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Biomedical subjects

B J Gersh

Publications and source records attributed to B J Gersh.

At least 19 recordsLinked to original sources
PubMed1999

Racial differences in the outcome of left ventricular dysfunction.

BACKGROUND: Population-based studies have found that black patients with congestive heart failure have a higher mortality rate than whites with the same condition. This finding has been attributed to differences in the severity, causes, and management of heart failure, the prevalence of coexisting conditions, and socioeconomic factors. Although these factors probably account for some of the higher mortality due to congestive heart failure among blacks, we hypothesized that racial differences in the natural history of left ventricular dysfunction might also have a role. METHODS: Using data from the Studies of Left Ventricular Dysfunction (SOLVD) prevention and treatment trials, in which all patients received standardized therapy and follow-up, we conducted a retrospective analysis of the outcomes of asymptomatic and symptomatic left ventricular systolic dysfunction among black and white participants. The mean (+/-SD) follow-up was 34.2+/-14.0 months in the prevention trial and 32.3+/-14.8 months in the treatment trial among the black and white participants. RESULTS: The overall mortality rates in the prevention trial were 8.1 per 100 person-years for blacks and 5.1 per 100 person years for whites. In the treatment trial, the rates were 16.7 per 100 person-years and 13.4 per 100 person-years, respectively. After adjustment for age, coexisting conditions, severity and causes of heart failure, and use of medications, blacks had a higher risk of death from all causes in both the SOLVD prevention trial (relative risk, 1.36; 95 percent confidence interval, 1.06 to 1.74; P=0.02) and the treatment trial (relative risk, 1.25; 95 percent confidence interval, 1.04 to 1.50; P=0.02). In both trials blacks were also at higher risk for death due to pump failure and for the combined end point of death from any cause or hospitalization for heart failure, our two predefined indicators of the progression of left ventricular systolic dysfunction. CONCLUSIONS: Blacks with mild-to-moderate left ventricular systolic dysfunction appear to be at higher risk for progression of heart failure and death from any cause than similarly treated whites. These results suggest that there may be racial differences in the outcome of asymptomatic and symptomatic left ventricular systolic dysfunction.

Analysis of Variance↗
PubMed1999

The effect of race and sex on physicians' recommendations for cardiac catheterization.

BACKGROUND: Epidemiologic studies have reported differences in the use of cardiovascular procedures according to the race and sex of the patient. Whether the differences stem from differences in the recommendations of physicians remains uncertain. METHODS: We developed a computerized survey instrument to assess physicians' recommendations for managing chest pain. Actors portrayed patients with particular characteristics in scripted interviews about their symptoms. A total of 720 physicians at two national meetings of organizations of primary care physicians participated in the survey. Each physician viewed a recorded interview and was given other data about a hypothetical patient. He or she then made recommendations about that patient's care. We used multivariate logistic-regression analysis to assess the effects of the race and sex of the patients on treatment recommendations, while controlling for the physicians' assessment of the probability of coronary artery disease as well as for the age of the patient, the level of coronary risk, the type of chest pain, and the results of an exercise stress test. RESULTS: The physicians' mean (+/-SD) estimates of the probability of coronary artery disease were lower for women (probability, 64.1+/-19.3 percent, vs. 69.2+/-18.2 percent for men; P<0.001), younger patients (63.8+/-19.5 percent for patients who were 55 years old, vs. 69.5+/-17.9 percent for patients who were 70 years old; P<0.001), and patients with nonanginal pain (58.3+/-19.0 percent, vs. 64.4+/-18.3 percent for patients with possible angina and 77.1+/-14.0 percent for those with definite angina; P=0.001). Logistic-regression analysis indicated that women (odds ratio, 0.60; 95 percent confidence interval, 0.4 to 0.9; P=0.02) and blacks (odds ratio, 0.60; 95 percent confidence interval, 0.4 to 0.9; P=0.02) were less likely to be referred for cardiac catheterization than men and whites, respectively. Analysis of race-sex interactions showed that black women were significantly less likely to be referred for catheterization than white men (odds ratio, 0.4; 95 percent confidence interval, 0.2 to 0.7; P=0.004). CONCLUSIONS: Our findings suggest that the race and sex of a patient independently influence how physicians manage chest pain.

Age Factors↗
PubMed1999

Relation between mode of pacing and long-term survival in the very elderly.

OBJECTIVES: This study analyzes the relationship between pacing mode and long-term survival in a large group of very elderly patients (> or = 80 years old). BACKGROUND: The relationship between pacing mode and long-term survival is not clear. Because the number of very elderly who are candidates for pacing is increasing, issues related to pacemaker (PM) use in the elderly have important clinical and economic implications. METHODS: We retrospectively reviewed 432 patients (mean age, 84.5+/-3.9 years) who received their initial PM (ventricular in 310 and dual chamber in 122) between 1980 and 1992. Follow-up was complete (3.5+/-2.6 years). Observed survival was estimated by the Kaplan-Meier method. Age- and gender-matched cohorts from the Minnesota population were used for expected survival. Log-rank test and Cox regression hazard model were used for univariate and multivariate analyses. RESULTS: Patients with ventricular PMs appeared to have poor overall survival compared with those with dual-chamber PMs. Observed survival after PM implantation in high grade atrioventricular block (AVB) patients was significantly worse than expected survival of the age- and gender-matched population (p < 0.0001), whereas observed survival of patients with sinus node dysfunction was not significantly different from expected survival of the matched population (p = 0.413). By univariate analysis, ventricular pacing in patients with AVB appeared to be associated with poor survival compared with dual-chamber pacing (hazard ratio [HR] 2.08; 95% confidence interval [CI] 1.33 to 3.33). After multivariate analysis, this difference was no longer significant (HR 1.41; 95% CI 0.88 to 2.27). Independent predictors of all-cause mortality were number of comorbid illnesses, New York Heart Association functional class, left ventricular depression and older age at implant. Pacing mode was not an independent predictor of overall survival. Older age at implantation, diabetes mellitus, dementia, history of paroxysmal atrial fibrillation and earlier year of implantation were independent predictors of ventricular pacemaker selection. CONCLUSIONS: After PM implantation, long-term survival among very elderly patients was not affected by pacing mode after correction of baseline differences. Selection bias was present in pacing mode in the very elderly, with ventricular pacing selected for sicker and older patients, perhaps partly explaining the apparent "beneficial impact on survival" observed with dual-chamber pacing.

Aged↗
PubMed1998

Current issues in reperfusion therapy.

With the establishment of thrombosis as the cause of myocardial infarction, the pivotal role of thrombolytics and primary angioplasty has evolved. Large randomized trials with innovative methodologies have examined the role of these reperfusion therapies in the management of acute coronary syndromes. Intravenous thrombolytic therapy decreases mortality in a broad group of patients with acute myocardial infarction. The GUSTO trial established intravenous tissue plasminogen activator (tPA) used in combination with intravenous heparin as the most effective thrombolytic therapy. Importantly, the time to achieve reperfusion is crucial to the mortality benefit observed, and rapid attainment of Thrombolysis in Myocardial Infarction (TIMI) trial grade 3 flow is achieved in only approximately 55% of patients who receive thrombolytics. Reocclusion, cellular damage, and microvascular dysfunction may contribute to less than optimal results. Percutaneous transluminal coronary angioplasty (PTCA) may be the preferred method of acute reperfusion therapy based on higher rates of TIMI grade 3 flow and lower rates of reocclusion and recurrent myocardial infarction. However, marked variation exists in outcomes and utilization rates among individual institutions, and the benefits of PTCA have not been consistently maintained at 6 months. The use of stents and anticoagulants may improve results, and pre-PTCA strategies also are under investigation. Limitations remain in the efficacy of current reperfusion therapies, supporting the search for improved thrombolytic agents, primary angioplasty, stents, and antithrombotics with the goal of improving TIMI 3 flow rates and achieving reperfusion more rapidly.

Angioplasty, Balloon, Coronary↗
PubMed1998

Management of chronic stable angina: medical therapy, percutaneous transluminal coronary angioplasty, and coronary artery bypass graft surgery. Lessons from the randomized trials.

PURPOSE: To review the available data on the treatment of chronic stable angina and formulate a rational approach to the use of pharmacologic therapy, percutaneous transluminal coronary angioplasty (PTCA), and coronary artery bypass graft surgery (CABG). DATA SOURCES: A MEDLINE search of English-language literature published between 1976 and 1996 and the bibliographies of relevant articles. STUDY SELECTION: Primary research articles, meta-analyses, and meeting abstracts related to the management of chronic stable angina with an emphasis on comparisons of medical therapy, PTCA, and CABG. DATA EXTRACTION: Three trials comparing medical therapy with PTCA, seven trials comparing medical therapy with CABG, and nine trials comparing PTCA with CABG. DATA SYNTHESIS: Low-risk patients with single-vessel coronary artery disease and normal left ventricular function had greater alleviation of symptoms with PTCA than with medical treatment; mortality rates and rates of myocardial infarction were unchanged. In high-risk patients (risk was defined by severity of ischemia, number of diseased vessels, and presence of left ventricular dysfunction), improvement of survival was greater with CABG than with medical therapy. In moderate-risk patients with multivessel coronary artery disease (most had two-vessel disease and normal left ventricular function), PTCA and CABG produced equivalent mortality rates and rates of myocardial infarction. CONCLUSIONS: In low-risk patients, a strategy of initial medical therapy is reasonable. In moderate-risk patients, PTCA and CABG produce similar mortality rates and rates of myocardial infarction but PTCA-treated patients require more revascularization procedures. In high-risk patients, CABG is usually preferred.

Angina Pectoris↗
PubMed1998

Adjunctive therapy after reperfusion therapy in acute myocardial infarction.

The current era has witnessed dramatic improvement in the treatment of acute myocardial infarction, due in large part to the more widespread use of thrombolytic therapy aimed at quickly restoring perfusion in the infarct-related artery. This review addresses the role of adjunctive pharmacologic therapy in the thrombolytic era, recognizing that much of the available clinical trial data supporting the role of adjunctive pharmacologic treatment strategies was conducted in patient populations not widely exposed to reperfusion therapy. This review, therefore, explores the data supporting the incremental benefit of therapy with beta blockers, nitrates, angiotensin-converting enzyme inhibitors, or magnesium in addition to thrombolytic therapy. Heparin and aspirin will not be discussed.

Adrenergic beta-Antagonists↗
PubMed1998

Treatment of chronic mitral regurgitation.

BACKGROUND: Chronic, severe mitral regurgitation is a common clinical entity that can lead to progressive, irreversible left ventricular dysfunction. New information on the natural history of this condition, coupled with advances in surgical technique, have changed the roles of medical and surgical therapies. METHODS: The current medical and surgical literature regarding chronic mitral regurgitation is critically reviewed. RESULTS: There is no well-defined role for medical therapy in chronic mitral regurgitation. The goal of the treating physician is therefore to choose the optimal timing for surgical intervention. This process begins with noninvasive quantification of the degree of regurgitation. If severe, a careful search for signs or symptoms of impending left ventricular dysfunction should follow. Recent advances in surgical techniques for mitral valve repair allow for correction of the valvular defect with minimal mortality risk and improved preservation of ventricular function and are an impetus for early operative intervention. Mitral valve repair may also be beneficial in the setting of severe dilated cardiomyopathy. CONCLUSIONS: The development of techniques for mitral valve repair has altered the treatment paradigm for severe mitral regurgitation. Surgical intervention before the onset of left ventricular dysfunction is recommended.

Chronic Disease↗
PubMed1998

Gender differences in use of stress testing and coronary heart disease mortality: a population-based study in Olmsted County, Minnesota.

OBJECTIVES: We sought to examine the utilization of exercise stress testing in relation to age and gender in a population-based setting. BACKGROUND: The utilization of noninvasive procedures has been shown to be associated with the subsequent use of invasive procedures. Yet, there are no population-based data on the utilization of stress testing; in particular, although gender differences in the use of invasive procedures have been reported, the use of noninvasive procedures has not been examined in relation to gender. METHODS: In Olmsted County, Minnesota, passive surveillance of the medical care of the community is provided through the Rochester Epidemiology Project. A population-based cohort of Olmsted County residents undergoing exercise tests was identified. The medical records of residents with prevalent and incident exercise tests in 1987 and 1988 were reviewed. For persons with an initial test (incidence cohort), data on clinical presentation, test indications and results were abstracted. Stress test utilization rates were calculated, and crude rates were directly adjusted to the age distribution of the 1980 U.S. population. To help interpret patterns of use at the population level, coronary heart disease mortality rates (International Classification of Diseases, 9th revision, codes 410 to 414) were calculated (crude and directly adjusted to the overall age distribution of the 1980 U.S. population) and used as an indicator of coronary disease burden. RESULTS: A total of 2,624 tests were performed. The crude utilization rate (per 100,000) was 1,888 for men and 703 for women (rate ratio for men over women 2.7, 95% confidence interval [CI] 2.5 to 2.9); it remained significantly higher in men across all age strata. The crude incidence rate (per 100,000) of initial stress tests was 1,112 for men and 517 for women (rate ratio 2.2, 95% CI 1.9 to 2.4). For both men and women, the incidence increased with age; however, incidence remained lower in women in all age strata. At the time that they underwent an initial test, women were more symptomatic and had poorer exercise performance than men. The rate ratio of men over women for coronary heart disease mortality was 1.1 (95% CI 0.9 to 1.2). The age-adjusted rate ratios for stress test utilization were 2.8 (95% CI 2.5 to 3.0), and that for coronary heart disease mortality was 1.9 (95% CI 1.7 to 2.2). CONCLUSIONS: These population-based data show that during the study period, the utilization of stress testing in Olmsted County was lower in women than in men. Women in the incidence cohort were older and more symptomatic and had poorer exercise performance than men. Such differences should be considered when examining the utilization of subsequent invasive procedures according to gender.

Adult↗
PubMed1998

Atrial fibrillation is associated with an increased risk for mortality and heart failure progression in patients with asymptomatic and symptomatic left ventricular systolic dysfunction: a retrospective analysis of the SOLVD trials. Studies of Left Ventricular Dysfunction.

OBJECTIVE: This study undertook to determine if the presence of atrial fibrillation in patients with asymptomatic and symptomatic left ventricular dysfunction was associated with increased mortality and, if so, whether the increase could be attributed to progressive heart failure or arrhythmic death. BACKGROUND: Atrial fibrillation is a common condition in heart failure with the potential to impact hemodynamics and progression of left ventricular systolic dysfunction as well as the electrophysiologic substrate for arrhythmias. The available data do not conclusively define the effect of atrial fibrillation on prognosis in heart failure. METHODS: A retrospective analysis of the Studies of Left Ventricular Dysfunction Prevention and Treatment Trials was conducted that compared patients with atrial fibrillation to those in sinus rhythm at baseline for the risk of all-cause mortality, progressive pump-failure death and arrhythmic death. RESULTS: The patients with atrial fibrillation at baseline, compared to those in sinus rhythm, had greater all-cause mortality (34% vs. 23%, p < 0.001), death attributed to pump-failure (16.7% vs. 9.4%, p < 0.001) and were more likely to reach the composite end point of death or hospitalization for heart failure (45% vs. 33%, p < 0.001), but there was no significant difference between the groups in arrhythmic deaths. After multivariate analysis, atrial fibrillation remained significantly associated with all-cause mortality (relative risk [RR] 1.34, 95% confidence interval [CI] 1.12 to 1.62, p=0.002), progressive pump-failure death (RR 1.42, 95% CI 1.09 to 1.85, p=0.01), the composite end point of death or hospitalization for heart failure (RR 1.26, 95% CI 1.03 to 1.42, p=0.02), but not arrhythmic death (RR 1.13; 95% CI 0.75 to 1.71; p=0.55). CONCLUSIONS: The presence of atrial fibrillation in patients with asymptomatic and symptomatic left ventricular systolic dysfunction is associated with an increased risk for all-cause mortality, largely explained by an increased risk for pump-failure death. These data suggest that atrial fibrillation is associated with progression of left ventricular systolic dysfunction.

Adult↗
PubMed1998

Changing practice of coronary bypass surgery and its impact on early risk and long-term survival.

Over the past 20 years, a steady evolution in cardiac surgical techniques for coronary bypass graft (CABG) surgery has occurred. Recent reports are refining our knowledge of early and late survival after CABG surgery. Studies have documented the changing importance of well-recognized risk factors. New models that take into account multiple factors and that predict early risk of CABG surgery with good reliability have been developed. Long-term survival has been related to factors such as age, gender, diabetes mellitus, race, smoking history, left ventricular function, estrogen treatment in women, and serum lipids. Several recent studies provide insight into decision making regarding CABG versus catheter interventions for both primary and secondary revascularization. Data concerning new techniques, such as minimally invasive surgery, document promising results but also the anticipated learning curve of new procedures. Overall, favorable short-term and long-term survival results after CABG surgery continue to be reported despite an increasing elderly and complex patient group undergoing cardiovascular surgical procedures.

Adult↗
PubMed1998

Cardiology for the primary care provider: heparin-induced thrombocytopenia.

Heparin-induced thrombocytopenia (HIT) is classified as two distinct entities: HIT I and HIT II. HIT I is mild thrombocytopenia that occurs in approximately 25% of patients within the first 5 days of starting therapy and is clinically benign. HIT II is a syndrome of severe thrombocytopenia and thrombosis that occurs 6 days to 14 days into therapy in about 2% of patients and is associated with considerable morbidity and mortality. The severe form of HIT appears to be due to antibodies directed against a complex of heparin and platelet factor 4 (PF4) that leads to platelet activation, endothelial injury, and thrombosis. Treatment is problematic, but heparin administration must be immediately discontinued. In uncontrolled trials, agents such as warfarin, hirudin, and danaparoid have shown some efficacy. Early recognition by monitoring daily platelet counts during therapy may decrease the incidence of thrombosis.

Aged↗
PubMed1997

Pathophysiology and treatment of single-vessel coronary artery disease.

The optimal treatment of patients with single-vessel coronary artery disease (CAD) and chronic stable angina is controversial. Therapeutic options include medical therapy with pharmacologic agents and/or coronary revascularization via surgery (coronary artery bypass grafting [CABG]), percutaneous transluminal coronary angioplasty (PTCA), and/or other transcatheter techniques. Early studies found no difference in survival between medical and surgical treatment of patients with single-vessel disease and chronic stable angina. Although PTCA has been shown to improve symptoms and quality of life in patients with single-vessel disease and severe symptoms, improvement in survival and prevention of future events are not established and multiple PTCA procedures or subsequent surgical treatment may be necessary. Medical therapy may be preferred in patients with mild or no symptoms. In patients with chronic stable angina, PTCA practice may not be consistent with current guidelines, particularly obtaining laboratory evidence of ischemia before the procedure. Stenoses that may lead to future coronary events cannot be accurately identified by angiography without evidence of ischemia or symptoms. Currently available comparative studies of patients with CAD do not reflect the impact of stent procedures and aggressive lipid lowering. Therefore, diagnostic and treatment options should be individualized in patients with single-vessel disease and chronic stable angina, and additional randomized trials are necessary to determine the optimal management of these patients.

Adrenergic beta-Antagonists↗