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James E Udelson

Publications and source records attributed to James E Udelson.

At least 37 records · Page 2Linked to original sources
PubMed2004

Training cardiovascular fellows in cardiovascular magnetic resonance and vascular imaging; Current status following the core cardiovascular training symposium (COCATS-2) guidelines.

OBJECTIVES: This survey study sought to characterize the current training environment in cardiovascular magnetic resonance (CMR) and vascular imaging and to quantify the magnitude of any gaps between current training practice and the recommendations of the Core Cardiovascular Training Symposium (COCATS-2) guidelines. BACKGROUND: The COCATS-2 guidelines published in 2002 newly included specific educational components of CMR and vascular imaging. An understanding of the current capabilities of training programs to meet these guidelines could produce efforts to improve training opportunities. METHODS: We surveyed all accredited adult cardiovascular training programs by using a 21-question, multiple-response survey. Data were collected on center and program characteristics, clinical activities, control of clinical activities, and needs and attitudes. Parallel data were collected for nuclear cardiology capabilities as a "base case." RESULTS: Only 13% of training programs reported "ownership" of CMR equipment, compared with 48% for nuclear equipment (p = 0.001). Dedicated fellow rotations in nuclear imaging are nearly universally present, whereas vascular (64%) and CMR imaging (29%) lag behind. A majority of programs do not use formal educational curricula for CMR and vascular imaging. Among centers with CMR training capabilities, the breadth of training opportunities is typically very limited, with most having only aortic imaging as their sole capability, except in predominately large training centers. The greatest need expressed by programs was educational assistance in the form of written and lecture curriculum materials. CONCLUSIONS: A substantial gap exists between the current training environment in CMR and vascular imaging and the recommendations of COCATS-2. Sharing training opportunities between centers is encouraged, particularly for smaller training programs, in order to capitalize on limited equipment, personnel, and curriculum resources.

Cardiology↗
PubMed2004

Ventricular remodeling in heart failure and the effect of beta-blockade.

Left ventricular (LV) remodeling has an important role in the progression of cardiovascular disease. An understanding of the process of LV remodeling has led to greater knowledge of the pathophysiology of heart failure. Drug therapies that slow or reverse the remodeling process seem to have favorable natural history effects in short-term and long-term therapy. Angiotensin-converting enzyme (ACE) inhibitors have been associated with a significant reduction in mortality, and the effect of beta-blockers on the remodeling process has now been studied across much of the spectrum of severity in patients with heart failure. beta-Blockade seems to add favorable and independent effects on the post-myocardial infarction remodeling process over and above those of ACE inhibitors. A combination of both drugs shows the greatest reduction in mortality (ie, the most favorable reverse remodeling). Differences in their effect on remodeling have been recently shown among the beta-blockers. Several studies and a meta-analysis suggest that carvedilol may be more favorable to outcome, having the most effect on LV remodeling.

Adrenergic beta-Antagonists↗
PubMed2004

Randomized, controlled dose-ranging study of the selective adenosine A2A receptor agonist binodenoson for pharmacological stress as an adjunct to myocardial perfusion imaging.

BACKGROUND: Dipyridamole and adenosine cause frequent side effects as a result of nonspecific adenosine receptor stimulation. Selective agonism of the adenosine A2A receptor should result in a similar degree of coronary vasodilation (and thus similar perfusion images) with fewer side effects. METHODS AND RESULTS: In a multicenter, randomized, single-blind, 2-arm crossover trial, 240 patients underwent 2 single photon emission computed tomographic (SPECT) imaging studies in random order, first after pharmacological stress with adenosine and a second study with the selective adenosine A2A receptor agonist binodenoson, using 1 of 4 dosing regimens. Safety, tolerability, and SPECT image concordance between the 2 agents were examined. Exact categorical agreement in the extent and severity of reversible perfusion defects ranged from 79% to 87%, with kappa values from 0.69 to 0.85, indicating very good to excellent agreement between binodenoson and adenosine. The risk of any safety event/side effect was significantly lower with any dose of binodenoson than with adenosine (P< or =0.01) because of a dose-related reduction in subjective side effects, as objective events were infrequent. There was a reduction in the severity of chest pain, dyspnea, and flushing in all binodenoson doses compared with adenosine (P<0.01), and the magnitude of severity reduction was dose-related. CONCLUSIONS: The selective adenosine A2A receptor agonist binodenoson results in an extent and severity of reversible perfusion defects on SPECT imaging similar to nonselective adenosine receptor stimulation, accompanied by a dose-related reduction in the incidence and severity of side effects.

Adenosine↗
PubMed2004

Prognostic and therapeutic implications of myocardial viability in patients with heart failure.

Substantial progress has been made in understanding the pathophysiology of regional and global left ventricular (LV) dysfunction and the states of hibernation and stunning in patients with heart failure. The clinical literature on the use of noninvasive imaging to assess myocardial viability has evolved from predicting improvement in regional LV function to predicting patient-related outcomes, including heart failure symptom improvement and survival after revascularization. A substantial body of observational cohort data demonstrates that mortality risk is high in patients with coronary artery disease and LV dysfunction who have substantial viable myocardium, and that risk is reduced by revascularization. Thus, noninvasive imaging of myocardial ischemia and viability can provide important prognostic information in patients with heart failure and LV dysfunction, and provide a signal of the potential benefit of revascularization.

Heart Failure↗
PubMed2003

Assessment of peripheral vascular endothelial function with finger arterial pulse wave amplitude.

BACKGROUND: Abnormalities in pulse wave amplitude (PWA) have been described in subjects with atherosclerosis and may be a marker of future cardiac events. We evaluated the relationship between changes in PWA of the finger and peripheral endothelial function. METHODS: We performed measurements of PWA with a novel finger plethysmograph (peripheral arterial tonometry [PAT]) and compared the findings with a simultaneous noninvasive measurement of peripheral endothelial function with brachial artery ultrasound scanning (BAUS) in 89 subjects. The PAT hyperemia ratio was defined as the ratio of PWA during reactive hyperemia relative to the baseline. Flow-mediated dilation (FMD) was defined by BAUS as the ratio of the brachial artery diameter during reactive hyperemia relative to the baseline. Sixty-eight subjects underwent exercise myocardial perfusion imaging (ExMPI). RESULTS: Fifty-four men and 35 women were examined. There was a linear relationship between the PAT hyperemia ratio and FMD during the same episode of reactive hyperemia (r = 0.55, P <.0001). Subjects in the lowest FMD quartile had the lowest PAT hyperemia ratio, whereas subjects in the highest FMD quartile had the highest PAT hyperemia ratio (P <.001 for trend). Similar to BAUS, the PAT hyperemia ratio was more impaired in subjects with cardiovascular risk factors and in subjects with ExMPI studies that were indicative of coronary artery disease. CONCLUSIONS: Assessment of PWA with PAT demonstrates patterns of abnormality similar to that of BAUS assessment of FMD. PWA during reactive hyperemia is influenced by factors known to affect endothelial function, including cardiovascular risk factors and coronary artery disease. These findings support the concept that analysis of PWA with PAT during reactive hyperemia may be used to study peripheral vascular endothelial function.

Blood Pressure↗
PubMed2003

New concepts in post-infarction ventricular remodeling.

An understanding of the process of left ventricular (LV) remodeling has led to greater knowledge of the pathophysiology of heart failure syndrome. This article examines the relationship between LV remodeling and clinical outcomes of heart failure syndrome from several different perspectives. The studies cited suggest that the post-myocardial infarction process is related to and associated with long-term progression of LV dysfunction, heart failure symptoms, and mortality. It is also demonstrated that drug therapies that slow or reverse the remodeling process appear to have favorable natural history effects in the short term as well as during long-term therapy.

Adrenergic beta-Antagonists↗
PubMed2002

Myocardial perfusion imaging for evaluation and triage of patients with suspected acute cardiac ischemia: a randomized controlled trial.

CONTEXT: Observational studies of acute myocardial perfusion imaging in emergency department (ED) patients with chest pain have suggested high sensitivity and negative predictive value for acute cardiac ischemia, but use of this method has not been prospectively tested. OBJECTIVE: To assess whether incorporating acute resting perfusion imaging into an ED evaluation strategy for patients with suspected acute ischemia but no initial electrocardiogram (ECG) changes diagnostic of acute ischemia improves clinical decision making for initial ED triage. DESIGN, SETTING, AND PATIENTS: Prospective, randomized controlled trial conducted at 7 academic medical centers and community hospitals between July 1997 and May 1999 among 2475 adult ED patients with chest pain or other symptoms suggestive of acute cardiac ischemia and with normal or nondiagnostic initial ECG results. INTERVENTION: Patients were randomly assigned to receive either the usual ED evaluation strategy (n = 1260) or the usual strategy supplemented with results from acute resting myocardial perfusion imaging using single-photon emission computed tomography with injection of 20 to 30 mCi of Tc-99m sestamibi (n = 1215), interpreted in real time by local staff physicians and with results provided to the ED physician for incorporation into clinical decision making. MAIN OUTCOME MEASURE: Appropriateness of triage decision either to admit to hospital/observation or to discharge directly home from the ED. RESULTS: Among patients with acute cardiac ischemia (ie, acute myocardial infarction [MI] or unstable angina; n = 329), there were no differences in ED triage decisions between those receiving standard evaluation and those whose evaluation was supplemented by a sestamibi scan. Among patients with acute MI (n = 56), 97% vs 96% were hospitalized (relative risk [RR], 1.00; 95% confidence interval [CI], 0.89-1.12), and among those with unstable angina (n = 273), 83% vs 81% were hospitalized (RR, 0.98; 95% CI, 0.87-1.10). However, among patients without acute cardiac ischemia (n = 2146), hospitalization was 52% with usual care vs 42% with sestamibi imaging (RR, 0.84; 95% CI, 0.77-0.92). CONCLUSIONS: Sestamibi perfusion imaging improves ED triage decision making for patients with symptoms suggestive of acute cardiac ischemia without obvious abnormalities on initial ECG. In this study, unnecessary hospitalizations were reduced among patients without acute ischemia, without reducing appropriate admission for patients with acute ischemia.

Acute Disease↗
PubMed2002

Myocardial viability testing and impact of revascularization on prognosis in patients with coronary artery disease and left ventricular dysfunction: a meta-analysis.

OBJECTIVES: This study pools data from published series examining late survival with revascularization versus medical therapy after myocardial viability testing in patients with severe coronary artery disease (CAD) and left ventricular (LV) dysfunction. BACKGROUND: Previous observational studies have suggested survival benefit in such patients if they are revascularized when myocardial viability is detected on imaging tests. METHODS: A MEDLINE database search returned 24 viability studies reporting patient survival using thallium perfusion imaging, F-18 fluorodeoxyglucose metabolic imaging or dobutamine echocardiography. Annual death rates were extracted, pooled and analyzed with a random effects model. The risk-adjusted relationship between severity of LV dysfunction, presence of viability and survival benefit associated with revascularization was assessed by meta-regression. RESULTS: There were 3,088 patients (2,228 men), ejection fraction 32 +/- 8%, followed for 25 +/- 10 months. In patients with viability, revascularization was associated with 79.6% reduction in annual mortality (16% vs. 3.2%, chi-square = 147, p < 0.0001) compared with medical treatment. Patients without viability had intermediate mortality, trending to higher rates with revascularization versus medical therapy (7.7% vs. 6.2%, p = NS). Patients with viability showed a direct relationship between severity of LV dysfunction and magnitude of benefit with revascularization (p < 0.001). There was no measurable performance difference for predicting revascularization benefit between the three testing techniques. CONCLUSIONS: This meta-analysis demonstrates a strong association between myocardial viability on noninvasive testing and improved survival after revascularization in patients with chronic CAD and LV dysfunction. Absence of viability was associated with no significant difference in outcomes, irrespective of treatment strategy.

Coronary Disease↗
PubMed2002

Pharmacological treatment of coronary artery disease with recombinant fibroblast growth factor-2: double-blind, randomized, controlled clinical trial.

BACKGROUND: Single-bolus intracoronary administration of fibroblast growth factor-2 (FGF2) improved symptoms and myocardial function in a phase I, open-label trial in patients with coronary artery disease. We conducted the FGF Initiating RevaScularization Trial (FIRST) to evaluate further the efficacy and safety of recombinant FGF2 (rFGF2). METHODS AND RESULTS: FIRST is a multicenter, randomized, double-blind, placebo-controlled trial of a single intracoronary infusion of rFGF2 at 0, 0.3, 3, or 30 microg/kg (n=337 patients). Efficacy was evaluated at 90 and 180 days by exercise tolerance test, myocardial nuclear perfusion imaging, Seattle Angina Questionnaire, and Short-Form 36 questionnaire. Exercise tolerance was increased at 90 days in all groups and was not significantly different between placebo and FGF-treated groups. rFGF2 reduced angina symptoms as measured by the angina frequency score of the Seattle Angina Questionnaire (overall P=0.035) and the physical component summary scale of the Short-Form 36 (pairwise P=0.033, all FGF groups versus placebo). These differences were more pronounced in highly symptomatic patients (baseline angina frequency score < or =40 or Canadian Cardiovascular Society score of III or IV). None of the differences were significant at 180 days because of continued improvement in the placebo group. Adverse events were similar across all groups, except for hypotension, which occurred with higher frequency in the 30-microg/kg rFGF2 group. CONCLUSIONS: A single intracoronary infusion of rFGF2 does not improve exercise tolerance or myocardial perfusion but does show trends toward symptomatic improvement at 90 (but not 180) days.

Adult↗
PubMed2002

Noninvasive assessment of left ventricular remodeling: concepts, techniques, and implications for clinical trials.

BACKGROUND: Over the past decade, our understanding of the cellular and biochemical mechanisms that underlie global changes in ventricular morphology and function has grown enormously. Nevertheless, although the sequence of events that lead to overt changes in the ventricle begin at the cellular level, in living patients we rarely have the opportunity to assess these phenomena as they occur. Thus, to study the process of remodeling in practice and in clinical trials, we have relied on assessments and measurements derived from cardiac imaging tests. METHODS AND RESULTS: Since the initial angiographic based methods for assessing ventricular remodeling in humans, a variety of techniques has been developed that have been used for assessment of ventricular size, shape, and function for both clinical and research studies. As two-dimensional echocardiography has emerged as the predominant noninvasive diagnostic method for clinical use in evaluating left ventricular function, this modality has become the most widely used technique to assess ventricular remodeling. Nevertheless, nuclear techniques that have proven both reliable and highly reproducible have also been used in clinical and research setting and, more recently, cardiac magnetic resonance imaging has offered the potential to obtain extremely high-quality images of the heart at much higher resolution than either of the other techniques. CONCLUSIONS: Each of these techniques carries specific advantages and disadvantages for assessment of remodeling in individual patients and in the context of large-scale clinical trials.

Clinical Trials as Topic↗
PubMed2002

Relation between left ventricular remodeling and clinical outcomes in heart failure patients with left ventricular systolic dysfunction.

BACKGROUND: A major advance in understanding the pathophysiology of the heart failure syndrome has been an understanding of the process of left ventricular (LV) remodeling. After any insult to the left ventricle resulting in diminished systolic performance and stroke volume, a series of histopathologic changes in the myocardium and structural changes in the LV chamber occurs over time. METHODS AND RESULTS: Early work on understanding this process of LV remodeling emerged from the studies of Pfeffer and colleagues, who used a rat model of myocardial infarction (MI). Compared to those with smaller MIs, rats with larger induced MIs underwent a substantially greater degree of chamber remodeling over time, and importantly, these structural changes were associated with significantly higher morality. These studies established for the first time the relation between the structural changes now widely known as LV remodeling and a natural history outcome in the setting of LV systolic dysfunction. Subsequently, these investigators demonstrated that angiotensin-converting enzyme (ACE) inhibition with captopril, when initiated soon after the induced MI, attenuated the remodeling process. Also observed was an improvement in survival among rats in whom the remodeling process has been attenuated. These important data paved the way for human studies that have subsequently provided substantial evidence to support two important concepts: (1) that LV remodeling is related to clinical outcomes that represent the natural history of the heart failure syndrome such as mortality and surrogate markers of the progression of heart failure, and (2) that therapeutic interventions in humans that slow or reverse the process of LV remodeling, such as ACE inhibitors and beta-blockers, appear to have a favorable effect on that natural history. CONCLUSIONS: This review will examine the issue of the relation between LV remodeling and clinical outcomes in the human heart failure syndrome from several interrelated aspects: (1) the relation between LV volume at one time point and subsequent oucome, (2) the relation between changes in LV volumes over time (LV remodeling) and clinical outcomes, and (3) the relation between the effect of medical therapeutic interventions on the LV remodeling process and the effect of those same medical interventions on natural history outcomes in human heart failure.

Adrenergic beta-Antagonists↗