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Coronary Artery Disease: HELP
Articles by Lloyd W. Klein
Based on 12 articles published since 2008

Between 2008 and 2019, Lloyd W. Klein wrote the following 12 articles about Coronary Artery Disease.
+ Citations + Abstracts
1 Guideline The Rationale for Performance of Coronary Angiography and Stenting Before Transcatheter Aortic Valve Replacement: From the Interventional Section Leadership Council of the American College of Cardiology. 2016

Ramee, Stephen / Anwaruddin, Saif / Kumar, Gautam / Piana, Robert N / Babaliaros, Vasilis / Rab, Tanveer / Klein, Lloyd W / Anonymous11460889 / Anonymous11470889. ·Ochsner Medical Center, New Orleans, Louisiana. · Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania. · Emory University/Atlanta VA Medical Center, Atlanta, Georgia. · Vanderbilt University Medical Center, Nashville, Tennessee. · Emory University School of Medicine, Atlanta, Georgia. · Rush Medical College, Chicago, Illinois. Electronic address: lloydklein@comcast.net. ·JACC Cardiovasc Interv · Pubmed #27931592.

ABSTRACT: Transcatheter aortic valve replacement (TAVR) is an effective, nonsurgical treatment option for patients with severe aortic stenosis. The optimal treatment strategy for treating concomitant coronary artery disease (CAD) has not been tested prospectively in a randomized clinical trial. Nevertheless, it is standard practice in the United States to perform coronary angiography and percutaneous coronary intervention for significant CAD at least 1 month before TAVR. All existing clinical trials were designed using this strategy. Therefore, it is wrong to extrapolate current American College of Cardiology/American Heart Association Appropriate Use Criteria against invasive procedures in asymptomatic patients to the TAVR population when evaluating the quality of care by cardiologists or hospitals. In this statement from the Interventional Section Leadership Council of the ACC, it is recommended that percutaneous coronary intervention should be considered in all patients with significant proximal coronary stenosis in major coronary arteries before TAVR, even though the indication is not covered in current guidelines.

2 Guideline ACCF/SCAI/STS/AATS/AHA/ASNC/HFSA/SCCT 2012 appropriate use criteria for coronary revascularization focused update: a report of the American College of Cardiology Foundation Appropriate Use Criteria Task Force, Society for Cardiovascular Angiography and Interventions, Society of Thoracic Surgeons, American Association for Thoracic Surgery, American Heart Association, American Society of Nuclear Cardiology, and the Society of Cardiovascular Computed Tomography. 2012

Anonymous780721 / Patel, Manesh R / Dehmer, Gregory J / Hirshfeld, John W / Smith, Peter K / Spertus, John A / Anonymous790721 / Masoudi, Frederick A / Dehmer, Gregory J / Patel, Manesh R / Smith, Peter K / Chambers, Charles E / Ferguson, T Bruce / Garcia, Mario J / Grover, Frederick L / Holmes, David R / Klein, Lloyd W / Limacher, Marian C / Mack, Michael J / Malenka, David J / Park, Myung H / Ragosta, Michael / Ritchie, James L / Rose, Geoffrey A / Rosenberg, Alan B / Russo, Andrea M / Shemin, Richard J / Weintraub, William S / Anonymous800721 / Wolk, Michael J / Bailey, Steven R / Douglas, Pamela S / Hendel, Robert C / Kramer, Christopher M / Min, James K / Patel, Manesh R / Shaw, Leslee / Stainback, Raymond F / Allen, Joseph M / Anonymous810721 / Anonymous820721 / Anonymous830721 / Anonymous840721 / Anonymous850721 / Anonymous860721 / Anonymous870721 / Anonymous880721. · ·J Thorac Cardiovasc Surg · Pubmed #22424518.

ABSTRACT: The American College of Cardiology Foundation (ACCF), Society for Cardiovascular Angiography and Interventions, Society of Thoracic Surgeons, and the American Association for Thoracic Surgery, along with key specialty and subspecialty societies, conducted an update of the appropriate use criteria (AUC) for coronary revascularization frequently considered. In the initial document, 180 clinical scenarios were developed to mimic patient presentations encountered in everyday practice and included information on symptom status, extent of medical therapy, risk level as assessed by noninvasive testing, and coronary anatomy. This update provides a reassessment of clinical scenarios the writing group felt to be affected by significant changes in the medical literature or gaps from prior criteria. The methodology used in this update is similar to the initial document, and the definition of appropriateness was unchanged. The technical panel scored the clinical scenarios on a scale of 1 to 9. Scores of 7 to 9 indicate that revascularization is considered appropriate and likely to improve patients' health outcomes or survival. Scores of 1 to 3 indicate revascularization is considered inappropriate and unlikely to improve health outcomes or survival. Scores in the mid-range (4 to 6) indicate a clinical scenario for which the likelihood that coronary revascularization will improve health outcomes or survival is uncertain. In general, as seen with the prior AUC, the use of coronary revascularization for patients with acute coronary syndromes and combinations of significant symptoms and/or ischemia is appropriate. In contrast, revascularization of asymptomatic patients or patients with low-risk findings on noninvasive testing and minimal medical therapy are viewed less favorably. The technical panel felt that based on recent studies, coronary artery bypass grafting remains an appropriate method of revascularization for patients with high burden of coronary artery disease (CAD). Additionally, percutaneous coronary intervention may have a role in revascularization of patients with high burden of CAD. The primary objective of the appropriate use criteria is to improve physician decision making and patient education regarding expected benefits from revascularization and to guide future research.

3 Editorial Ambiguities in Selecting the Optimal Strategy for the Nonculprit Stenosis in STEMI. 2017

Klein, Lloyd W / Lotfi, Amir. ·Rush Medical College, Chicago, Illinois. Electronic address: lloydklein@comcast.net. · Baystate Medical Center, Springfield, Massachusetts. ·JACC Cardiovasc Interv · Pubmed #28231900.

ABSTRACT: -- No abstract --

4 Editorial SCAI position statement concerning coverage policies for percutaneous coronary interventions based on the appropriate use criteria. 2016

Klein, Lloyd W / Blankenship, James C / Kolansky, Daniel M / Dean, Larry S / Naidu, Srihari S / Chambers, Charles E / Duffy, Peter L / Anonymous2810861. ·Rush Medical College, Chicago, IL. · Geisinger Medical Center, Danville, PA. · University of Pennsylvania School of Medicine, Philadelphia, PA. · University of Washington, Seattle, WA. · Winthrop University Hospital, Mineola, NY. · Hershey Medical Center, Hershey, PA. · FirstHealth of the Carolinas, Reid Heart Center, Pinehurst, NC. ·Catheter Cardiovasc Interv · Pubmed #26968441.

ABSTRACT: -- No abstract --

5 Review Long-term outcomes following fractional flow reserve-guided treatment of angiographically ambiguous left main coronary artery disease: A meta-analysis of prospective cohort studies. 2015

Mallidi, Jaya / Atreya, Auras R / Cook, James / Garb, Jane / Jeremias, Allen / Klein, Lloyd W / Lotfi, Amir. ·Department of Medicine, Division of Cardiology, Baystate Medical Center, Tufts University, Springfield, Massachusetts. · Department of Medicine, Division of Biostatistics, Baystate Medical Center, Tufts University, Springfield, Massachusetts. · Department of Medicine, Division of Cardiovascular Medicine, Stony Brook University Medical Center, Stony Brook, New York. · Department of Medicine, Division of Cardiology, Advocate Illinois Masonic Medical Center, Rush Medical College, Chicago, Illinois. ·Catheter Cardiovasc Interv · Pubmed #25676445.

ABSTRACT: OBJECTIVE: To define the long term outcomes of Fractional Flow Reserve (FFR) guided revascularization of ambiguous left main coronary artery (LMCA) lesions by performing a pooled meta-analysis of all available studies. BACKGROUND: Prospective studies evaluating the use of fractional flow reserve (FFR) for clinical decision-making in ambiguous unprotected left main coronary artery (LMCA) stenosis suggest the relative safety of that approach, but any final conclusions are limited by small sample size. We performed a pooled meta-analysis of studies to define the long-term outcomes in these patients. METHODS: Six prospective cohort studies involving 525 patients met the inclusion criteria. Patients underwent revascularization (revascularization group) or medical therapy (deferred group) based on FFR. The primary outcome was defined as rate of major cardiovascular events (a composite of death from all causes, nonfatal myocardial infarctions and subsequent revascularizations). The secondary outcomes included individual components of the primary end point. Pooled effect sizes were calculated using a fixed effects model. RESULTS: Based on the FFR results, 217 patients (41%) underwent revascularization. There was no statistically significant difference between the groups in the rates of primary end point (P = 0.15), all-cause mortality (P = 0.06) or nonfatal myocardial infarctions (P = 0.76). However, there was a significant increase in the rate of subsequent revascularizations in the deferred patients (P = 0.002). CONCLUSION: The long term clinical outcomes in patients with ambiguous LMCA stenosis for whom revascularization is deferred based on FFR are favorable and similar to the revascularized group in terms of overall mortality and subsequent myocardial infarctions.

6 Review Pathophysiology of coronary vascular remodeling: relationship with traditional risk factors for coronary artery disease. 2014

Pant, Rojina / Marok, Rajinder / Klein, Lloyd W. ·From the *Department of Medicine, Advocate Illinois Masonic Medical Center, Chicago, Illinois; and †Department of Internal Medicine / Cardiology Section, Advocate Illinois Masonic Medical Center and Rush Medical College, Chicago, Illinois. ·Cardiol Rev · Pubmed #23873211.

ABSTRACT: The relationship between cardiovascular risk factors and vascular remodeling is a relatively new area of investigation. We discuss the various mechanisms by which cardiovascular risk factors cause vascular remodeling. Endothelial dysfunction, lipoprotein alterations, inflammation, and platelet activation are the mechanisms by which remodeling occurs. Plaque composition also plays an important role in directing remodeling. Plaque with extensive calcification is more likely to undergo constrictive remodeling. Positive and negative remodeling is based on how these factors coordinate and determine the direction of remodeling. Matrix metalloproteinases perform a crucial role in vascular remodeling. Advanced glycation end-products are key substances involved in the negative remodeling associated with diabetes. Remodeling in hypertension can be either eutrophic or hypertrophic. Endothelial dysfunction and low-grade inflammation lead to negative remodeling in hypertension. Dyslipidemia can be associated with either positive or negative remodeling. High high-density lipoprotein is associated with positive remodeling and high low-density lipoprotein with negative remodeling. Smoking causes endothelial dysfunction, increased oxidative stress, and decreased nitric oxide synthesis leading to inward remodeling. Aging also causes endothelial dysfunction and predisposes to negative remodeling. Knowledge of these associations can elucidate various clinical presentations and guide therapeutic choices in the future.

7 Article Clinical Trials Versus Clinical Practice: When Evidence and Practice Diverge--Should Nondiabetic Patients With 3-Vessel Disease and Stable Ischemic Heart Disease Be Preferentially Treated With CABG? 2015

Kansara, Pranav / Weiss, Sandra / Weintraub, William S / Hann, Matthew C / Tcheng, James / Rab, S Tanveer / Klein, Lloyd W / Anonymous2670849. ·Department of Cardiology, Christiana Care Health System, Newark, Delaware. · Duke University Health System, Durham, North Carolina. · Emory University School of Medicine, Atlanta, Georgia. · Rush Medical College, Chicago, Illinois. Electronic address: lloydklein@comcast.net. ·JACC Cardiovasc Interv · Pubmed #26585614.

ABSTRACT: -- No abstract --

8 Article Angiographic validation of the American College of Cardiology Foundation-the Society of Thoracic Surgeons Collaboration on the Comparative Effectiveness of Revascularization Strategies study. 2014

Chakrabarti, Anjan K / Grau-Sepulveda, Maria V / O'Brien, Sean / Abueg, Cassandra / Ponirakis, Angelo / Delong, Elizabeth / Peterson, Eric / Klein, Lloyd W / Garratt, Kirk N / Weintraub, William S / Gibson, C Michael. ·From the Cardiovascular Division, Department of Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA (A.K.C., C.M.G.) · PERFUSE Angiographic Core Laboratories and Data Coordinating Center, Beth Israel Deaconess Medical Center, Boston, MA (A.K.C., C.A., C.M.G.) · Duke Clinical Research Institute, Duke University, Durham, NC (M.V.G.-S., S.O., E.D., E.P.) · American College of Cardiology, Washington, DC (A.P.) · Division of Internal Medicine, Department of Medicine, Rush University, Chicago, IL (L.W.K.) · Northshore-LIJ/Lenox Hill Hospital, New York, NY (K.N.G.) · and Christiana Care Health System, Newark, DE (W.S.W.). ·Circ Cardiovasc Interv · Pubmed #24496239.

ABSTRACT: BACKGROUND: The goal of this study was to compare angiographic interpretation of coronary arteriograms by sites in community practice versus those made by a centralized angiographic core laboratory. METHODS AND RESULTS: The study population consisted of 2013 American College of Cardiology-National Cardiovascular Data Registry (ACC-NCDR) records with 2- and 3- vessel coronary disease from 54 sites in 2004 to 2007. The primary analysis compared Registry (NCDR)-defined 2- and 3-vessel disease versus those from an angiographic core laboratory analysis. Vessel-level kappa coefficients suggested moderate agreement between NCDR and core laboratory analysis, ranging from kappa=0.39 (95% confidence intervals, 0.32-0.45) for the left anterior descending artery to kappa=0.59 (95% confidence intervals, 0.55-0.64) for the right coronary artery. Overall, 6.3% (n=127 out of 2013) of those patients identified with multivessel disease at NCDR sites had had 0- or 1-vessel disease by core laboratory reading. There was no directional bias with regard to overcall, that is, 12.3% of cases read as 3-vessel disease by the sites were read as <3-vessel disease by the core laboratory, and 13.9% of core laboratory 3-vessel cases were read as <3-vessel by the sites. For a subset of patients with left main coronary disease, registry overcall was not linked to increased rates of mortality or myocardial infarction. CONCLUSIONS: There was only modest agreement between angiographic readings in clinical practice and those from an independent core laboratory. Further study will be needed because the implications for patient management are uncertain.

9 Article How appropriate for assessing quality are the 2009 Appropriateness Criteria for Coronary Revascularization? 2009

Klein, Lloyd W. ·Advocate Illinois Masonic Medical Center, Professional Office Building Suite 625, 3000 North Halsted Avenue, Chicago, IL 60614, USA. lloydklein@comcast.net ·J Invasive Cardiol · Pubmed #19901408.

ABSTRACT: -- No abstract --

10 Article A longitudinal assessment of coronary interventional program quality: a report from the American College of Cardiology-National Cardiovascular Data Registry. 2009

Klein, Lloyd W / Kolm, Paul / Xu, Xin / Krone, Ronald J / Anderson, H Vernon / Rumsfeld, John S / Brindis, Ralph G / Weintraub, William S. ·Rush Medical College, Chicago, Illinois, USA. ·JACC Cardiovasc Interv · Pubmed #19463415.

ABSTRACT: OBJECTIVES: This study applied risk adjustment methods to evaluate member institutions of the American College of Cardiology-National Cardiovascular Data Registry with respect to in-hospital mortality in percutaneous coronary intervention patients over a 4-year period to assess variability in risk-adjusted performance measures. BACKGROUND: Cardiac catheterization laboratories, hospital networks, and third-party payers are interested in assessing the outcomes of percutaneous coronary interventions. Evaluation of outcomes without considering case selection may lead to erroneous conclusions about program quality. METHODS: The National Cardiovascular Data Registry database was queried for all percutaneous coronary intervention cases performed between January 1, 2001, and September 30, 2004. Random effects logistic regression was used to develop models of in-hospital mortality and compute an expected mortality rate for each program. The observed mortality rate in each program was divided by the program's predicted rate to obtain the observed/expected (O/E) mortality ratio. Change in the O/E ratio was assessed by a generalized estimating equation approach to repeated measures. An index of variability was calculated by the mean absolute difference between O/E ratios of each pair of years. RESULTS: There were 664,909 interventional procedures performed in 403 National Cardiovascular Data Registry programs from 2001 to 2004. There was no significant systematic change in O/E ratios over the 4-year period, but there was significantly greater variation in O/E ratios associated with lower percutaneous coronary intervention volume programs. CONCLUSIONS: Our risk-adjustment models had very good discrimination and were relatively consistent over the study period. There was substantial within-program variation in O/E ratios. This information would provide an indication for a detailed examination of individual programs.

11 Article A new hypothesis of the developmental origin of congenital left anterior descending coronary artery to pulmonary artery fistulas. 2008

Klein, Lloyd W. ·Rush Medical College, Chicago, Illinois, USA. lloydklein@comcast.net ·Catheter Cardiovasc Interv · Pubmed #18307238.

ABSTRACT: The embryologic origin of fistulous communications between a coronary artery and the pulmonary artery has traditionally been explained as the persistence of an immature supernumerary coronary artery with its origin in the pulmonary trunk. Although this hypothesis is consistent with the occurrence of the termination of the fistula in the posterior sinus of the pulmonary artery, it does not completely explain several morphologic and physiologic aspects. In this report, we present a case illustrating the classic anatomic features of left anterior descending artery to pulmonary artery fistulas and develop a new hypothesis of its embryologic origin and re-emergence in adults that fully explains its angiographic appearance and clinical attributes.

12 Minor ASCERT: the American College of Cardiology Foundation--the Society of Thoracic Surgeons Collaboration on the comparative effectiveness of revascularization strategies. 2010

Klein, Lloyd W / Edwards, Fred H / DeLong, Elizabeth R / Ritzenthaler, Laura / Dangas, George D / Weintraub, William S. · ·JACC Cardiovasc Interv · Pubmed #20129582.

ABSTRACT: -- No abstract --