Gaurav Parmar, MD, MPH

All Publications

• Impact of Statin Therapy on Mortality and Cardiovascular Outcomes in End-Stage Renal Disease: A Systematic Review and Meta-Analysis. Cardiology in review Mohammed, A. S., Takagi, M. A., Yasmeen, U., Desai, R., Ramaiyah, S., Vasudeva, R., Parmar, G., Gupta, K. 2026

  Abstract

  Cardiovascular disease (CVD) is the leading cause of death among patients with end-stage renal disease (ESRD). The majority of the randomized controlled trials (RCTs) evaluating statin therapy in patients with dialysis did not show statistically significant mortality benefit. In contrast, recent observational studies have consistently demonstrated improvement in mortality. Although the benefits of statin in this population remain controversial, there is also ambiguity regarding the benefit of statin therapy in patients with dialysis and established atherosclerotic cardiovascular disease (ASCVD). A systematic review and meta-analysis was conducted to evaluate the effects of statin therapy in patients with ESRD using the PubMed and Google Scholar databases. Our objective was to assess all-cause and cardiovascular mortality in mixed ESRD populations (with and without ASCVD), as well as in patients with ESRD and established ASCVD. A total of 396,163 patients in 28 studies were included. Overall, statin therapy significantly reduced all-cause mortality [hazard ratios (HR) = 0.75; 95% confidence intervals (CI, 0.68-0.83)] and cardiovascular mortality (HR = 0.75; 95% [CI, 0.60-0.94]). The majority of the benefits were associated with observational data whereas RCTs did not show any mortality benefits. Among patients with ESRD and established ASCVD in observational studies, statin therapy was associated with reduced all-cause mortality (HR = 0.84; 95% [CI, 0.74-0.95]), but there were little or no cardiovascular mortality benefits. There was substantial heterogeneity amongst the studies. In conclusion, real-world data demonstrated the beneficial role of statins in the ESRD population. These findings are hypothesis-generating and highlight the need for prospective trials focused on patients with ESRD and established ASCVD.

  View details for DOI 10.1097/CRD.0000000000001306

  View details for PubMedID 42157355

• Endovascular mechanical thrombectomy vs. catheter-directed thrombolysis in pulmonary embolism: insights from the National Readmission Database. European heart journal. Acute cardiovascular care Majmundar, M., Majmundar, V., Bhat, V., Patel, K. N., Parmar, G., Alli, A., Rohr, A., Monteleone, P., Sethi, S. S., Gupta, K. 2026; 14 (12): 711-719

  Abstract

  Catheter-based therapies for pulmonary embolism (PE), including endovascular mechanical thrombectomy (MT) and catheter-directed thrombolysis (CDT), are increasingly being used in clinical practice. However, real-world comparative data between these two modalities are scarce. We aimed to evaluate and compare the outcomes of MT and CDT in patients with PE.This retrospective cohort study utilized the 2021 National Readmission Database (NRD) to identify adults with a primary diagnosis of PE who underwent either MT or CDT. The primary outcome was in-hospital mortality, while secondary outcomes included major bleeding, cardiac arrest, vascular complications, and post-discharge readmissions. Propensity-score matching was applied, followed by logistic and Cox-proportional hazard regression analyses. Subgroup analyses were conducted based on hospital procedural volume. After propensity-score matching, 7376 patients who underwent MT and 7355 who underwent CDT were included. MT was associated with higher odds of in-hospital mortality (4.4% vs. 3.4%; OR: 1.31, 95% CI: 1.01-1.68; P = 0.04) and major bleeding (6.3% vs. 3.6%; OR: 1.79, 95% CI: 1.39-2.32; P < 0.001) compared with CDT. No significant differences were observed in post-discharge mortality, although all-cause readmissions were higher in the MT group. Higher hospital procedural volumes were associated with lower in-hospital mortality and lower major bleeding rates in both MT and CDT.Endovascular CDT was associated with lower in-hospital mortality and major bleeding compared to MT in PE. As hospital procedural volume increased, both these outcomes improved, while difference in outcomes between MT and CDT reduced.

  View details for DOI 10.1093/ehjacc/zuaf110

  View details for PubMedID 40848264

• Clinical Presentation, Management, and Outcomes of Access-Related Radial Artery Pseudoaneurysms: A Single-Center, Retrospective Cohort Study. Journal of the Society for Cardiovascular Angiography & Interventions Vlach, M., Choudhry, A., Vasudeva, R., Vindhyal, M., Gunasekaran, P., Parmar, G., Haj, G., Serfas, J. D., Wiley, M., Tadros, P., Hockstad, E., Spaedy, A., Decamp, S., Gupta, K. 2026; 5 (1): 104065

  Abstract

  Radial artery pseudoaneurysm (RAP) is a rare complication of procedural radial access. There is a paucity of data regarding clinical presentation, characteristics, and management.We identified patients with RAP by querying our center's electronic medical records. A manual chart review was performed, and a descriptive analysis was conducted.We identified 35 patients with RAP (mean age, 68.3 years; 62.9% women). Of these, 71.4 % of pseudoaneurysms were caused by arterial access for coronary procedures. Sixty percent were on anticoagulation. The most common symptoms were swelling (88.6%) and pain (45.7%). The median time from procedure to diagnosis was 13 days (IQR, 1-33.5 days), and the median time from procedure to symptom onset was 1 day (IQR, 0-8.5 days). Initial treatment modality was mechanical compression in 19 patients (54.3%). Of those who underwent compression, the RAP thrombosed in 9 patients (47.4%) and failed in 10 patients (52.6%) who then underwent successful surgical repair. Those with RAP resolution with compression had a shorter time to ultrasound diagnosis (1 vs 6.5 days) and smaller size (1.6 vs 2.4 cm). Surgery was successful in all but 1 patient.Study findings show that RAPs often present several days after the index procedure, although symptoms occur much earlier. The RAPs occur disproportionately in women and those on anticoagulation. Compression is successful in only half the patients. Earlier presentation and smaller size predict success. Surgery is almost universally successful, and thrombin injection is rarely used. Our results suggest a need for prospective studies to assess strategies for earlier identification of RAP.

  View details for DOI 10.1016/j.jscai.2025.104065

  View details for PubMedID 41919018

  View details for PubMedCentralID PMC13033806

• Acute Limb Ischemia After Percutaneous Coronary Intervention for Stable Coronary Artery Disease. Journal of the American Heart Association Majmundar, M., Chan, W. C., Bhat, V., Abualenain, M., Patel, K. N., Ramani, G., Parmar, G., Gupta, K. 2025; 14 (9): e040026

  Abstract

  Despite its severity, there is limited information on the incidence, predictors, and outcomes of acute limb ischemia (ALI) after percutaneous coronary interventions (PCIs) in stable coronary artery disease.We included all patients undergoing PCI for stable coronary artery disease in the Nationwide Readmissions Database from 2016 to 2020, identifying them using appropriate International Classification of Diseases, Tenth Revision, Clinical Modification (ICD-10-CM), codes. Our primary outcomes were the incidence and predictors of ALI. A total of 629 656 patients underwent PCI for stable coronary artery disease. Of this sample, 3456 (0.55%) had ALI. Peripheral artery disease was the strongest predictor of post-PCI ALI (odds ratio, 53.03 [95% CI, 43.76-64.28], P<0.001). Patients with ALI had a 1.6 times greater risk of in-hospital mortality and a 4.7 times greater risk of in-hospital major amputation. Forty point nine percent of patients with ALI underwent embolectomy, while 11.6% received thrombolysis. Outcomes were similar between ALI of the upper and lower extremity. Patients undergoing embolectomy had greater in-hospital mortality, while the thrombolysis group had greater in-hospital major amputation.ALI is an uncommon complication of PCI but is associated with a high risk of mortality and amputation. Peripheral artery disease is the strongest predictor of post-PCI ALI.

  View details for DOI 10.1161/JAHA.124.040026

  View details for PubMedID 40265592

  View details for PubMedCentralID PMC12184235

• Pulmonary Embolism in Patients with End-Stage Kidney Disease Starting Dialysis. JAMA network open Patel, K. N., Chan, W. C., Bhat, V., Majmundar, M. M., Mehta, H., Munguti, C., Munshi, K., Yarlagadda, S. G., Parmar, G. M., Sharma, A. M., Kadian-Dodov, D., Satterwhite, L. G., Hu, J., Baker Ms, J., Gupta, K. 2025; 8 (3): e250848

  View details for DOI 10.1001/jamanetworkopen.2025.0848

  View details for PubMedID 40094668

  View details for PubMedCentralID PMC11915059

• State-of-the-Art Overview of Diagnosis and Treatment of Raynaud’s Phenomenon Curr Treat Options Cardio Med Asmar, S., Serhal, M., Schainfeld, R., Rosenfield, K., Unizony, S., Castelino, F., Weinberg, I., Parmar, G. 2025: 45

  View details for DOI 10.1007/s11936-025-01109-y

• High ankle-brachial index participants experienced similar long-term mortality as peripheral artery disease in a national sample of community-dwelling adults. Journal of vascular surgery Parmar, G. M., Tanikella, R., Gupta, K., Dicks, A. B., Sakhuja, R., Schainfeld, R., Dua, A., Weinberg, I. 2024; 80 (4): 1251-1259

  Abstract

  Only a few small studies have shown the association between high ankle-brachial pressure index (ABI >1.4) and adverse cardiovascular (CV) events and mortality. Although there is abundant literature depicting the association between ABI and overall systemic atherosclerosis, it typically focuses on low ABI. Furthermore, historically, many studies focusing on peripheral artery disease have excluded high ABI participants. We aimed to study the mortality outcomes of persons with high ABI in the National Health and Nutrition Examination Survey (NHANES).We obtained ABI from participants aged ≥40 years for survey years 1999 to 2004. We defined low a ABI as ≤0.9, normal ABI as 0.9 to 1.4, and high ABI as >1.4 or if the ankle pressures were >245 mm Hg. Demographics, various comorbidities, and laboratory test results were obtained at the time of the survey interview. Multivariable adjusted hazard ratios (HRs) along with 95% confidence intervals (CIs) were calculated for CV and all-cause mortality via Cox proportional hazards regression. Mortality was linked to all NHANES participants for follow-up through December 31, 2019, by the Centers for Disease Control and Prevention.We identified 7639 NHANES participants with available ABI. Of these, 6787 (89%) had a normal ABI, 646 (8%) had a low ABI, and 206 (3%) had elevated ABI. Of participants with high ABI, 50% were men, 15% were African Americans, 10% were current smokers, 56% had hypertension, 33% had diabetes, 15% had chronic kidney disease (CKD), and 18% had concomitant coronary artery disease (CAD). Diabetes (odds ratio [OR], 2.4; 95% CI, 1.7-3.2), CAD (OR, 1.6; 95% CI, 1.0-2.4), and CKD (OR, 1.5; 95% CI, 1.0-2.3) at baseline were associated with having a high ABI, respectively. A high ABI was associated independently with elevated CV (HR, 2.6; 95% CI, 2.1-3.1; P < .0001) and all-cause mortality (HR, 2.5; 95% CI, 2.2-2.8; P < .0001) after adjusting for covariates, including diabetes, CKD, CAD, current smoking, cancer, and hypertension.A high ABI is associated with an elevated CV and all-cause mortality, similar to patients with PAD. High ABI participants should receive the same attention and aggressive medical therapies as patients with PAD.

  View details for DOI 10.1016/j.jvs.2024.06.005

  View details for PubMedID 38866374

• Diagnosis of Pulmonary Embolism: A Review of Evidence-Based Approaches. Journal of clinical medicine Thomas, S. E., Weinberg, I., Schainfeld, R. M., Rosenfield, K., Parmar, G. M. 2024; 13 (13)

  Abstract

  Venous thromboembolism, commonly presented as pulmonary embolism and deep-vein thrombosis, is a paramount and potentially fatal condition with variable clinical presentation. Diagnosis is key to providing appropriate treatment in a safe and timely fashion. Clinical judgment and assessment using clinical scoring systems should guide diagnostic testing, including laboratory and imaging modalities, for optimal results and to avoid unnecessary testing.

  View details for DOI 10.3390/jcm13133722

  View details for PubMedID 38999289

  View details for PubMedCentralID PMC11242034

• Outcomes of peripheral artery disease and polyvascular disease in patients with end-stage kidney disease. Journal of vascular surgery Mehta, H., Chan, W. C., Aday, A. W., Jones, W. S., Parmar, G. M., Hance, K., Thors, A., Alli, A., Wiley, M., Tadros, P., Gupta, K. 2024; 79 (5): 1170-1178.e10

  Abstract

  Patients with peripheral artery disease (PAD) and end-stage kidney disease are a high-risk population, and concomitant atherosclerosis in coronary arteries (CAD) or cerebral arteries (CVD) is common. The aim of the study was to assess long-term outcomes of PAD and the impact of coexistent CAD and CVD on outcomes.The United States Renal Data System was used to identify patients with PAD within 6 months of incident dialysis. Four groups were formed: PAD alone, PAD with CAD, PAD with CVD, and PAD with CAD and CVD. PAD-specific outcomes (chronic limb-threatening ischemia, major amputation, percutaneous/surgical revascularization, and their composite, defined as major adverse limb events [MALE]) as well as all-cause mortality, myocardial infarction, and stroke were studied.The study included 106,567 patients (mean age, 71.2 years; 40.8% female) with a median follow-up of 546 days (interquartile range, 214-1096 days). Most patients had PAD and CAD (49.8%), 25.8% had PAD alone, and 19.2% had all three territories involved. MALE rate in patients with PAD was 22.3% and 35.0% at 1 and 3 years, respectively. In comparison to PAD alone, the coexistence of both CAD and CVD (ie, polyvascular disease) was associated with a higher adjusted rates of all-cause mortality (hazard ratio [HR], 1.28; 95% confidence interval [CI], 1.24-1.31), myocardial infarction (HR, 1.78; 95% CI, 1.69-1.88), stroke (HR, 1.66; 95% CI, 1.52,1.80), and MALE (HR, 1.07; 95% CI, 1.04-1.11).Patients with end-stage kidney disease have a high burden of PAD with poor long-term outcomes, which worsen, in an incremental fashion, with the involvement of each additional diseased arterial bed.

  View details for DOI 10.1016/j.jvs.2024.01.016

  View details for PubMedID 38244643

• Impact of preexisting coronary artery and peripheral artery disease on outcomes in diabetic patients after kidney transplant. Vascular medicine (London, England) Jiwani, S., Chan, W. C., Majmundar, M., Patel, K. N., Mehta, H., Sharma, A., Parmar, G., Wiley, M., Tadros, P., Hockstad, E., Yarlagadda, S. G., Gupta, A., Gupta, K. 2024; 29 (2): 135-142

  Abstract

  Atherosclerotic cardiovascular disease is highly prevalent in patients with end-stage kidney disease (ESKD). Kidney transplant (KT) improves patient survival and cardiovascular outcomes. The impact of preexisting coronary artery disease (CAD) and peripheral artery disease (PAD) on posttransplant outcomes remains unclear.This is a retrospective study utilizing the United States Renal Data System. Adult diabetic dialysis patients who underwent first KT between 2006 and 2017 were included. The study population was divided into four cohorts based on presence of CAD/PAD: (1) polyvascular disease (CAD + PAD); (2) CAD without PAD; (3) PAD without CAD; (4) no CAD or PAD (reference cohort). The primary outcome was 3-year all-cause mortality. Secondary outcomes were incidence of posttransplant myocardial infarction (MI), cerebrovascular accidents (CVA), and graft failure.The study population included 19,329 patients with 64.4% men, mean age 55.4 years, and median dialysis duration of 2.8 years. Atherosclerotic cardiovascular disease was present in 28% of patients. The median follow up was 3 years. All-cause mortality and incidence of posttransplant MI were higher with CAD and highest in patients with polyvascular disease. The cohort with polyvascular disease had twofold higher all-cause mortality (16.7%, adjusted hazard ratio (aHR) 1.5, p < 0.0001) and a fourfold higher incidence of MI (12.7%, aHR 3.3, p < 0.0001) compared to the reference cohort (8.0% and 3.1%, respectively). There was a higher incidence of posttransplant CVA in the cohort with PAD (3.4%, aHR 1.5, p = 0.01) compared to the reference cohort (2.0%). The cohorts had no difference in graft failure rates.Preexisting CAD and/or PAD result in worse posttransplant survival and cardiovascular outcomes in patients with diabetes mellitus and ESKD without a reduction in graft survival.

  View details for DOI 10.1177/1358863X231205574

  View details for PubMedID 37936422

• Atorvastatin Effect on Clopidogrel Efficacy in Patients with Peripheral Artery Disease. Annals of vascular surgery Suarez Ferreira, S. P., Hall, R. P., Majumdar, M., Goudot, G., Jessula, S., Bellomo, T., Lee, I., Kukreja, N., Parmar, G., Boada, A. E., Dua, A. 2023; 95: 74-79

  Abstract

  Both clopidogrel and atorvastatin metabolism are rooted in hepatic cytochrome p450 activation. There are published reports of atorvastatin interfering with clopidogrel metabolism by inhibiting the activation of clopidogrel. This in turn would decrease the therapeutic effect of clopidogrel potentially resulting in an increase in thrombotic events in patients who are taking both medications. The emergence of viscoelastic assays, such as Thromboelastography with platelet mapping (TEG-PM), has been utilized to identify prothrombotic states and may provide insight into a patient's microvascular coagulation profile. The aim of this prospective, observational study was to delineate the differences in platelet function between patients on clopidogrel alone versus those on clopidogrel and atorvastatin in patients that are undergoing peripheral revascularization.All patients undergoing revascularization between December 2020 and August 2022 were prospectively evaluated. Patients on clopidogrel and atorvastatin were compared to those on clopidogrel alone. Serial perioperative TEG-PM analysis was performed up to 6 months postoperatively and the platelet function in terms of percent inhibition was evaluated in both groups. Statistical analysis was performed using unpaired t-test to identify differences in platelet function.Over the study period, a total of 182 patients were enrolled. Of this cohort 72 patients met study criteria. 87 samples from the 72 patients were analyzed. 31 (43.05%) patients were on clopidogrel alone and 41 (56.94%) were on clopidogrel and atorvastatin. Patients on clopidogrel alone showed significantly greater platelet inhibition compared to those on clopidogrel and atorvastatin [49.01% vs. 34.54%, P = 0.03]. There was no statistical difference in platelet inhibition between groups in terms of aspirin use alone versus aspirin and atorvastatin.Patients on clopidogrel and atorvastatin showed significantly less platelet inhibition compared to those on clopidogrel alone, supporting the concept that atorvastatin may interfere with the therapeutic effect of clopidogrel. Patients taking atorvastatin may require an alternative antiplatelet therapy regimen that does not include clopidogrel to achieve adequate thromboprophylaxis.

  View details for DOI 10.1016/j.avsg.2023.05.023

  View details for PubMedID 37257642

  View details for PubMedCentralID PMC10524645

• Mortality differences by race over 20 years in individuals with peripheral artery disease. Vascular medicine (London, England) Dicks, A. B., Lakhter, V., Elgendy, I. Y., Schainfeld, R. M., Mohapatra, A., Giri, J., Weinberg, M. D., Weinberg, I., Parmar, G. 2023; 28 (3): 214-221

  Abstract

  Racial disparities exist in patients with peripheral artery disease (PAD), with Black individuals having worse PAD-specific outcomes. However, mortality risk in this population has been mixed. As such, we sought to evaluate all-cause mortality by race among individuals with PAD.We analyzed data from the National Health and Nutrition Examination Survey (NHANES). Baseline data were obtained from 1999 to 2004. Patients with PAD were grouped according to self-reported race. Multivariable Cox proportional hazards regression was performed to calculate adjusted hazard ratios (HR) by race. A separate analysis was performed to study the effect of burden of social determinants of health (SDoH) on all-cause mortality.Of 647 individuals identified, 130 were Black and 323 were White. Black individuals had more premature PAD (30% vs 20%, p < 0.001) and a higher burden of SDoH compared to White individuals. Crude mortality rates were higher in Black individuals in the 40-49-year and 50-69-year age groups compared to White individuals (6.7% vs 6.1% and 8.8% vs 7.8%, respectively). Multivariable analysis demonstrated that Black individuals with both PAD and coronary artery disease (CAD) had a 30% higher hazard of death over 20 years compared to White individuals (HR = 1.3, 95% CI: 1.0-2.1). The cumulative burden of SDoH marginally (10-20%) increased the risk of all-cause mortality.In a nationally representative sample, Black individuals with PAD and CAD had higher rates of mortality compared to their White counterparts. These findings add further proof to the ongoing racial disparities among Black individuals with PAD and highlight the necessity to identify ways to mitigate these differences.

  View details for DOI 10.1177/1358863X231159947

  View details for PubMedID 37010137

• A Case Report: Acute Respiratory Distress in a Patient with Anemia J Fam Med. Kotnala, S., Wadhawan, S., Parmar, G. 2021; 8 (6): 1262
• Image Challenge: The Road Less Traveled Emergency Med. Gupta, S., Parmar, G. 2020; 11: 398
• A Quick Fix for Better Walking? That's Probably a Bit of a Stretch. Cardiovascular revascularization medicine : including molecular interventions Weinberg, I., Parmar, G. 2019; 20 (8): 628-629

  View details for DOI 10.1016/j.carrev.2019.07.003

  View details for PubMedID 31420071

• Statin use improves limb salvage after intervention for peripheral arterial disease. Journal of vascular surgery Parmar, G. M., Novak, Z., Spangler, E., Patterson, M., Passman, M. A., Beck, A. W., Pearce, B. J. 2019; 70 (2): 539-546

  Abstract

  Statin use is recommended in all patients with peripheral arterial disease (PAD) owing to its morbidity and mortality benefits. However, the effect of statin use on limb salvage in patients with PAD after intervention is unclear. We examined the effect of statin use on limb salvage and survival among patients with PAD undergoing surgical or endovascular intervention.A total of 488 patients with PAD were identified who underwent surgical (n = 297) or endovascular (n = 191) intervention between 2009 and 2010. Information was collected from electronic medical records and the Social Security Death Index. Predictors of ongoing statin use were identified first by univariate analysis and then via multivariable logistic regression. Survival and freedom from amputation were identified using Kaplan-Meier plots and adjusted hazard ratios by Cox regression.Of the 488 patients with PAD with intervention, 39% were non-whites, 44% were females, 41% received statins, 56% received antiplatelets, 26% received oral anticoagulants, 9% required a major amputation, and 11% died during follow-up of up to 88 months. Statin users were more often male (P = .03), white (P = .03), smokers (P < .01), and had higher comorbidities such as coronary artery disease (P < .01), hypertension (P < .01), and diabetes (P < .01). Antiplatelet use was not associated with limb salvage (P = .13), but did improve survival (P < .01). Dual antiplatelet therapy did not show any benefit over monotherapy for limb salvage (P = .4) or survival (P = .3). Statin use was associated with improved survival (P = .04), and improved limb salvage (hazard ratio, 0.3; 95% confidence interval, 0.1-0.7) after adjusting for severity of disease, traditional risk factors, and concurrent antiplatelet use.Statin use in patients with PAD with interventions was associated with improved limb salvage and survival. Despite existing guidelines, statin therapy was low in our PAD population, and efforts are ongoing to increase their use across the health care system.

  View details for DOI 10.1016/j.jvs.2018.07.089

  View details for PubMedID 30718113

• Influence of Age on Warfarin Dose, Anticoagulation Control, and Risk of Hemorrhage. Pharmacotherapy Shendre, A., Parmar, G. M., Dillon, C., Beasley, T. M., Limdi, N. A. 2018; 38 (6): 588-596

  Abstract

  We assessed the influence of age on warfarin dose, percentage time in target range (PTTR), and risk of major hemorrhage.Warfarin users recruited into a large prospective inception cohort study were categorized into three age groups: young (younger than 50 yrs), middle aged (50-70 yrs), and elderly (older than 70 yrs). The influence of age on warfarin dose and PTTR was assessed using regression analysis; risk of major hemorrhage was assessed using proportional hazards analysis. Models were adjusted for demographic, clinical, and genetic factors.Two outpatient anticoagulation clinics.A total of 1498 anticoagulated patients.Warfarin dose (mg/day), PTTR, major hemorrhage.Of the 1498 patients, 22.8% were young, 44.1% were middle aged, and 33.1% were elderly. After accounting for clinical and genetic factors, compared with young warfarin users, warfarin dose requirements were 10.6% lower among the middle aged and an additional 10.6% lower for the elderly. Compared with young patients, middle-aged and elderly patients spent more time in target international normalized ratio (INR) range (p<0.0001), despite having fewer INR assessments (p<0.0001). Compared with young warfarin users, absolute risk of hemorrhage was marginally higher among the middle aged (p=0.08) and significantly higher among the elderly (p=0.016). Compared with young warfarin users, after adjustment, the relative risk of hemorrhage increased by 31% for each age category (p=0.026).In a real-world setting, despite achieving better anticoagulation control, elderly patients had a higher risk of major hemorrhagic events. As the population ages and the candidacy for oral anticoagulation increases, strategies that mitigate the elevated risk of hemorrhage need to be identified.

  View details for DOI 10.1002/phar.2089

  View details for PubMedID 29393514

  View details for PubMedCentralID PMC6014885

• Effect of lipid-modifying drug therapy on survival after abdominal aortic aneurysm repair. Journal of vascular surgery Parmar, G. M., Lowman, B., Combs, B. R., Taylor, S. M., Patterson, M. A., Passman, M. A., Jordan, W. D. 2013; 58 (2): 355-63

  Abstract

  Lipid-modifying drug therapy (LMDT) is recommended in all patients having coronary or noncoronary atherosclerotic disease. However, the effect of LMDT after abdominal aortic aneurysm (AAA) repair, especially in the absence of other atherosclerotic manifestations, is unclear. We examined the distribution of prevalence of LMDT among patients undergoing AAA repair and its effect on survival in the presence and absence of other atherosclerotic diseases.We identified patients treated at University of Alabama at Birmingham between 1985 and 2010 who had a prior AAA repair. Information was collected from health system medical charts, medical communication, and national death indices. We assessed the predictors of prevalence of LMDT by univariate analysis using t-test for continuous and χ(2) test for categorical variables, and then performed multivariate logistic regression. The survival was determined using Kaplan-Meier plots, and adjusted hazard ratios were calculated using Cox proportion regression.A total of 2063 patients underwent AAA repair procedure. Of these, 9% were African-American, and 20% were female. Thirty-five percent received LMDT, and 32% died during the follow-up period of up to 240 months. Significant predictors for being on LMDT included white race (odds ratio [OR], 1.6; 95% confidence interval [CI], 1.1-2.2), presence of other atherosclerotic disease or diabetes (OR, 2.4; 95% CI, 1.9-3.0), hypertension (OR, 4.0; 95% CI, 3.1-5.2), smoking (OR, 1.6; 95% CI, 1.2-2.1), and endovascular AAA repair (OR, 1.9; 95% CI, 1.5-2.3). LMDT was associated with improved survival (hazard ratio, 0.6; 95% CI, 0.5-0.8) after controlling for traditional risk factors, diabetes, and other atherosclerotic diseases.LMDT after AAA is associated with an increased survival compared with patients who were not using drug therapy for dyslipidemia. Aggressive management of dyslipidemia should be considered in all patients undergoing AAA repair irrespective of other atherosclerotic disease status and risk factor profile.

  View details for DOI 10.1016/j.jvs.2013.01.036

  View details for PubMedID 23561430

• Hospital laboratory reporting may be a barrier to detection of 'microsize' myocardial infarction in the US: an observational study. BMC health services research Safford, M. M., Parmar, G., Barasch, C. S., Halanych, J. H., Glasser, S. P., Goff, D. C., Prineas, R. J., Brown, T. M. 2013; 13: 162

  Abstract

  International guidelines recommend that the decision threshold for troponin should be the 99th percentile of a normal population, or, if the laboratory assay is not sufficiently precise at this low level, the level at which the assay achieves a 10% or better coefficient of variation (CV). Our objectives were to examine US hospital laboratory troponin reports to determine whether either the 99th percentile or the 10% CV level were clearly indicated, and whether nonconcordance with these guidelines was a potential barrier to detecting clinically important microscopic or 'microsize' myocardial infarctions (MIs). To confirm past reports of the clinical importance of microsize MIs, we also contrasted in-hospital, 28-day and 1-year mortality among those with microsize and nonmicrosize MI.In the REasons for Geographic And Racial Differences in Stroke national prospective cohort study (n=30,239), 1029 participants were hospitalized for acute coronary syndrome (ACS) between 2003-2009. For each case, we recorded all thresholds of abnormal troponin on the laboratory report and whether the 99th percentile or 10% CV value were clearly identified. All cases were expert adjudicated for presence of MI. Peak troponin values were used to classify MIs as microsize MI (< five times the lowest listed upper limit of normal) and nonmicrosize MI.Participants were hospitalized at 649 acute care US hospitals, only 2% of whose lab reports clearly identified the 99th percentile or the 10% CV level; 52% of reports indicated an indeterminate range, a practice that is no longer recommended. There were 183 microsize MIs and 353 nonmicrosize MIs. In-hospital mortality tended to be lower in the microsize than in the nonmicrosize MI group (1.1 vs. 3.6%, p = 0.09), but 28-day and 1-year mortality were similar (2.5% vs. 2.7% [p = 0.93] and 5.2% vs. 4.3% [p = 0.64], respectively).Current practices in many US hospitals created barriers to the clinical recognition of microsize MI, which was common and clinically important in our study. Improved hospital troponin reporting is warranted.

  View details for DOI 10.1186/1472-6963-13-162

  View details for PubMedID 23635044

  View details for PubMedCentralID PMC3648433

• Awareness and management of chronic disease, insurance status, and health professional shortage areas in the REasons for Geographic And Racial Differences in Stroke (REGARDS): a cross-sectional study. BMC health services research Durant, R. W., Parmar, G., Shuaib, F., Le, A., Brown, T. M., Roth, D. L., Hovater, M., Halanych, J. H., Shikany, J. M., Prineas, R. J., Samdarshi, T. J., Safford, M. M. 2012; 12: 208

  Abstract

  Limited financial and geographic access to primary care can adversely influence chronic disease outcomes. We examined variation in awareness, treatment, and control of hypertension, diabetes, and hyperlipidemia according to both geographic and financial access to care.We analyzed data on 17,458 participants in the REasons for Geographic And Racial Differences in Stroke (REGARDS) study with either hypertension, hyperlipidemia, or diabetes and living in either complete Health Professional Shortage Area (HPSA) counties or non-HPSA counties in the U.S. All analyses were stratified by insurance status and adjusted for sociodemographics and health behaviors.2,261 residents lived in HPSA counties and 15,197 in non-HPSA counties. Among the uninsured, HPSA residents had higher awareness of both hypertension (adjusted OR 2.30, 95% CI 1.08, 4.89) and hyperlipidemia (adjusted OR 1.50, 95% CI 1.01, 2.22) compared to non-HPSA residents. Also among the uninsured, HPSA residents with hypertension had lower blood pressure control (adjusted OR 0.45, 95% CI 0.29, 0.71) compared with non-HPSA residents. Similar differences in awareness and control according to HPSA residence were absent among the insured.Despite similar or higher awareness of some chronic diseases, uninsured HPSA residents may achieve control of hypertension at lower rates compared to uninsured non-HPSA residents. Federal allocations in HPSAs should target improved quality of care as well as increasing the number of available physicians.

  View details for DOI 10.1186/1472-6963-12-208

  View details for PubMedID 22818296

  View details for PubMedCentralID PMC3571909

• Awareness, treatment and control of hypertension, diabetes and hyperlipidemia and area-level mortality regions in the Reasons for Geographic and Racial Differences in Stroke (REGARDS) study. Journal of health care for the poor and underserved Shuaib, F. M., Durant, R. W., Parmar, G., Brown, T. M., Roth, D. L., Hovater, M., Halanych, J. H., Shikany, J. M., Howard, G., Safford, M. M. 2012; 23 (2): 903-21

  Abstract

  Health Professional Shortage Areas (HPSA) receive extra federal resources, but recent reports suggest that HPSA may not consistently identify areas of need.To assess areas of need based on county-level ischemic heart disease (IHD) and stroke mortality regions.Need was defined by lack of awareness, treatment, or control of hypertension, diabetes, or hyperlipidemia. Counties were categorized into race-specific tertiles of IHD and stroke mortality using 1999-2006 CDC data. Multivariable logistic regression was used to model the relationships between IHD and stroke mortality region and each element of need.Awareness and treatment of cardiovascular (CVD) risk factors were similar for residents in counties across IHD and stroke mortality tertiles, but control tended to be lower in counties with the highest mortality.High stroke and IHD mortality identify distinct regions from current HPSA designations, and may be an additional criterion for designating areas of need.

  View details for DOI 10.1353/hpu.2012.0045

  View details for PubMedID 22643632

  View details for PubMedCentralID PMC3771503

• Protocol implementation of selective postoperative lumbar spinal drainage after thoracic aortic endograft. Journal of vascular surgery Keith, C. J., Passman, M. A., Carignan, M. J., Parmar, G. M., Nagre, S. B., Patterson, M. A., Taylor, S. M., Jordan, W. D. 2012; 55 (1): 1-8; discussion 8

  Abstract

  Spinal cord ischemia (SCI) remains a significant concern in patients undergoing endovascular repair involving the thoracic aorta (thoracic endovascular aortic repair [TEVAR]). Perioperative lumbar spinal drainage has been widely practiced for open repair, but there is no consensus treatment protocol using lumbar drainage for SCI associated with TEVAR. This study analyzes the efficacy of an institutional protocol using selective lumbar drainage reserved for patients experiencing SCI following TEVAR.A prospectively maintained registry was reviewed to identify all patients who underwent TEVAR from January 2000 through June 2010. Preoperative characteristics, intraoperative details, and outcomes, including neurologic deficit and mortality at 30 days and 1 year were determined based on reporting standards. Patients developing symptoms of SCI in the postoperative setting were compared with those without neurologic symptoms. SCI patients who received selective lumbar drainage were grouped based on resolution of neurologic function, with risk factors and outcomes of these subgroups analyzed with χ(2), t test, logistic regression, and analysis of variance (ANOVA).Two hundred seventy-eight TEVARs were performed on 251 patients. Twelve patients accounting for 12 TEVARs were excluded from analysis: 5 patients experienced SCI preoperatively, 4 patients were drained preoperatively, 2 expired intraoperatively, and 1 procedure was aborted. Of the remaining 266 procedures in 239 patients, 16 (6.0%) developed SCI within the 30-day postoperative period. Risk factors for SCI reaching statistical significance included length of aortic coverage (P = .036), existence of infrarenal aortic pathology (P = .026), and history of stroke (P = .043). Stent graft coverage of the left subclavian artery origin was required in 28.9% (n = 77) and was not associated with SCI (P = .52). Ten of 16 post-TEVAR SCI patients received selective postoperative lumbar drains and were categorized based on resolution of symptoms into complete resolution (n = 3; 30%), partial resolution (n = 4; 40%), and no resolution (n = 3; 30%). No patient characteristics or risk factors reached significance in comparison of lumbar drained patients and nondrained patients. All seven drained patients without complete resolution of SCI died within the first year after surgery, while all three of the complete responders survived (P = .017). In patients with SCI, increased all-cause mortality was observed at 1 year (56.3% vs 20.4%; P = .003).A protocol utilizing selective postoperative lumbar spinal drainage can be used safely for patients developing SCI after TEVAR with acceptably low permanent neurologic deficit, although overall survival of patients experiencing SCI after TEVAR is diminished relative to non-SCI patients.

  View details for DOI 10.1016/j.jvs.2011.07.086

  View details for PubMedID 21981799

• Long-term single institution comparison of endovascular aneurysm repair and open aortic aneurysm repair. Journal of vascular surgery Quinney, B. E., Parmar, G. M., Nagre, S. B., Patterson, M., Passman, M. A., Taylor, S., Chambers, J., Jordan, W. D. 2011; 54 (6): 1592-7; discussion 1597-8

  Abstract

  Since the development of endovascular aneurysm repair (EVAR), there remains concerns regarding its durability, need for secondary procedures, and associated long-term morbidity. We compared these two approaches to evaluate secondary interventions and their respective long-term durability.All patients who had undergone endovascular and open abdominal aortic aneurysm (AAA) repair were identified from a prospectively maintained registry. Health system charts, medical communication, and national death indexes were reviewed. Secondary interventions were classified as vascular (aortic graft or remote) and nonvascular (incisional or gastrointestinal).Between July 1985 and September 2009, 1908 patients underwent 1986 AAA repair procedures (EVAR = 1066; open = 920). Patients were followed up to 290 months (mean 27.6 ± 35.9) and identified with 427 surgical encounters (EVAR 233% to 21.9%; open 194% to 21.1%). Most encounters (338% to 74.6%) were related to vascular disease: 178 (EVAR = 131; open = 47) related to the aortic graft; 160 (EVAR = 93; open = 67) were related to nonaortic vascular disease. The remaining 89 surgical encounters included incisional hernias, small bowel obstruction, intra-abdominal abscesses, and wound dehiscence requiring operation. Of these 89 encounters (EVAR = 9; open = 80), 44 patients required surgical intervention and 36 required hospitalization without surgical procedure. Over the period of 100 months, the all-cause mortality rate was 25.2% after EVAR and 39.1% after open repair. One-year survival was 88.0% (SE 0.01) and 85.0% (SE 0.01), while 5-year survival was 58.0% (SE 0.02) and 53.0% (SE 0.02) for EVAR and open repair, respectively (log-rank P value < .0164). Seven-year survival was 46% (SE 0.03) for EVAR and 36% (SE 0.03) for open AAA repair.EVAR requires more late secondary vascular interventions than open AAA repair, but patients who undergo open repair have more nonvascular long-term morbidity. Long-term survival is better after EVAR compared to open repair in this selected patient group.

  View details for DOI 10.1016/j.jvs.2011.06.114

  View details for PubMedID 22137301

• Health Professional Shortage Areas, insurance status, and cardiovascular disease prevention in the Reasons for Geographic and Racial Differences in Stroke (REGARDS) Study. Journal of health care for the poor and underserved Brown, T. M., Parmar, G., Durant, R. W., Halanych, J. H., Hovater, M., Muntner, P., Prineas, R. J., Roth, D. L., Samdarshi, T. E., Safford, M. M. 2011; 22 (4): 1179-89

  Abstract

  Individuals with cardiovascular disease (CVD) living in Health Professional Shortage Areas (HPSA) may receive less preventive care than others. The Reasons for Geographic And Racial Differences in Stroke Study (REGARDS) surveyed 30,239 African American (AA) and White individuals older than 45 years of age between 2003-2007. We compared medication use for CVD prevention by HPSA and insurance status, adjusting for sociodemographic factors, health behaviors, and health status. Individuals residing in partial HPSA counties were excluded. Mean age was 64±9 years, 42% were AA, 55% were women, and 93% had health insurance; 2,545 resided in 340 complete HPSA counties and 17,427 in 1,145 non-HPSA counties. Aspirin, beta-blocker, and ACE-inhibitor use were similar by HPSA and insurance status. Compared with insured individuals living in non-HPSA counties, statin use was lower among uninsured participants living in non-HPSA and HPSA counties. Less medication use for CVD prevention was not associated with HPSA status, but less statin use was associated with lack of insurance.

  View details for DOI 10.1353/hpu.2011.0127

  View details for PubMedID 22080702

  View details for PubMedCentralID PMC3586412

• Agreement on cause of death between proxies, death certificates, and clinician adjudicators in the Reasons for Geographic and Racial Differences in Stroke (REGARDS) study. American journal of epidemiology Halanych, J. H., Shuaib, F., Parmar, G., Tanikella, R., Howard, V. J., Roth, D. L., Prineas, R. J., Safford, M. M. 2011; 173 (11): 1319-26

  Abstract

  Death certificates may lack accuracy and misclassify the cause of death. The validity of proxy-reported cause of death is not well established. The authors examined death records on 336 participants in the Reasons for Geographic and Racial Differences in Stroke (REGARDS) Study, a national cohort study of 30,239 community-dwelling US adults (2003-2010). Trained experts used study data, medical records, death certificates, and proxy reports to adjudicate causes of death. The authors computed agreement on cause of death from the death certificate, proxy, and adjudication, as well as sensitivity and specificity for certain diseases. Adjudicated cause of death had a higher rate of agreement with proxy reports (73%; Cohen's kappa (κ) statistic = 0.69) than with death certificates (61%; κ = 0.54). The agreement between proxy reports and adjudicators was better than agreement with death certificates for all disease-specific causes of death. Using the adjudicator assessments as the "gold standard," for disease-specific causes of death, proxy reports had similar or higher specificity and higher sensitivity (sensitivity = 50%-89%) than death certificates (sensitivity = 31%-81%). Proxy reports may be more concordant with adjudicated causes of death than with the causes of death listed on death certificates. In many settings, proxy reports may represent a better strategy for determining cause of death than reliance on death certificates.

  View details for DOI 10.1093/aje/kwr033

  View details for PubMedID 21540327

  View details for PubMedCentralID PMC3101067

• Cardiovascular outcome ascertainment was similar using blinded and unblinded adjudicators in a national prospective study. Journal of clinical epidemiology Parmar, G., Ghuge, P., Halanych, J. H., Funkhouser, E., Safford, M. M. 2010; 63 (10): 1159-63

  Abstract

  Observational studies can avoid biases by blinding medical records to characteristics of interest before outcome adjudication. However, blinding is costly. We assessed the effect of blinding race and geography on outcome ascertainment.The Reasons for Geographic and Racial Differences in Stroke - Myocardial Infarction (REGARDS-MI) Study is an ancillary study to the REGARDS national prospective cohort study including 30,228 participants. The primary characteristics of interest are race and geography, and the prespecified acceptable agreement rate between adjudicators is set at less than 80%. We selected 116 suspected cardiovascular events that underwent adjudication with usual blinding. At least 3 months later, cases were readjudicated without blinding race and geographic location of the patient. We assessed differences in outcome ascertainment using Cohen's kappa statistic and ARs.Agreement between blinded and unblinded reviews was good to excellent for all four outcomes. kappa statistics were 0.80 (chest pain), 0.85 (heart failure), 0.86 (revascularization), and 0.74 (MI) (P<0.0001 for all). Within each outcome, ARs were similar for race and geographic groups (agreement: 83-100%).In observational studies, blinding medical record review for outcome ascertainment for some types of patient characteristics may cause an unwarranted expense.

  View details for DOI 10.1016/j.jclinepi.2009.12.017

  View details for PubMedID 20430582

  View details for PubMedCentralID PMC2913162