–up period of 95 days (IQR 63–145), the median AI–ECG score decreased significantly to 0.25 (IQR 0.14–0.51, p = 0.007). Our results demonstrate a measurable difference in the myocardial effects …