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Coronary Artery Disease: HELP
Articles by William S. Weintraub
Based on 36 articles published since 2008
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Between 2008 and 2019, William Weintraub wrote the following 36 articles about Coronary Artery Disease.
 
+ Citations + Abstracts
Pages: 1 · 2
1 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.

2 Editorial Cost-Effectiveness and Economic Burden of PCI. 2018

Iantorno, Micaela / Weintraub, William S. ·Section of Interventional Cardiology, MedStar Heart & Vascular Institute, Georgetown University, Washington, DC. · Section of Interventional Cardiology, MedStar Heart & Vascular Institute, Georgetown University, Washington, DC. Electronic address: William.s.weintraub@medstar.net. ·Cardiovasc Revasc Med · Pubmed #30146118.

ABSTRACT: -- No abstract --

3 Editorial Reconsidering the Gatekeeper Paradigm for Percutaneous Coronary Intervention in Stable Coronary Disease Management. 2017

Schulman-Marcus, Joshua / Weintraub, William S / Boden, William E. ·Division of Cardiology, Albany Medical Center, Albany Medical College,Albany, New York. Electronic address: schulmj1@mail.amc.edu. · Division of Cardiology, Christiana Healthcare System,Newark, Delaware. · VA New England Healthcare System, Massachusetts Veterans Epidemiology, Research, and Informatics Center (MAVERIC), Boston University School of Medicine,Boston, Massachusetts. ·Am J Cardiol · Pubmed #28818317.

ABSTRACT: Major randomized clinical trials over the last decade support the role of optimal medical therapy for the initial management approach for patients with stable coronary artery disease (CAD), whereas percutaneous coronary intervention (PCI) ought to be reserved for patients with persistent symptoms despite optimal medical therapy. Likewise, several studies have continued to demonstrate the superiority of coronary artery bypass grafting surgery over PCI in many patients with extensive multivessel CAD, especially those with diabetes. Nevertheless, the decision-making paradigm for patients with stable CAD often continues to propagate the upfront use of "ad hoc PCI" and disadvantages alternative therapeutic approaches. In our editorial, we discuss how multiple systemic and interpersonal factors continue to favor early revascularization with PCI in stable patients. We discuss whether the interventional cardiologist can be an unbiased "gatekeeper" for the use of PCI or whether other physicians should also be involved with the patient in decision-making. Finally, we offer suggestions that can redefine the gatekeeper role to facilitate an evidence-based approach that embraces shared decision-making.

4 Editorial Coronary Revascularization in the Current Era. 2015

Weiss, Sandra / Weintraub, William. ·Christiana Care Health System, Newark, DE, USA. Electronic address: SWeiss@christianacare.org. · Christiana Care Health System, Newark, DE, USA. ·Prog Cardiovasc Dis · Pubmed #26471932.

ABSTRACT: -- No abstract --

5 Editorial Predicting cardiovascular events with coronary calcium scoring. 2008

Weintraub, William S / Diamond, George A. · ·N Engl J Med · Pubmed #18367744.

ABSTRACT: -- No abstract --

6 Review A narrative overview: Have clinical trials of PCI vs medical therapy addressed the right question? 2018

Morrone, Doralisa / Marzilli, Mario / Panico, Roberta Antonazzo / Kolm, Paul / Weintraub, William S. ·Christiana Care Health System, Newark, DE, USA; Surgery Pathology, Medical, Molecular and Critic Area Department-Cardiovascular Disease Section, Pisa University, Italy. Electronic address: doralisa.morrone@unipi.it. · Surgery Pathology, Medical, Molecular and Critic Area Department-Cardiovascular Disease Section, Pisa University, Italy. · Christiana Care Health System, Newark, DE, USA. ·Int J Cardiol · Pubmed #29957261.

ABSTRACT: BACKGROUND: In RCTs about revascularization, the terms "coronary artery disease" and "ischemic heart disease" are sometimes used interchangeably. This can create confusion concerning inclusion and exclusion criteria, which may lead to uncertain results. OBJECTIVE: Our purpose is to investigate whether the study populations in randomized controlled trials (RCTs) which compared percutaneous coronary revascularization to medical therapy for stable ischemic heart disease specifically enrolled patients with demonstrable ischemia, and how many patients were included in trials with evidence of coronary atherosclerosis but without evidence of ischemia. METHODS: Trial published data were obtained from ACME I, ACME II, RITA I, RITA II, MASS I, MASS II, AVERT, ACIP, COURAGE and FAME2. Published data were used to calculate the number of patients included in the trials with a negative stress test but significant coronary artery stenosis and the number of patients excluded from the trials with a positive stress test or angina, but without significant coronary artery stenosis at the time of angiography. RESULTS: A total of 196,433 patients were screened between 1998 and 2011. Overall about 30% of patients were excluded if they did not meet the angiographic criteria, even though the presence of inducible ischemia or angina, and, about 20% of patients were included without inducible ischemia. CONCLUSION: RCTs have contributed to the confusion between coronary artery disease and ischemic heart disease. This may limit the ability to interpret the results and apply them in practice.

7 Review Should Chronic Total Occlusion Be Treated With Coronary Artery Bypass Grafting? Chronic Total Occlusion Should Not Routinely Be Treated With Coronary Artery Bypass Grafting. 2016

Weintraub, William S / Garratt, Kirk N. ·From the Christiana Care Health System, Newark, DE. wweintraub@christianacare.org. · From the Christiana Care Health System, Newark, DE. ·Circulation · Pubmed #27143549.

ABSTRACT: -- No abstract --

8 Review Comparison of percutaneous coronary intervention with drug eluting stents versus coronary artery bypass grafting in patients with multivessel coronary artery disease: Meta-analysis of six randomized controlled trials. 2015

Fanari, Zaher / Weiss, Sandra A / Zhang, Wei / Sonnad, Seema S / Weintraub, William S. ·Section of Cardiology, Christiana Care Health System, Newark, DE. Electronic address: zfanari@gmail.com. · Section of Cardiology, Christiana Care Health System, Newark, DE. · Value Institute, Christiana Care Health System, Newark, DE. · Section of Cardiology, Christiana Care Health System, Newark, DE; Value Institute, Christiana Care Health System, Newark, DE. ·Cardiovasc Revasc Med · Pubmed #25662779.

ABSTRACT: OBJECTIVE: To compare outcomes of percutaneous coronary intervention (PCI) with drug eluting stent (DES) and Coronary Artery Bypass Grafting (CABG) in patients with multivessel Coronary Artery Disease (CAD) using data from randomized controlled trials (RCT). BACKGROUND: PCI and CABG are established strategies for coronary revascularization in the setting of ischemic heart disease. Multiple RCTs have compared outcomes of the two modalities in patients with multivessel CAD. METHODS: We did a meta-analysis from six RCTs in the contemporary era comparing the effectiveness of PCI with DES to at 1 year, 2 years and 5 years respectively. RESULTS: Compared to CABG, at one year PCI was associated with a significantly higher incidence of TVR (RR=2.31; 95% CI: [1.80-2.96]; P=<0.0001), lower incidence of stroke (RR=0.35; 95% CI: [0.19-0.62]; P=0.0003), and no difference in death (RR=1.02; 95% CI: [0.77-1.36]; P=0.88) or MI (RR=1.16; 95% CI: [0.72-1.88]; P=0.53). At 5 years, PCI was associated with a higher incidence of death (RR=1.3; 95% CI: [1.10-1.54]; P=0.0026) and MI (RR=2.21; 95% CI: [1.75-2.79]; P=<0.0001). While the higher incidence of MI with PCI was noticed in both diabetic and non-diabetics, death was increased mainly in diabetic patients. CONCLUSION: In patients with multi-vessel CAD, PCI with DES is associated with no significant difference in death or MI at 1 or 2 years. However at 5 years, PCI is associated with higher incidence of death and MI.

9 Review Meta-analysis of three randomized controlled trials comparing coronary artery bypass grafting with percutaneous coronary intervention using drug-eluting stenting in patients with diabetes. 2014

Fanari, Zaher / Weiss, Sandra A / Zhang, Wei / Sonnad, Seema S / Weintraub, William S. ·Division of Cardiology, Christiana Care Health System, Newark, DE, USA zfanari@christianacare.org. · Division of Cardiology, Christiana Care Health System, Newark, DE, USA. · Value Institute, Christiana Care Health System, Newark, DE, USA. · Division of Cardiology, Christiana Care Health System, Newark, DE, USA Value Institute, Christiana Care Health System, Newark, DE, USA. ·Interact Cardiovasc Thorac Surg · Pubmed #25185569.

ABSTRACT: OBJECTIVES: Coronary artery bypass grafting (CABG) was found to be the preferred strategy of revascularization in patients with diabetes in the bare-metal stent (BMS) era. The introduction of drug-eluting stents (DESs) led to a significant reduction in the rates of repeat revascularization (RRV) when compared with BMSs. We did a collaborative analysis of data from randomized controlled trials in the contemporary era to compare CABG versus percutaneous coronary intervention using DESs in diabetic patients. METHODS: We performed a systematic review and meta-analysis from randomized trials in the contemporary era comparing PCI with DESs with CABG in diabetic patients with multivessel disease. A comprehensive literature search (1 January 2003 to 18 May 2013) identified randomized controlled trials that reported long-term outcomes comparing PCI using DESs with CABG in 2974 diabetic patients. RESULTS: At 1 year, PCI was associated with a significant increase in the incidence of RRV [2.48 (1.56-3.94); P ≤0.0001], lower incidence of stroke [relative risk (RR) = 0.43 (0.19-0.81); P = 0.017], and no difference in death or myocardial infarction (MI). At 5 years, PCI was still associated with a lower incidence of stroke, but was associated with a significant increase in the incidence of death [RR = 1.36 (1.11-1.66); P = 0.0033] and MI [RR = 2.01 (1.54-2.62); P ≤0.0001]. CONCLUSIONS: In patients with diabetes, PCI was associated with no difference in death and MI at 1 year. However, at 5 years, PCI was associated with a higher incidence of death and MI. PCI was associated with a higher incidence of RRV but a lower incidence of stroke.

10 Review Comparative effectiveness of revascularization strategies in stable ischemic heart disease: current perspective and literature review. 2013

Fanari, Zaher / A Weiss, Sandra / Weintraub, William S. ·Christiana Care Health System, Newark, DE, USA. ·Expert Rev Cardiovasc Ther · Pubmed #24138520.

ABSTRACT: Percutaneous coronary intervention (PCI) and coronary artery bypass grafting (CABG) are established strategies for coronary revascularization in the setting of ischemic heart disease. Multiple randomized controlled trials and observational studies have compared the impact of the two modalities on the patients' quality of life, mortality and morbidity, as well as the cost-effectiveness of these modalities in different clinical setting. CABG is the preferred strategy for revascularizations in patients with multi-vessel disease, especially in those with higher risk secondary to associated diabetes, left ventricular dysfunction or more complex lesions. PCI is a reasonable revascularization modality in patients with ischemia and single or low-risk multi-vessel disease and those with unprotected left main with low complexity anatomy. Compared with PCI, CABG is associated with less repeat revascularization, better quality of life and improved survival in high-risk patients. Although CABG is associated with higher cost, it is probably associated with a reasonable cost per quality-adjusted life-year gained in many patients. Therefore, CABG will often be a cost-effective strategy, especially in patients with high angiographic complexity and/or diabetes.

11 Review Antiplatelet therapy in patients undergoing percutaneous coronary intervention: economic considerations. 2013

Weintraub, William S / Mandel, Leonid / Weiss, Sandra A. · ·Pharmacoeconomics · Pubmed #24022207.

ABSTRACT: Percutaneous coronary intervention (PCI) is one of the most common medical procedures performed for treatment of coronary artery disease. Antiplatelet medications as adjunctive therapy for PCI are used routinely, with indications for specific agents or their combinations varying depending on the clinical scenario. While the cost-effectiveness of well-established agents has been extensively studied, newer drugs have not been evaluated as thoroughly. In addition, the clinical application of some antiplatelet drugs has recently changed, thus making older studies of cost effectiveness less applicable to the current landscape of clinical practice. This article reviews cost-effectiveness considerations of antiplatelet therapies in the treatment of coronary artery disease in patients undergoing PCI. Aspirin, P2Y12 inhibitors including clopidogrel and the newer agents prasugrel and ticagrelor, as well as glycoprotein (GP) IIb/IIIa inhibitors, are discussed. Overall, the use of dual antiplatelet therapy with aspirin and a P2Y12 inhibitor in patients undergoing PCI improves ischaemic outcomes and appears to be cost effective. The few available studies suggest that the recently approved medications prasugrel and ticagrelor are cost-effective alternatives to clopidogrel. However, no direct comparison between these two newer agents is available. The indications for GP IIb/IIIa inhibitors have changed in the current PCI era, and there is a paucity of cost-effectiveness data for their use in contemporary care.

12 Article Optimal medical therapy with or without percutaneous coronary intervention in women with stable coronary disease: A pre-specified subset analysis of the Clinical Outcomes Utilizing Revascularization and Aggressive druG Evaluation (COURAGE) trial. 2016

Acharjee, Subroto / Teo, Koon K / Jacobs, Alice K / Hartigan, Pamela M / Barn, Kulpreet / Gosselin, Gilbert / Tanguay, Jean-Francois / Maron, David J / Kostuk, William J / Chaitman, Bernard R / Mancini, G B John / Spertus, John A / Dada, Marcin R / Bates, Eric R / Booth, David C / Weintraub, William S / O'Rourke, Robert A / Boden, William E / Anonymous6050859. ·Einstein Medical Center Philadelphia, Philadelphia, PA. · Hamilton General Hospital/Master University, Hamilton, Canada. · Boston Medical Center, Boston, MA. · VA Connecticut Healthcare System, West Haven, CT. · Geisinger Medical Center, Danville, PA. · Montreal Heart Institute/Université de Montréal, Montreal, QC, Canada. · Vanderbilt University Medical Center, Nashville, TN. · London Health Science Centre, London, ON, Canada. · Saint Louis University School of Medicine, St. Louis, MT. · Vancouver Hospital and Health Science Centre, Vancouver, BC, Canada. · Mid America Heart Institute, Kansas City, MO. · Hartford Hosp, Hartford, CT. · University of Michigan, Ann Arbor, MI. · University of Kentucky Med Center, Lexington, KY. · Christiana Healthcare System and Center for Outcomes Research, Newark, DE. · South Texas Veterans Health Care System-Audie Murphy Campus, San Antonio, TX. · Stratton VA Medical Center, Albany Medical College, Albany, NY. Electronic address: william.boden@va.gov. ·Am Heart J · Pubmed #26920603.

ABSTRACT: OBJECTIVES: To determine whether sex-based differences exist in clinical effectiveness of percutaneous coronary intervention (PCI) when added to optimal medical therapy (OMT) in patients with stable coronary artery disease. BACKGROUND: A prior pre-specified unadjusted analysis from COURAGE showed that women randomized to PCI had a lower rate of death or myocardial infarction during a median 4.6-year follow-up with a trend for interaction with respect to sex. METHODS: We analyzed outcomes in 338 women (15%) and 1949 men (85%) randomized to PCI plus OMT versus OMT alone after adjustment for relevant baseline characteristics. RESULTS: There was no difference in treatment effect by sex for the primary end point (death or myocardial infarction; HR, 0.89; 95% CI, 0.77-1.03 for women and HR, 1.02, 95% CI 0.96-1.10 for men; P for interaction = .07). Although the event rate was low, a trend for interaction by sex was nonetheless noted for hospitalization for heart failure, with only women, but not men, assigned to PCI experiencing significantly fewer events as compared to their counterparts receiving OMT alone (HR, 0.59; 95% CI, 0.40-0.84, P < .001 for women and HR, 0.86; 95% CI, 0.74-1.01, P = .47 for men; P for interaction = .02). Both sexes randomized to PCI experienced significantly reduced need for subsequent revascularization (HR, 0.72; 95% CI, 0.62-0.83, P < .001 for women; HR, 0.84; 95% CI, 0.79-0.89, P < .001 for men; P for interaction = .02) with evidence of a sex-based differential treatment effect. CONCLUSION: In this adjusted analysis of the COURAGE trial, there were no significant differences in treatment effect on major outcomes between men and women. However, women assigned to PCI demonstrated a greater benefit as compared to men, with a reduction in heart failure hospitalization and need for future revascularization. These exploratory observations require further prospective study.

13 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 --

14 Article Effect of baseline exercise capacity on outcomes in patients with stable coronary heart disease (a post hoc analysis of the clinical outcomes utilizing revascularization and aggressive drug evaluation trial). 2015

Padala, Santosh K / Sidhu, Mandeep S / Hartigan, Pamela M / Maron, David J / Teo, Koon K / Spertus, John A / Mancini, G B John / Sedlis, Steven P / Chaitman, Bernard R / Heller, Gary V / Weintraub, William S / Boden, William E. ·Department of Medicine, Albany Medical Center, Albany, New York. · Department of Medicine, Albany Medical Center, Albany, New York; Department of Medicine, Samuel S. Stratton VA Medical Center and Albany Medical College, Albany, New York. · Cooperative Studies Program Coordinating Center, VA Connecticut, West Haven, Connecticut. · Department of Medicine, Stanford University, Stanford, California. · Population Health Research Institute, McMaster University, Hamilton, Ontario, Canada. · Department of Medicine, Mid America Heart Institute and University of Missouri-Kansas City, Kansas City, Missouri. · Department of Medicine, University of British Columbia, Vancouver, British Columbia, Canada. · Department of Medicine, VA New York Harbor, New York University School of Medicine, New York, New York. · Department of Medicine, St. Louis University, St. Louis, Missouri. · Department of Medicine, Intersocietal Accreditation Commission, Elicott City, Maryland. · Department of Medicine, Christiana Care Health System, Newark, Delaware. · Department of Medicine, Albany Medical Center, Albany, New York; Department of Medicine, Samuel S. Stratton VA Medical Center and Albany Medical College, Albany, New York. Electronic address: william.boden@va.gov. ·Am J Cardiol · Pubmed #26410604.

ABSTRACT: The impact of baseline exercise capacity on clinical outcomes in patients with stable ischemic heart disease randomized to an initial strategy of optimal medical therapy (OMT) with or without percutaneous coronary intervention (PCI) in the Clinical Outcomes Utilizing Revascularization and Aggressive Drug Evaluation (COURAGE) trial has not been studied. A post hoc analysis was performed in 1,052 patients of COURAGE (PCI + OMT: n = 527, OMT: n = 525) who underwent exercise treadmill testing at baseline. Patients were categorized into 2 exercise capacity groups based on metabolic equivalents (METs) achieved during baseline exercise treadmill testing (<7 METs: n = 464, ≥7 METs: n = 588) and were followed for a median of 4.6 years. The primary composite end point of death or myocardial infarction was similar in the PCI + OMT group and the OMT group for patients with exercise capacity <7 METs (19.1% vs 16.1%, p = 0.31) and ≥7 METs (13.3% vs 10.3%, p = 0.27). After adjusting for baseline covariates, the hazard ratio (99% confidence interval) for the primary end point for the PCI + OMT group versus the OMT group was 1.42 (0.90 to 2.23, p = 0.05) and for the exercise capacity subgroups of ≥7 METs and <7 METs was 0.75 (0.46 to 1.22, p = 0.13). There was no statistically significant interaction between the original treatment arm allocation (PCI + OMT vs OMT) and baseline exercise capacity. In conclusion, there was no difference in the long-term clinical outcomes in patients with exercise capacity <7 METs compared with ≥7 METs, irrespective of whether they were assigned to initial PCI. Patients with exercise capacity <7 METs did not derive a proportionately greater clinical benefit from PCI + OMT compared with those patients who received OMT alone.

15 Article Validation of the appropriate use criteria for percutaneous coronary intervention in patients with stable coronary artery disease (from the COURAGE trial). 2015

Bradley, Steven M / Chan, Paul S / Hartigan, Pamela M / Nallamothu, Brahmajee K / Weintraub, William S / Sedlis, Steven P / Dada, Marcin / Maron, David J / Kostuk, William J / Berman, Daniel S / Teo, Koon K / Mancini, G B John / Boden, William E / Spertus, John A. ·Division of Cardiology, Department of Medicine, VA Eastern Colorado Health Care System, Denver, Colorado; Department of Medicine, University of Colorado School of Medicine at the Anschutz Medical Campus, Aurora, Colorado. Electronic address: smbradle@gmail.com. · Department of Cardiovascular Research, Saint Luke's Mid America Heart Institute, Missouri; Department of Medicine, University of Missouri-Kansas City, Missouri. · Department of Medicine, Clinical Epidemiology Research Center, VA Connecticut Healthcare Center, West Haven, Connecticut. · Department of Medicine, University of Michigan Medical School, Ann Arbor, Michigan. · Department of Medicine, Christiana Care Health System, Newark, Delaware. · Division of Cardiology, Department of Medicine, VA New York Harbor Health Care System, New York, New York; Department of Medicine, New York University School of Medicine, New York, New York. · Department of Medicine, Hartford Hospital, Hartford, Connecticut. · Department of Medicine, Stanford University School of Medicine, Stanford, California. · Department of Medicine, London Health Sciences Centre, University of Western Ontario, London, Ontario, Canada. · Department of Medicine, Cedars-Sinai Medical Center, Los Angeles, California. · Department of Medicine, McMaster University, Hamilton, Ontario, Canada. · Department of Medicine, University of British Columbia, Vancouver, British Columbia, Canada. · Department of Medicine, Western New York VA Healthcare Network, Buffalo, New York; Buffalo General Hospital, SUNY, Buffalo, New York. ·Am J Cardiol · Pubmed #25960375.

ABSTRACT: Establishing the validity of appropriate use criteria (AUC) for percutaneous coronary intervention (PCI) in the setting of stable ischemic heart disease can support their adoption for quality improvement. We conducted a post hoc analysis of 2,287 Clinical Outcomes Utilizing Revascularization and Aggressive Drug Evaluation trial patients with stable ischemic heart disease randomized to PCI with optimal medical therapy (OMT) or OMT alone. Within appropriateness categories, we compared rates of death, myocardial infarction, revascularization subsequent to initial therapy, and angina-specific health status as determined by the Seattle Angina Questionnaire in patients randomized to PCI + OMT to those randomized to OMT alone. A total of 1,987 patients (87.9%) were mapped to the 2012 publication of the AUC, with 1,334 (67.1%) classified as appropriate, 551 (27.7%) uncertain, and 102 (5.1%) as inappropriate. There were no significant differences between PCI and OMT alone in the rate of mortality and myocardial infarction by appropriateness classification. Rates of revascularization were significantly lower in patients initially receiving PCI + OMT who were classified as appropriate (hazard ratio 0.65; 95% confidence interval 0.53 to 0.80; p <0.001) or uncertain (hazard ratio 0.49; 95% confidence interval 0.32 to 0.76; p = 0.001). Furthermore, among patients classified as appropriate by the AUC, Seattle Angina Questionnaire scores at 1 month were better in the PCI-treated group compared with the medical therapy group (80 ± 23 vs 75 ± 24 for angina frequency, 73 ± 24 vs 68 ± 24 for physical limitations, and 68 ± 23 vs 60 ± 24 for quality of life; all p <0.01), with differences generally persisting through 12 months. In contrast, health status scores were similar throughout the first year of follow-up in PCI + OMT patients compared with OMT alone in patients classified as uncertain or inappropriate. In conclusion, these findings support the validity of the AUC in efforts to improve health care quality through optimal use of PCI.

16 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.

17 Article Predicting outcome in the COURAGE trial (Clinical Outcomes Utilizing Revascularization and Aggressive Drug Evaluation): coronary anatomy versus ischemia. 2014

Mancini, G B John / Hartigan, Pamela M / Shaw, Leslee J / Berman, Daniel S / Hayes, Sean W / Bates, Eric R / Maron, David J / Teo, Koon / Sedlis, Steven P / Chaitman, Bernard R / Weintraub, William S / Spertus, John A / Kostuk, William J / Dada, Marcin / Booth, David C / Boden, William E. ·University of British Columbia, Vancouver, British Columbia, Canada. Electronic address: mancini@mail.ubc.ca. · Veterans Affairs Cooperative Studies Program Coordinating Center, Connecticut VA Healthcare System, West Haven, Connecticut. · Emory University School of Medicine, Atlanta, Georgia. · Cedars-Sinai Heart Institute, University of California, Los Angeles, California. · University of Michigan Medical Center, Ann Arbor, Michigan. · Vanderbilt University Medical Center, Nashville, Tennessee. · McMaster University Medical Center, Hamilton, Ontario, Canada. · VA New York Harbor Healthcare System, New York Campus, New York University School of Medicine, New York, New York. · St. Louis University Hospital, St. Louis, Missouri. · Christiana Care Health System, Newark, Delaware. · Mid America Heart Institute, University of Missouri, Kansas City, Missouri. · London Health Sciences Centre, University of Western Ontario, London, Ontario, Canada. · Hartford Hospital, Hartford, Connecticut. · University of Kentucky, Lexington, Kentucky. · New York Health Care System, Buffalo General Hospital and the State University of New York at Buffalo, Buffalo, New York. ·JACC Cardiovasc Interv · Pubmed #24440015.

ABSTRACT: OBJECTIVES: The aim of this study was to determine the relative utility of anatomic and ischemic burden of coronary artery disease for predicting outcomes. BACKGROUND: Both anatomic burden and ischemic burden of coronary artery disease determine patient prognosis and influence myocardial revascularization decisions. When both measures are available, their relative utility for prognostication and management choice is controversial. METHODS: A total of 621 patients enrolled in the COURAGE (Clinical Outcomes Utilizing Revascularization and Aggressive Drug Evaluation) trial with baseline quantitative nuclear single-photon emission computed tomography (SPECT) and quantitative coronary angiography were studied. Several multiple regression models were constructed to determine independent predictors of the endpoint of death, myocardial infarction (MI) (excluding periprocedural MI) and non-ST-segment elevation acute coronary syndromes (NSTE-ACS). Ischemic burden during stress SPECT, anatomic burden derived from angiography, left ventricular ejection fraction, and assignment to either optimal medical therapy (OMT) + percutaneous coronary intervention (PCI) or OMT alone were analyzed. RESULTS: In nonadjusted and adjusted regression models, anatomic burden and left ventricular ejection fraction were consistent predictors of death, MI, and NSTE-ACS, whereas ischemic burden and treatment assignment were not. There was a marginal (p = 0.03) effect of the interaction term of anatomic and ischemic burden for the prediction of clinical outcome, but separately or in combination, neither anatomy nor ischemia interacted with therapeutic strategy to predict outcome. CONCLUSIONS: In a cohort of patients treated with OMT, anatomic burden was a consistent predictor of death, MI, and NSTE-ACS, whereas ischemic burden was not. Importantly, neither determination, even in combination, identified a patient profile benefiting preferentially from an invasive therapeutic strategy. (Clinical Outcomes Utilizing Revascularization and Aggressive Drug Evaluation [COURAGE]; NCT00007657).

18 Article Health status and quality of life in patients with stable coronary artery disease and chronic kidney disease treated with optimal medical therapy or percutaneous coronary intervention (post hoc findings from the COURAGE trial). 2013

Sedlis, Steven P / Jurkovitz, Claudine T / Hartigan, Pamela M / Kolm, Paul / Goldfarb, David S / Lorin, Jeffrey D / Dada, Marcin / Maron, David J / Spertus, John A / Mancini, G B John / Teo, Koon K / Boden, William E / Weintraub, William S / Anonymous6210768. ·Department of Medicine, Veterans Affairs New York Harbor Health Care System, New York University School of Medicine, New York, New York. Electronic address: steven.sedlis@va.gov. ·Am J Cardiol · Pubmed #24011740.

ABSTRACT: Chronic kidney disease (CKD) is an important clinical co-morbidity that increases the risk of death and myocardial infarction in patients with coronary artery disease (CAD) even when treated with guideline-directed therapies. It is unknown, however, whether CKD influences the effects of CAD treatments on patients' health status, their symptoms, function, and quality of life. We performed a post hoc analysis of the Clinical Outcomes Utilizing Revascularization and Aggressive Drug Evaluation (COURAGE) study to compare health status in patients with stable CAD with and without CKD defined as a glomerular filtration rate of <60 ml/min/1.73 m(2) randomized to either percutaneous coronary intervention (PCI) and optimal medical therapy (OMT) or OMT alone. Health status was measured at baseline, 1, 3, 6, 12, 24, and 36 months of follow-up with the Seattle Angina Questionnaire in 310 patients with CKD and 1,719 patients without CKD. Linear mixed-effects models were used to analyze Seattle Angina Questionnaire scores longitudinally. Mean scores for angina-related quality of life, angina frequency, and physical limitation domains improved from baseline values in both patients with and without CKD and plateaued. Early improvement (1 to 6 months) was more common in patients treated with PCI plus OMT than with OMT alone in both patients with and without CKD. Treatment satisfaction scores were high at baseline in all groups and did not change significantly over time. In conclusion, although CKD is an important determinant of event-free survival in patients with stable CAD, it neither precludes satisfactory treatment of angina with PCI plus OMT or OMT alone nor is it associated with an unsatisfactory quality of life.

19 Article Enhanced mortality risk prediction with a focus on high-risk percutaneous coronary intervention: results from 1,208,137 procedures in the NCDR (National Cardiovascular Data Registry). 2013

Brennan, J Matthew / Curtis, Jeptha P / Dai, David / Fitzgerald, Susan / Khandelwal, Akshay K / Spertus, John A / Rao, Sunil V / Singh, Mandeep / Shaw, Richard E / Ho, Kalon K L / Krone, Ronald J / Weintraub, William S / Weaver, W Douglas / Peterson, Eric D / Anonymous5020767. ·Department of Medicine, Duke Clinical Research Institute, Durham, North Carolina 27705, USA. ·JACC Cardiovasc Interv · Pubmed #23968699.

ABSTRACT: OBJECTIVES: This study sought to update and validate a contemporary model for inpatient mortality following percutaneous coronary intervention (PCI), including variables indicating high clinical risk. BACKGROUND: Recently, new variables were added to the CathPCI Registry data collection form. This modification allowed us to better characterize the risk of death, including recent cardiac arrest and duration of cardiogenic shock. METHODS: Data from 1,208,137 PCI procedures performed between July 2009 and June 2011 at 1,252 CathPCI Registry sites were used to develop both a "full" and pre-catheterization PCI in-hospital mortality risk model using logistic regression. To support prospective implementation, a simplified bedside risk score was derived from the pre-catheterization risk model. Model performance was assessed by discrimination and calibration metrics in a separate split sample. RESULTS: In-hospital mortality was 1.4%, ranging from 0.2% among elective cases (45.1% of total cases) to 65.9% among patients with shock and recent cardiac arrest (0.2% of total cases). Cardiogenic shock and procedure urgency were the most predictive of inpatient mortality, whereas the presence of a chronic total occlusion, subacute stent thrombosis, and left main lesion location were significant angiographic predictors. The full, pre-catheterization, and bedside risk prediction models performed well in the overall validation sample (C-indexes 0.930, 0.928, 0.925, respectively) and among pre-specified patient subgroups. The model was well calibrated across the risk spectrum, although slightly overestimating risk in the highest risk patients. CONCLUSIONS: Clinical acuity is a strong predictor of PCI procedural mortality. With inclusion of variables that further characterize clinical stability, the updated CathPCI Registry mortality models remain well-calibrated across the spectrum of PCI risk.

20 Article 2013 ACCF/AHA key data elements and definitions for measuring the clinical management and outcomes of patients with acute coronary syndromes and coronary artery disease: a report of the American College of Cardiology Foundation/American Heart Association Task Force on Clinical Data Standards (Writing Committee to Develop Acute Coronary Syndromes and Coronary Artery Disease Clinical Data Standards). 2013

Cannon, Christopher P / Brindis, Ralph G / Chaitman, Bernard R / Cohen, David J / Cross, J Thomas / Drozda, Joseph P / Fesmire, Francis M / Fintel, Dan J / Fonarow, Gregg C / Fox, Keith A / Gray, Darryl T / Harrington, Robert A / Hicks, Karen A / Hollander, Judd E / Krumholz, Harlan / Labarthe, Darwin R / Long, Janet B / Mascette, Alice M / Meyer, Connie / Peterson, Eric D / Radford, Martha J / Roe, Matthew T / Richmann, James B / Selker, Harry P / Shahian, David M / Shaw, Richard E / Sprenger, Sharon / Swor, Robert / Underberg, James A / Van de Werf, Frans / Weiner, Bonnie H / Weintraub, William S. · ·Crit Pathw Cardiol · Pubmed #23680811.

ABSTRACT: -- No abstract --

21 Article Impact of adding ezetimibe to statin to achieve low-density lipoprotein cholesterol goal (from the Clinical Outcomes Utilizing Revascularization and Aggressive Drug Evaluation [COURAGE] trial). 2013

Maron, David J / Hartigan, Pamela M / Neff, David R / Weintraub, William S / Boden, William E / Anonymous1750754. ·Vanderbilt University School of Medicine, Nashville, Tennessee, USA. david.maron@vanderbilt.edu ·Am J Cardiol · Pubmed #23538020.

ABSTRACT: In the Clinical Outcomes Utilizing Revascularization and Aggressive Drug Evaluation (COURAGE) study, a revascularization strategy trial with optimal medical therapy in both arms, the low-density lipoprotein (LDL) cholesterol goal was 60 to 85 mg/dl; this was revised to <70 mg/dl in 2004. COURAGE patients (n = 2,287) were titrated with increasing statin doses to achieve the initial LDL cholesterol goal using a prespecified protocol. Ezetimibe was not available when study enrollment began in 1999 but became available after approval in 2003. After maximizing statin dose, ezetimibe was added to reach the LDL cholesterol goal in 34% of patients (n = 734). Median baseline LDL cholesterol was higher in patients who received ezetimibe than in those who did not (109 vs 96 mg/dl). At baseline, 18% of patients who would later receive ezetimibe had LDL cholesterol <85 mg/dl, and 8% had LDL cholesterol <70 mg/dl. On maximum tolerated statin (with or without other lipid-lowering drugs), 40% had LDL cholesterol <85 mg/dl and 23% had LDL cholesterol <70 mg/dl before starting ezetimibe. At the final study visit, 68% of ezetimibe patients achieved LDL cholesterol <85 mg/dl, and 46% achieved LDL cholesterol <70 mg/dl. Using Cox regression analysis, the most significant factors associated with achieving LDL cholesterol goals were lower baseline LDL cholesterol, average statin dose, and ezetimibe use. In conclusion, after maximizing statin dose, the addition of ezetimibe results in a substantial increase in the percentage of patients who reach LDL cholesterol goal, a key component of optimal medical therapy.

22 Article 2013 ACCF/AHA key data elements and definitions for measuring the clinical management and outcomes of patients with acute coronary syndromes and coronary artery disease: a report of the American College of Cardiology Foundation/American Heart Association Task Force on clinical data standards (writing committee to develop acute coronary syndromes and coronary artery disease clinical data standards). 2013

Cannon, Christopher P / Brindis, Ralph G / Chaitman, Bernard R / Cohen, David J / Cross, J Thomas / Drozda, Joseph P / Fesmire, Francis M / Fintel, Dan J / Fonarow, Gregg C / Fox, Keith A / Gray, Darryl T / Harrington, Robert A / Hicks, Karen A / Hollander, Judd E / Krumholz, Harlan / Labarthe, Darwin R / Long, Janet B / Mascette, Alice M / Meyer, Connie / Peterson, Eric D / Radford, Martha J / Roe, Matthew T / Richmann, James B / Selker, Harry P / Shahian, David M / Shaw, Richard E / Sprenger, Sharon / Swor, Robert / Underberg, James A / Van de Werf, Frans / Weiner, Bonnie H / Weintraub, William S. · ·J Am Coll Cardiol · Pubmed #23369353.

ABSTRACT: -- No abstract --

23 Article 2013 ACCF/AHA key data elements and definitions for measuring the clinical management and outcomes of patients with acute coronary syndromes and coronary artery disease: a report of the American College of Cardiology Foundation/American Heart Association Task Force on Clinical Data Standards (Writing Committee to Develop Acute Coronary Syndromes and Coronary Artery Disease Clinical Data Standards). 2013

Cannon, Christopher P / Brindis, Ralph G / Chaitman, Bernard R / Cohen, David J / Cross, J Thomas / Drozda, Joseph P / Fesmire, Francis M / Fintel, Dan J / Fonarow, Gregg C / Fox, Keith A / Gray, Darryl T / Harrington, Robert A / Hicks, Karen A / Hollander, Judd E / Krumholz, Harlan / Labarthe, Darwin R / Long, Janet B / Mascette, Alice M / Meyer, Connie / Peterson, Eric D / Radford, Martha J / Roe, Matthew T / Richmann, James B / Selker, Harry P / Shahian, David M / Shaw, Richard E / Sprenger, Sharon / Swor, Robert / Underberg, James A / Van de Werf, Frans / Weiner, Bonnie H / Weintraub, William S / Anonymous3720748 / Anonymous3730748 / Anonymous3740748 / Anonymous3750748 / Anonymous3760748 / Anonymous3770748 / Anonymous3780748 / Anonymous3790748 / Anonymous3800748. · ·Circulation · Pubmed #23357718.

ABSTRACT: -- No abstract --

24 Article Angiographic disease progression and residual risk of cardiovascular events while on optimal medical therapy: observations from the COURAGE Trial. 2011

Mancini, G B John / Hartigan, Pamela M / Bates, Eric R / Sedlis, Steven P / Maron, David J / Spertus, John A / Berman, Daniel S / Kostuk, William J / Shaw, Leslee J / Weintraub, William S / Teo, Koon K / Dada, Marcin / Chaitman, Bernard R / O'Rourke, Robert A / Boden, William E / Anonymous1630709. ·University of British Columbia, Vancouver Hospital Research Pavilion, 828 W. 10th Avenue, Vancouver, BC, Canada. mancini@mail.ubc.ca ·Circ Cardiovasc Interv · Pubmed #22045968.

ABSTRACT: BACKGROUND: The extent to which recurrent events in patients with stable coronary artery disease is attributable to progression of an index lesion originally ≥50% diameter stenosis (DS) but not revascularized or originally <50% DS is unknown during optimal medical therapy (OMT). METHODS AND RESULTS: In the COURAGE (Clinical Outcomes Utilizing Revascularization and Aggressive Drug Evaluation) trial, 205 patients assigned to OMT plus percutaneous coronary intervention (PCI) and 284 patients assigned to OMT only had symptom-driven angiograms suitable for analysis. Percentages of patients in the OMT+PCI and OMT-only cohorts with index lesions originally <50% DS were 30% and 32%, respectively; 20% and 68% had index lesions originally ≥50% DS. In both groups, index lesions originally <50% or ≥50% DS represented <4% and <25% of all such lesions, respectively. The only angiographic predictor of myocardial infarction or acute coronary syndrome was the number of lesions originally ≥50% DS that had not been revascularized (odds ratio, 1.15; confidence limits, 1.01-1.31; P<0.04). CONCLUSIONS: Lesions originally <50% DS were index lesions in one third of patients referred for symptom-driven repeat angiography, but represented <4% of all such lesions. Nonrevascularized lesions originally ≥50% DS were more often index lesions in OMT-only patients, but still represented a minority (<25%) of all such lesions. These findings underscore the need for improved therapies to arrest plaque progression and reliable strategies for selecting stenoses warranting PCI.

25 Article Intensive multifactorial intervention for stable coronary artery disease: optimal medical therapy in the COURAGE (Clinical Outcomes Utilizing Revascularization and Aggressive Drug Evaluation) trial. 2010

Maron, David J / Boden, William E / O'Rourke, Robert A / Hartigan, Pamela M / Calfas, Karen J / Mancini, G B John / Spertus, John A / Dada, Marcin / Kostuk, William J / Knudtson, Merril / Harris, Crystal L / Sedlis, Steven P / Zoble, Robert G / Title, Lawrence M / Gosselin, Gilbert / Nawaz, Shah / Gau, Gerald T / Blaustein, Alvin S / Bates, Eric R / Shaw, Leslee J / Berman, Daniel S / Chaitman, Bernard R / Weintraub, William S / Teo, Koon K / Anonymous42950656. ·Departments of Medicine and Emergency Medicine, Vanderbilt University School of Medicine, Nashville, Tennessee 37232-8800, USA. david.maron@vanderbilt.edu ·J Am Coll Cardiol · Pubmed #20338496.

ABSTRACT: OBJECTIVES: This paper describes the medical therapy used in the COURAGE (Clinical Outcomes Utilizing Revascularization and Aggressive Drug Evaluation) trial and its effect on risk factors. BACKGROUND: Most cardiovascular clinical trials test a single intervention. The COURAGE trial tested multiple lifestyle and pharmacologic interventions (optimal medical therapy) with or without percutaneous coronary intervention in patients with stable coronary disease. METHODS: All patients, regardless of treatment assignment, received equivalent lifestyle and pharmacologic interventions for secondary prevention. Most medications were provided at no cost. Therapy was administered by nurse case managers according to protocols designed to achieve predefined lifestyle and risk factor goals. RESULTS: The patients (n = 2,287) were followed for 4.6 years. There were no significant differences between treatment groups in proportion of patients achieving therapeutic goals. The proportion of smokers decreased from 23% to 19% (p = 0.025), those who reported <7% of calories from saturated fat increased from 46% to 80% (p < 0.001), and those who walked >or=150 min/week increased from 58% to 66% (p < 0.001). Body mass index increased from 28.8 +/- 0.13 kg/m(2) to 29.3 +/- 0.23 kg/m(2) (p < 0.001). Appropriate medication use increased from pre-randomization to 5 years as follows: antiplatelets 87% to 96%; beta-blockers 69% to 85%; renin-angiotensin-aldosterone system inhibitors 46% to 72%; and statins 64% to 93%. Systolic blood pressure decreased from a median of 131 +/- 0.49 mm Hg to 123 +/- 0.88 mm Hg. Low-density lipoprotein cholesterol decreased from a median of 101 +/- 0.83 mg/dl to 72 +/- 0.88 mg/dl. CONCLUSIONS: Secondary prevention was applied equally and intensively to both treatment groups in the COURAGE trial by nurse case managers with treatment protocols and resulted in significant improvement in risk factors. Optimal medical therapy in the COURAGE trial provides an effective model for secondary prevention among patients with chronic coronary disease. (Clinical Outcomes Utilizing Revascularization and Aggressive Drug Evaluation; NCT00007657).

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