Jennifer Tremmel

All Publications

• Patient-Reported Psychological Distress After Spontaneous Coronary Artery Dissection: EVIDENCE FOR POST-TRAUMATIC STRESS. Journal of cardiopulmonary rehabilitation and prevention Edwards, K. S., Vaca, K. C., Naderi, S., Tremmel, J. A. 2019

  Abstract

  PURPOSE: High rates of depression and anxiety are reported among patients who have experienced spontaneous coronary artery dissection (SCAD) but the incidence of post-traumatic stress disorder (PTSD) is unknown. The purpose of this study was to investigate symptoms of PTSD in women who have experienced SCAD.METHODS: This cross-sectional pilot study included 14 female SCAD patients, mean age of 51 yr, who responded to standardized psychosocial questionnaires at a median of 35 mo post-SCAD. Patients were identified by cardiologists as having had a SCAD event and were concurrently invited to participate in a psychosocial group for SCAD survivors.RESULTS: Participants reported current symptoms of stress (93%), insomnia (57%), anxiety (71%), depression (36%), and PTSD (43%). Eight of the 11 women who reported having a mental health history (72.7%) indicated that their symptoms were related to having experienced SCAD. Health-related quality of life and social support were comparable with other all-female cardiac samples. Patterns of perceived control were more similar to those of patients with cancer than other cardiac patients in that SCAD patients ranked "chance" as more likely than "self-control" to impact medical outcomes.CONCLUSIONS: The prevalence of PTSD symptoms in this first-known assessment of post-traumatic stress among SCAD patients is concerning. The unexpected nature of SCAD and lack of known treatment options may play a role in patient distress. Future research is needed to accurately estimate rates of PTSD after SCAD and assess the benefits of treatment.

  View details for DOI 10.1097/HCR.0000000000000460

  View details for PubMedID 31343583

• Psychological Distress Among Female Cardiac Patients Presenting to a Women's Heart Health Clinic AMERICAN JOURNAL OF CARDIOLOGY Edwards, K. S., Hekler, A. C., Baum, J., Nejedly, M., Tsai, S., Khandelwal, A., Naderi, S., Hoover, V., Tremmel, J. A. 2019; 123 (12): 2026–30

  View details for DOI 10.1016/j.amjcard.2019.03.029

  View details for Web of Science ID 000472238900022

• Psychological Distress Among Female Cardiac Patients Presenting to a Women's Heart Health Clinic. The American journal of cardiology Edwards, K. S., Hekler, A. C., Baum, J., Nejedly, M., Tsai, S., Khandelwal, A., Naderi, S., Hoover, V., Tremmel, J. A. 2019

  Abstract

  Female cardiac patients are at greater risk for mental health disorders than their male counterparts, and these mental health disorders have been associated with increased cardiac morbidity and mortality. However, few studies have closely examined the mental health disorders found among the female cardiac population. The primary aim of this study was to examine the prevalence of psychological distress in a sample of female cardiac outpatients at an academic medical center. A secondary aim was to determine whether different demographic variables, cardiac risk factors, or cardiac diagnoses were associated with different levels of emotional distress. A survey, including demographic information, medical status, and standardized symptom measures was completed by 117 female patients scheduled for medical visits at an outpatient women's heart health clinic over a 4-month period. Using standardized self-report questionnaires, 38% scored in the moderate-to-severe range for at least 1 mental disorder and 50% endorsed current insomnia. Symptoms of clinical depression (20%) and anxiety (42)% were endorsed at higher rates than predominantly male or mixed comparison samples. Although there was no apparent relation between the severity of cardiac problems and the degree of psychological distress, women with diagnoses of hyperlipidemia, prediabetes, and diabetes reported greater psychological distress than those without these problems. Women with lower income also reported more psychological distress. In conclusion, our findings suggest an unmet need for integrated mental health services for female cardiac patients.

  View details for PubMedID 31006484

• EXPRESS: Myocardial Bridge - An Unrecognized Cause of Chest Pain in Pulmonary Arterial Hypertension. Pulmonary circulation Rajmohan, D., Sung, Y. K., Kudelko, K., Perez, V. i., Haddad, F., Tremmel, J., Schnittger, I., Zamanian, R. T., Spiekerkoetter, E. F. 2019: 2045894019860738

  View details for DOI 10.1177/2045894019860738

  View details for PubMedID 31187693

• Asymmetric dimethylarginine predicts impaired epicardial coronary vasomotion in patients with angina in the absence of obstructive coronary artery disease. International journal of cardiology Parikh, R. V., Pargaonkar, V., Ball, R. L., Kobayashi, Y., Kimura, T., Yeung, A. C., Cooke, J. P., Tremmel, J. A. 2019

  Abstract

  Impaired epicardial coronary vasomotion is a potential mechanism of angina and a predictor of adverse cardiovascular outcomes in patients without angiographic evidence of obstructive coronary artery disease (CAD). We sought to evaluate the association of asymmetric dimethylarginine (ADMA)-a marker of nitric oxide-mediated vascular dysfunction-with epicardial coronary vasomotor dysfunction in this select population.Invasive testing for epicardial vasomotor dysfunction was performed using intracoronary acetylcholine in the left anterior descending coronary artery. Impaired vasomotor response was defined as a luminal constriction of >20% on quantitative coronary angiography. Plasma ADMA levels were measured using high performance liquid chromatography. A robust multivariate linear mixed-effect model approach and Akaike information criterion were used to determine predictors of vasomotor dysfunction.In 191 patients with angina in the absence of obstructive CAD, abnormal epicardial vasomotion was observed in 137 (71.7%) patients. Median ADMA rose as the extent of impairment progressed: none (0.48 [0.44-0.59] μM), any (0.51 [0.46-0.60] μM, p = 0.12), focal (0.54 [0.49,0.61] μM, p = 0.17), and diffuse (0.55 [0.49,0.63] μM, p = 0.02). In unadjusted analysis, ADMA was highly predictive of vasomotor dysfunction (χ2=15.1, p = 0.002). Notably, ADMA remained a significant predictor even after adjusting for other factors in the best fit model (χ2=10.0, p = 0.02).ADMA is an independent predictor of epicardial coronary vasomotor dysfunction in patients with angina in the absence of obstructive CAD. These data support a very early mechanistic role of ADMA in the continuum of atherosclerotic heart disease.

  View details for DOI 10.1016/j.ijcard.2019.07.062

  View details for PubMedID 31416658

• Breastfeeding Duration and the Risk of Coronary Artery Disease. Journal of women's health (2002) Rajaei, S., Rigdon, J., Crowe, S., Tremmel, J., Tsai, S., Assimes, T. L. 2018

  Abstract

  BACKGROUND: Previous studies have suggested that prolonged breastfeeding has beneficial effects on the health of the mother including the reduction of long-term risk of coronary artery disease (CAD). The mechanism of this association remains unclear.METHODS: We surveyed 643 women aged 40-65 years receiving outpatient care at Stanford University Hospital on their reproductive/lactation history, including 137 women (cases) with clinically confirmed CAD. Survey data were supplemented with traditional risk factor data for CAD obtained from the participant's medical record. We then conducted logistic regression analyses to assess the relationship between breastfeeding duration and case-control status for each of the two separate definitions of duration. The first was based on the participant's single longest duration of breastfeeding considering all live births reported and the second was based on a participant's total duration of breastfeeding summed over all live births. For each of these two definitions, we ran three sequential models each with a different reference group-(1) nulliparous women, (2) parous women that never breastfed, and (3) parous women with a short duration of breastfeeding-successively excluding women in the reference group of the previous model(s).RESULTS: Just over one-half (51.6%) of the women surveyed reported a history of breastfeeding. We found nominally significant associations (p=0.04-0.12) for our multivariate analyses that modeled maximum duration of breastfeeding. When compared with nulliparous women, parous women who either never breastfed or always breastfed for <5 months had approximately double the risk of CAD. Among parous women, women who breastfeed for ≥5 months at least once in their lifetime had a 30% decrease risk of CAD compared with those who did not initiate breastfeeding. Among parous women who breastfed ≥1 month, women who breastfed ≥5 months had 50% decreased risk of CAD. We found similar point estimates of effect for analogous analyses modeling maximum breastfeeding duration but p-values for these analyses were not significant. Unadjusted analyses demonstrated higher valued odds ratios and lower p-values suggesting the presence of some confounding by traditional risk factors.CONCLUSIONS: Parous women who breastfeed ≥5 months in at least one pregnancy seem to be at decreased risk of CAD later in their life, whereas parous women who either never breastfed or discontinued breastfeeding early seem to be at increased risk. More research is needed to more reliably quantify and determine the nature of the relationship between parity, breastfeeding duration, and risk of CAD.

  View details for PubMedID 30523760

• Is Post-Percutaneous Coronary Intervention Fractional Flow Reserve of Value in Chronic Total Occlusions? CIRCULATION-CARDIOVASCULAR INTERVENTIONS Tremmel, J. A., Fearon, W. F. 2018; 11 (11)

  View details for DOI 10.1161/CIRCINTERVENTIONS.118.007360

  View details for Web of Science ID 000450657500012

• Vascular Access-Related Complications in Women: Temporal Trends, Emerging Data, and the Current State of Interventional Cardiology Practice CURRENT ATHEROSCLEROSIS REPORTS Chacko, Y., Parikh, R. V., Tremmel, J. A. 2018; 20 (8): 41

  Abstract

  Women undergoing cardiac catheterization, percutaneous coronary intervention, transcatheter aortic valve replacement, and other structural heart interventions have a significantly higher risk of vascular complications and bleeding than men, leading to significant morbidity and mortality. This review highlights the importance of recognizing female sex as a specific and independent risk factor, and focuses on mechanisms of increased risk and strategies to minimize that risk. Smaller caliber peripheral vessels, low body weight, variations in platelet reactivity, and inappropriate dosing of anticoagulant and antiplatelet agents are the currently identified mechanisms for elevated bleeding and vascular complication risk in women. Radial-preferred access, smaller caliber sheaths, imaging-guided arterial puncture, and more judicious anticoagulant dosing have led to reduced bleeding and vascular complication rates in both sexes, especially women. Obtaining proficiency in these strategies should be a priority for operators in order to improve safety and procedural outcomes in women.

  View details for PubMedID 29884916

• Surgical unroofing of hemodynamically significant myocardial bridges in a pediatric population. The Journal of thoracic and cardiovascular surgery Maeda, K., Schnittger, I., Murphy, D. J., Tremmel, J. A., Boyd, J. H., Peng, L., Okada, K., Pargaonkar, V. S., Hanley, F. L., Mitchell, R. S., Rogers, I. S. 2018

  Abstract

  BACKGROUND: Although myocardial bridges (MBs) are traditionally regarded as incidental findings, it has been reported that adult patients with symptomatic MBs refractory to medical therapy benefit from unroofing. However, there is limited literature in the pediatric population. The aim of our study was to evaluate the indications and outcomes for unroofing in pediatric patients.METHODS: We retrospectively reviewed all pediatric patients with MB in our institution who underwent surgical relief. Clinical characteristics, relevant diagnostic data, intraoperative findings, and postoperative outcomes were evaluated.RESULTS: Between 2012 and 2016, 14 pediatric patients underwent surgical unroofing of left anterior descending artery MBs. Thirteen patients had anginal symptoms refractory to medical therapy, and 1 patient was asymptomatic until experiencing aborted sudden cardiac arrest during exercise. Thirteen patients underwent exercise stress echocardiography, all of which showed mid-septal dys-synergy. Coronary computed tomography imaging confirmed the presence of MBs in all patients. Intravascular ultrasound imaging confirmed the length of MBs: 28.2±16.3mm, halo thickness: 0.59±0.24mm, and compression of left anterior descending artery at resting heart rate: 33.0±11.6%. Invasive hemodynamic assessment with dobutamine confirmed the physiologic significance of the MBs with diastolic fractional flow reserve: 0.59±0.13. Unroofing was performed with the patient under cardiopulmonary bypass (CPB) in the initial 9 cases and without CPB in the subsequent 5 cases. All patients were discharged without complications. The 13 symptomatic patients reported resolution of symptoms on follow-up, and improvement in symptoms and quality of life was documented using the Seattle Angina Questionnaire version 7.CONCLUSIONS: Unroofing of MBs can be safely performed in pediatric patients, with or without use of CPB. In symptomatic patients, unroofing can provide relief of symptoms refractory to medical therapy.

  View details for PubMedID 30005887

• EFFECT OF RANOLAZINE ON SYMPTOMS AND QUALITY OF LIFE IN PATIENTS WITH ANGINA IN THE ABSENCE OF OBSTRUCTIVE CORONARY ARTERY DISEASE: A RETROSPECTIVE COHORT STUDY Pargaonkar, V., Tremmel, J., Schnittger, I., Khandelwal, A. ELSEVIER SCIENCE INC. 2018: 161

  View details for DOI 10.1016/S0735-1097(18)30702-2

  View details for Web of Science ID 000429659701011

• SUBCLINICAL LEFT VENTRICULAR DYSFUNCTION IN WOMEN WITH ANGINA IN THE ABSENCE OF OBSTRUCTIVE CORONARY ARTERY DISEASE: A COMPREHENSIVE INVASIVE AND ECHOCARDIOGRAPHIC STUDY Bouajila, S., Pargaonkar, V., Kobayashi, Y., Kobayashi, Y., Haddad, F., Tremmel, J. ELSEVIER SCIENCE INC. 2018: 132

  View details for DOI 10.1016/S0735-1097(18)30673-9

  View details for Web of Science ID 000429659700133

• MYOCARDIAL BRIDGE MUSCLE INDEX (MMI): A MARKER OF DISEASE SEVERITY AND ITS RELATIONSHIP WITH ENDOTHELIAL DYSFUNCTION AND SYMPTOMATIC OUTCOME IN PATIENTS WITH ANGINA AND A HEMODYNAMICALLY SIGNIFICANT MYOCARDIAL BRIDGE Pargaonkar, V., Schnittger, I., Rogers, I., Tanaka, S., Yamada, R., Kimura, T., Boyd, J., Tremmel, J. ELSEVIER SCIENCE INC. 2018: 160

  View details for DOI 10.1016/S0735-1097(18)30701-0

  View details for Web of Science ID 000429659701010

• Accuracy of non-invasive stress testing in women and men with angina in the absence of obstructive coronary artery disease. International journal of cardiology Pargaonkar, V. S., Kobayashi, Y., Kimura, T., Schnittger, I., Chow, E. K., Froelicher, V. F., Rogers, I. S., Lee, D. P., Fearon, W. F., Yeung, A. C., Stefanick, M. L., Tremmel, J. A. 2018

  Abstract

  While >20% of patients presenting to the cardiac catheterization laboratory with angina have no obstructive coronary artery disease (CAD), a majority (77%) have an occult coronary abnormality (endothelial dysfunction, microvascular dysfunction (MVD), and/or a myocardial bridge (MB)). There are little data regarding the ability of noninvasive stress testing to identify these occult abnormalities in patients with angina in the absence of obstructive CAD.We retrospectively evaluated 155 patients (76.7% women) with angina and no obstructive CAD who underwent stress echocardiography and/or electrocardiography before angiography. We evaluated Duke treadmill score, heart rate recovery (HRR), metabolic equivalents, and blood pressure response. During angiography, patients underwent invasive testing for endothelial dysfunction (decrease in epicardial coronary artery diameter >20% after intracoronary acetylcholine), MVD (index of microcirculatory resistance ≥25), and intravascular ultrasound for the presence of an MB.Stress echocardiography and electrocardiography were positive in 58 (43.6%) and 57 (36.7%) patients, respectively. Endothelial dysfunction was present in 96 (64%), MVD in 32 (20.6%), and an MB in 83 (53.9%). On multivariable logistic regression, stress echo was not associated with any abnormality, while stress ECG was associated with endothelial dysfunction. An abnormal HRR was associated with endothelial dysfunction and MVD, but not an MB.Conventional stress testing is insufficient for identifying occult coronary abnormalities that are frequently present in patients with angina in the absence of obstructive CAD. A normal stress test does not rule out a non-obstructive coronary etiology of angina, nor does it negate the need for comprehensive invasive testing.

  View details for DOI 10.1016/j.ijcard.2018.10.073

  View details for PubMedID 30527992

• Is Post-Percutaneous Coronary Intervention Fractional Flow Reserve of Value in Chronic Total Occlusions? Circulation. Cardiovascular interventions Tremmel, J. A., Fearon, W. F. 2018; 11 (11): e007360

  View details for PubMedID 30571221

• Late breaking trials of 2016 in coronary artery disease: Commentary covering SCAI, ACC, TCT, EuroPCR, ESC, and AHA. Catheterization and cardiovascular interventions : official journal of the Society for Cardiac Angiography & Interventions Seto, A. H., Dehghani, P., Shah, B., Anwaruddin, S., Safirstein, J., Tremmel, J. A. 2017; 89 (6): 1028-1034

  Abstract

  The SCAI Publications Committee and Emerging Leadership Mentorship (ELM) Fellows concisely summarize and provide context on the most important coronary trials presented at large international meetings in 2016, including SCAI, ACC, TCT, EuroPCR, ESC, and AHA. The intent is to allow quick assimilation of trial results into interventional practice, and enable busy interventional cardiologists to stay up to date. © 2017 Wiley Periodicals, Inc.

  View details for DOI 10.1002/ccd.26940

  View details for PubMedID 28276150

• Myocardial Bridges on Coronary Computed Tomography Angiography　- Correlation With Intravascular Ultrasound and Fractional Flow Reserve. Circulation journal : official journal of the Japanese Circulation Society Forsdahl, S. H., Rogers, I. S., Schnittger, I., Tanaka, S., Kimura, T., Pargaonkar, V. S., Chan, F. P., Fleischmann, D., Tremmel, J. A., Becker, H. C. 2017

  Abstract

  Myocardial bridges (MB) are commonly seen on coronary CT angiography (CCTA) in asymptomatic individuals, but in patients with recurrent typical angina symptoms, yet no obstructive coronary artery disease (CAD), evaluation of their potential hemodynamic significance is clinically relevant. The aim of this study was to compare CCTA to invasive coronary angiography (ICA), including intravascular ultrasound (IVUS), to confirm MB morphology and estimate their functional significance in symptomatic patients.Methods and Results:We retrospectively identified 59 patients from our clinical databases between 2009 and 2014 in whom the suspicion for MB was raised by symptoms of recurrent typical angina in the absence of significant obstructive CAD on ICA. All patients underwent CCTA, ICA and IVUS. MB length and depth by CCTA agreed well with length (0.6±23.7 mm) and depth (CT coverage) as seen on IVUS. The product of CT length and depth (CT coverage), (MB muscle index (MMI)), ≥31 predicted an abnormal diastolic fractional flow reserve (dFFR) ≤0.76 with a sensitivity and specificity of 74% and 62% respectively (area under the curve=0.722).In patients with recurrent symptoms of typical angina yet no obstructive CAD, clinicians should consider dynamic ischemia from an MB in the differential diagnosis. The product of length and depth (i.e., MMI) by CCTA may provide some non-invasive insight into the hemodynamic significance of a myocardial bridge, as compared with invasive assessment with dFFR.

  View details for PubMedID 28690285

• Pyruvate controls the checkpoint inhibitor PD-L1 and suppresses T cell immunity. The Journal of clinical investigation Watanabe, R., Shirai, T., Namkoong, H., Zhang, H., Berry, G. J., Wallis, B. B., Schaefgen, B., Harrison, D. G., Tremmel, J. A., Giacomini, J. C., Goronzy, J. J., Weyand, C. M. 2017; 127 (7): 2725–38

  Abstract

  Patients with coronary artery disease (CAD) are at high risk for reactivation of the varicella zoster virus (VZV) and development of herpes zoster (HZ). Here, we found that macrophages from patients with CAD actively suppress T cell activation and expansion, leading to defective VZV-specific T cell immunity. Monocyte-derived and plaque-infiltrating macrophages from patients with CAD spontaneously expressed high surface density of the immunoinhibitory ligand programmed death ligand-1 (PD-L1), thereby providing negative signals to programmed death-1+ (PD-1+) T cells. We determined that aberrant PD-L1 expression in patient-derived macrophages was metabolically controlled. Oversupply of the glycolytic intermediate pyruvate in mitochondria from CAD macrophages promoted expression of PD-L1 via induction of the bone morphogenetic protein 4/phosphorylated SMAD1/5/IFN regulatory factor 1 (BMP4/p-SMAD1/5/IRF1) signaling pathway. Thus, CAD macrophages respond to nutrient excess by activating the immunoinhibitory PD-1/PD-L1 checkpoint, leading to impaired T cell immunity. This finding indicates that metabolite-based immunotherapy may be a potential strategy for restoring adaptive immunity in CAD.

  View details for PubMedID 28604383

• Myocardial bridges: Overview of diagnosis and management. Congenital heart disease Rogers, I. S., Tremmel, J. A., Schnittger, I. 2017

  Abstract

  A myocardial bridge is a segment of a coronary artery that travels into the myocardium instead of the normal epicardial course. Although it is general perception that myocardial bridges are normal variants, patients with myocardial bridges can present with symptoms, such as exertional chest pain, that cannot be explained by a secondary etiology. Such patients may benefit from individualized medical/surgical therapy. This article describes the prevalence, clinical presentation, classification, evaluation, and management of children and adults with symptomatic myocardial bridges.

  View details for PubMedID 28675696

• Myocardial bridging is associated with exercise-induced ventricular arrhythmia and increases in QT dispersion. Annals of noninvasive electrocardiology : the official journal of the International Society for Holter and Noninvasive Electrocardiology, Inc Nishikii-Tachibana, M., Pargaonkar, V. S., Schnittger, I., Haddad, F., Rogers, I. S., Tremmel, J. A., Wang, P. J. 2017

  Abstract

  A myocardial bridge (MB) has been associated with ventricular arrhythmia and sudden death during exercise. QT dispersion (QTd) is a measure of abnormal repolarization and may predict ventricular arrhythmia. We investigated the frequency of ventricular arrhythmias during exercise and the QTd at rest and after exercise, in patients with an MB compared to a normal cohort.We studied the rest and stress ECG tracings of patients with an MB suspected by focal septal buckling on exercise echocardiography (EE) (Echo-MB group, N = 510), those with an MB confirmed by another examination (MB group, N = 110), and healthy controls (Control group, N = 198).The frequency of exercise-induced premature ventricular contractions (PVCs) was significantly higher in the Echo-MB and MB groups compared with the Control group (both p < .001). In all, 25 patients (4.9%) in the Echo-MB group, seven patients (6.4%) in the MB group and no patients in the Control group had exercise-induced non-sustained ventricular tachycardia (NSVT). There was no difference in the baseline QTd between the groups. In the Echo-MB and MB groups, QTd postexercise increased significantly when compared with baseline (both p < .001). Patients with NSVT had a higher frequency of male gender and an even greater increase in QTd with exercise compared with the non-NSVT group.There is an increased frequency of exercise-induced PVCs and NSVT in patients with MBs. Exercise significantly increases QTd in MB patients, with an even greater increase in QTd in MB patients with NSVT. Exercise in MB patients results in ventricular arrhythmias and abnormalities in repolarization.

  View details for PubMedID 28921787

• Surgical Unroofing of Hemodynamically Significant Left Anterior Descending Myocardial Bridges. Annals of thoracic surgery Boyd, J. H., Pargaonkar, V. S., Scoville, D. H., Rogers, I. S., Kimura, T., Tanaka, S., Yamada, R., Fischbein, M. P., Tremmel, J. A., Mitchell, R. S., Schnittger, I. 2016

  Abstract

  Left anterior descending artery myocardial bridges (MBs) range from clinically insignificant incidental angiographic findings to a potential cause of sudden cardiac death. Within this spectrum, a group of patients with isolated, symptomatic, and hemodynamically significant MBs despite maximally tolerated medical therapy exist for whom the optimal treatment is controversial. We evaluated supraarterial myotomy, or surgical unroofing, of the left anterior descending MBs as an isolated procedure in these patients.In 50 adult patients, we prospectively evaluated baseline clinical characteristics, risk factors, and medications for coronary artery disease, relevant diagnostic data (stress echocardiography, computed tomography angiography, stress coronary angiogram with dobutamine challenge for measurement of diastolic fractional flow reserve, and intravascular ultrasonography), and anginal symptoms using the Seattle Angina Questionnaire. These patients then underwent surgical unroofing of their left anterior descending artery MBs followed by readministration of the Seattle Angina Questionnaire at 6.6-month (range, 2 to 13) follow-up after surgery.Dramatic improvements were noted in physical limitation due to angina (52.0 versus 87.1, p < 0.001), anginal stability (29.6 versus 66.4, p < 0.001), anginal frequency (52.1 versus 84.7, p < 0.001), treatment satisfaction (76.1 versus 93.9, p < 0.001), and quality of life (25.0 versus 78.9, p < 0.001), all five dimensions of the Seattle Angina Questionnaire. There were no major complications or deaths.Surgical unroofing of carefully selected patients with MBs can be performed safely as an independent procedure with significant improvement in symptoms postoperatively. It is the optimal treatment for isolated, symptomatic, and hemodynamically significant MBs resistant to maximally tolerated medical therapy.

  View details for DOI 10.1016/j.athoracsur.2016.08.035

  View details for PubMedID 27745841

• Myocardial Bridge and Acute Plaque Rupture. Journal of investigative medicine high impact case reports Perl, L., Daniels, D., Schwartz, J., Tanaka, S., Yeung, A., Tremmel, J. A., Schnittger, I. 2016; 4 (4): 2324709616680227-?

  Abstract

  A myocardial bridge (MB) is a common anatomic variant, most frequently located in the left anterior descending coronary artery, where a portion of the coronary artery is covered by myocardium. Importantly, MBs are known to result in a proximal atherosclerotic lesion. It has recently been postulated that these lesions predispose patients to acute coronary events, even in cases of otherwise low-risk patients. One such mechanism may involve acute plaque rupture. In this article, we report 2 cases of patients with MBs who presented with acute coronary syndromes despite having low cardiovascular risk. Their presentation was life-risking and both were treated urgently and studied with coronary angiographies and intravascular ultrasound. This latter modality confirmed a rupture of an atherosclerotic plaque proximal to the MB as a likely cause of the acute events. These cases, of unexplained acute coronary syndrome in low-risk patients, raise the question of alternative processes leading to the event and the role MB play as an underlying cause of ruptured plaques. In some cases, an active investigation for this entity may be warranted, due to the prognostic implications of the different therapeutic modalities, should an MB be discovered.

  View details for DOI 10.1177/2324709616680227

  View details for PubMedID 28251167

• Late Breaking Trials of 2015 in Coronary Artery Disease: Commentary Covering ACC, EuroPCR, SCAI, TCT, ESC, and AHA CATHETERIZATION AND CARDIOVASCULAR INTERVENTIONS Seto, A. H., Safirstein, J., Anwaruddin, S., Dehghani, P., Shah, B., Tremmel, J. A. 2016; 87 (7): 1224-1230

  Abstract

  The SCAI Publications Committee and Emerging Leadership Mentorship (ELM) Fellows concisely summarize and provide context on the most important coronary trials presented at large international meetings in 2015, including the MATRIX, ABSORB, and TOTAL trials. The intent is to allow quick assimilation of trial results into interventional practice, and enable busy interventional cardiologists to stay up to date. © 2016 Wiley Periodicals, Inc.

  View details for DOI 10.1002/ccd.26474

  View details for Web of Science ID 000379985100013

  View details for PubMedID 26946364

• Bilateral Giant Coronary Artery Aneurysms Complicated by Acute Coronary Syndrome and Cardiogenic Shock. Annals of thoracic surgery Chiu, P., Lynch, D., Jahanayar, J., Rogers, I. S., Tremmel, J., Boyd, J. 2016; 101 (4): e95-7

  Abstract

  Giant coronary aneurysms are rare. We present a 25-year-old woman with a known history of non-Kawasaki/nonatherosclerotic bilateral coronary aneurysms. She was transferred to our facility with acute coronary syndrome complicated by cardiogenic shock. Angiography demonstrated giant bilateral coronary aneurysms and complete occlusion of the left anterior descending (LAD) artery. Emergent coronary artery bypass grafting was performed. Coronary artery bypass grafting is the preferred approach for addressing giant coronary aneurysms. Intervention on the aneurysm varies in the literature. Aggressive revascularization is recommended in the non-Kawasaki/nonatherosclerotic aneurysm patient, and ligation should be performed in patients with thromboembolic phenomena.

  View details for DOI 10.1016/j.athoracsur.2015.06.104

  View details for PubMedID 27000621

• Functional Versus Anatomic Assessment of Myocardial Bridging by Intravascular Ultrasound: Impact of Arterial Compression on Proximal Atherosclerotic Plaque. Journal of the American Heart Association Yamada, R., Tremmel, J. A., Tanaka, S., Lin, S., Kobayashi, Y., Hollak, M. B., Yock, P. G., Fitzgerald, P. J., Schnittger, I., Honda, Y. 2016; 5 (4)

  Abstract

  The presence of a myocardial bridge (MB) has been shown to promote atherosclerotic plaque formation proximal to the MB, presumably because of hemodynamic disturbances provoked by retrograde blood flow toward this segment in cardiac systole. We aimed to determine the anatomic and functional properties of an MB related to the extent of atherosclerosis assessed by intravascular ultrasound.We enrolled 100 patients with angina but no significant obstructive coronary artery disease who had an intravascular ultrasound-detected MB in the left anterior descending artery (median age 54 years, 36% male). The MB was identified with intravascular ultrasound by the presence of an echolucent band (halo). Anatomically, the MB length was 22±13 mm, and halo thickness was 0.7±0.6 mm. Functionally, systolic arterial compression was 23±12%. The maximum plaque burden up to 20 mm proximal to the MB entrance was significantly greater than the maximum plaque burden within the MB segment. Among the intravascular ultrasound-defined MB properties, arterial compression was the sole MB parameter that demonstrated a significant positive correlation with maximum plaque burden up to 20 mm proximal to the MB entrance (r=0.254, P=0.011 overall; r=0.545, P<0.001 low coronary risk). In multivariate analysis, adjusting for clinical characteristics and coronary risk factors, arterial compression was independently associated with maximum plaque burden up to 20 mm proximal to the MB entrance.In patients with an MB in the left anterior descending artery, the percentage of arterial compression is related directly to the burden of atherosclerotic plaque located proximally to the MB, particularly in patients who otherwise have low coronary risk. This may prove helpful in identifying high-risk MB patients.

  View details for DOI 10.1161/JAHA.114.001735

  View details for PubMedID 27098967

• To Define Is to Limit: Is That Good or Bad When it Comes to Chest Pain? JACC. Cardiovascular interventions Tremmel, J. A. 2016; 9 (6): 562–64

  View details for PubMedID 26947385

• Investing in our future: Update on the SCAI Emerging Leader Mentorship (ELM) Program. Catheterization and cardiovascular interventions : official journal of the Society for Cardiac Angiography & Interventions Feldman, D. N., Aronow, H. D., Swaminathan, R. V., Dawn Abbott, J., Tremmel, J. A., Kapur, N. K., Breinholt, J. P., Asgar, A. W., Pinto, D. S., Tu, T. M., Rosenfield, K. M., Naidu, S. S. 2016; 88 (5): 674–77

  View details for PubMedID 27865069

• Response to Letters Regarding Article, "Invasive Evaluation of Patients With Angina in the Absence of Obstructive Coronary Artery Disease" CIRCULATION Tremmel, J. A., Fearon, W. F., Lee, B., Lim, H., Yong, A. S., Yamada, R., Tanaka, S., Lee, D. P., Yeung, A. C. 2015; 132 (20): E244

  View details for PubMedID 26572677

• How Can We Further Optimize the Invasive Evaluation of Coronary Physiology? JACC-CARDIOVASCULAR INTERVENTIONS Fearon, W. F., Tremmel, J. A. 2015; 8 (13): 1692–94

  View details for PubMedID 26585619

• Exercise Strain Echocardiography in Patients With a Hemodynamically Significant Myocardial Bridge Assessed by Physiological Study JOURNAL OF THE AMERICAN HEART ASSOCIATION Kobayashi, Y., Tremmel, J. A., Kobayashi, Y., Amsallem, M., Tanaka, S., Yamada, R., Rogers, I. S., Haddad, F., Schnittger, I. 2015; 4 (11)

  Abstract

  Although a myocardial bridge (MB) is often regarded as a benign coronary variant, recent studies have associated MB with focal myocardial ischemia. The physiological consequences of MB on ventricular function during stress have not been well established.We enrolled 58 patients with MB of the left anterior descending artery, diagnosed by intravascular ultrasound. Patients underwent invasive physiological evaluation of the MB by diastolic fractional flow reserve during dobutamine challenge and exercise echocardiography. Septal and lateral longitudinal strain (LS) were assessed at rest and immediately after exercise and compared with strain of matched controls. Absolute and relative changes in strain were also calculated. The mean age was 42.5±16.0 years. Fifty-five patients had a diastolic fractional flow reserve ≤0.76. At rest, there was no significant difference between the 2 groups in septal LS (19.0±1.8% for patients with MB versus 19.2±1.5% for control, P=0.53) and lateral LS (20.1±2.0% versus 20.0±1.6%, P=0.83). With stress, compared with controls, patients with MB had a lower peak septal LS (18.9±2.6% versus 21.7±1.6%, P<0.001) and lower absolute (-0.1±2.1% versus 2.5±1.3%, P<0.001) and relative change (-0.6±11.2% versus 13.1±7.8%, P<0.001) in septal LS, whereas there was no significant difference in lateral LS. In multivariate analysis, diastolic fractional flow reserve and length were independent determinants of lower changes in septal LS.Patients with a hemodynamically significant MB, determined by invasive diastolic fractional flow reserve, have significantly lower change in septal LS on exercise echocardiography, suggesting that septal LS may be useful for noninvasively assessing the hemodynamic significance of an MB.

  View details for DOI 10.1161/JAHA.115.002496

  View details for Web of Science ID 000366615600020

  View details for PubMedID 26581225

• Exercise Strain Echocardiography in Patients With a Hemodynamically Significant Myocardial Bridge Assessed by Physiological Study. Journal of the American Heart Association Kobayashi, Y., Tremmel, J. A., Kobayashi, Y., Amsallem, M., Tanaka, S., Yamada, R., Rogers, I. S., Haddad, F., Schnittger, I. 2015; 4 (11)

  Abstract

  Although a myocardial bridge (MB) is often regarded as a benign coronary variant, recent studies have associated MB with focal myocardial ischemia. The physiological consequences of MB on ventricular function during stress have not been well established.We enrolled 58 patients with MB of the left anterior descending artery, diagnosed by intravascular ultrasound. Patients underwent invasive physiological evaluation of the MB by diastolic fractional flow reserve during dobutamine challenge and exercise echocardiography. Septal and lateral longitudinal strain (LS) were assessed at rest and immediately after exercise and compared with strain of matched controls. Absolute and relative changes in strain were also calculated. The mean age was 42.5±16.0 years. Fifty-five patients had a diastolic fractional flow reserve ≤0.76. At rest, there was no significant difference between the 2 groups in septal LS (19.0±1.8% for patients with MB versus 19.2±1.5% for control, P=0.53) and lateral LS (20.1±2.0% versus 20.0±1.6%, P=0.83). With stress, compared with controls, patients with MB had a lower peak septal LS (18.9±2.6% versus 21.7±1.6%, P<0.001) and lower absolute (-0.1±2.1% versus 2.5±1.3%, P<0.001) and relative change (-0.6±11.2% versus 13.1±7.8%, P<0.001) in septal LS, whereas there was no significant difference in lateral LS. In multivariate analysis, diastolic fractional flow reserve and length were independent determinants of lower changes in septal LS.Patients with a hemodynamically significant MB, determined by invasive diastolic fractional flow reserve, have significantly lower change in septal LS on exercise echocardiography, suggesting that septal LS may be useful for noninvasively assessing the hemodynamic significance of an MB.

  View details for DOI 10.1161/JAHA.115.002496

  View details for PubMedID 26581225

• Effect of Sex Differences on Invasive Measures of Coronary Microvascular Dysfunction in Patients With Angina in the Absence of Obstructive Coronary Artery Disease JACC-CARDIOVASCULAR INTERVENTIONS Kobayashi, Y., Fearon, W. F., Honda, Y., Tanaka, S., Pargaonkar, V., Fitzgerald, P. J., Lee, D. P., Stefanick, M., Yeung, A. C., Tremmel, J. A. 2015; 8 (11): 1433-1441

  Abstract

  This study investigated sex differences in coronary flow reserve (CFR) and the index of microcirculatory resistance (IMR) in patients with angina in the absence of obstructive coronary artery disease.Coronary microvascular dysfunction is associated with worse long-term outcomes, especially in women. Coronary flow reserve (CFR) and the index of microcirculatory resistance (IMR) are 2 methods of assessing the coronary microcirculation.We prospectively enrolled 117 women and 40 men with angina in the absence of obstructive coronary artery disease. We performed CFR, IMR, fractional flow reserve, and quantitative coronary angiography in the left anterior descending artery. Coronary flow was assessed with a thermodilution method by obtaining mean transit time (Tmn) (an inverse correlate to absolute flow) at rest and hyperemia.All patients had minimal atherosclerosis by quantitative coronary angiography (% diameter stenosis: 23.2 ± 12.3%), and epicardial disease was milder in women (fractional flow reserve: 0.88 ± 0.04 vs. 0.87 ± 0.04; p = 0.04). IMR was similar between the sexes (20.7 ± 9.8 vs. 19.1 ± 8.0; p = 0.45), but CFR was lower in women (3.8 ± 1.6 vs. 4.8 ± 1.9; p = 0.004). This was primarily due to a shorter resting Tmn in women (p = 0.005), suggesting increased resting coronary flow, whereas hyperemic Tmn was identical (p = 0.79). In multivariable analysis, female sex was an independent predictor of lower CFR and shorter resting Tmn.Despite similar microvascular function in women and men by IMR, CFR is lower in women. This discrepancy appears to be due to differences in resting coronary flow between the sexes. The effect of sex differences should be considered in interpretation of physiological indexes using resting coronary flow.

  View details for DOI 10.1016/j.jcin.2015.03.045

  View details for Web of Science ID 000361757600013

• Invasive physiologic and anatomic multimodality assessment of myocardial bridging. Coronary artery disease Schwartz, J. G., Tanaka, S., Schnittger, I., Tremmel, J. A. 2015; 26: e38-40

  View details for DOI 10.1097/MCA.0000000000000206

  View details for PubMedID 26247269

• Preventing Radial Artery Occlusion by Using Reverse Barbeau Assessment: Bringing Evidence-Based Practice to the Bedside. Critical care nurse Bonnett, C., Becker, N., Hann, B., Haynes, A., Tremmel, J. 2015; 35 (4): 77-82

  View details for DOI 10.4037/ccn2015428

  View details for PubMedID 26232806

• Late breaking trials of 2014 in coronary artery disease: Commentary covering ACC, EuroPCR, SCAI, TCT, ESC, and AHA. Catheterization and cardiovascular interventions Tremmel, J. A., Bhatt, D. L., Pinto, D. S., Grines, C. L. 2015; 86 (1): 73-79

  Abstract

  With the plethora of clinical trials, it is difficult for busy interventional cardiologists to stay up to date. Therefore, the SCAI Publications Committee concisely summarizes and provides editorial commentary on the most important coronary trials from the large international meetings of 2014. The intent is to allow quick assimilation of trial results into interventional practice. © 2015 Wiley Periodicals, Inc.

  View details for DOI 10.1002/ccd.25942

  View details for PubMedID 25854985

• Prevalence and Prognostic Role of Right Ventricular Involvement in Stress-Induced Cardiomyopathy JOURNAL OF CARDIAC FAILURE Finocchiaro, G., Kobayashi, Y., Magavern, E., Zhou, J. Q., Ashley, E., Sinagra, G., Schnittger, I., Knowles, J. W., Fearon, W. F., Haddad, F., Tremmel, J. A. 2015; 21 (5): 419-425

  Abstract

  Stress-induced cardiomyopathy (SCM) is a reversible cardiomyopathy observed in patients without significant coronary disease. The aim of this study was to assess the incidence and clinical significance of right ventricular (RV) involvement in SCM.We retrospectively analyzed echocardiograms from 40 consecutive patients who presented with SCM at Stanford University Medical Center from September 2000 to November 2010. The primary end point was overall mortality. RV involvement was observed in 20 patients (50%; global RV hypokinesia in 15 patients and focal RV apical akinesia in 5 patients). The independent correlates of RV involvement were older age (odds ratio [OR] 1.09, 95% confidence interval [CI] 1.02-1.7two, P = .01) and LVEF (per 10% decrease: OR 3.60, CI 1.77-7.32; P = .02). At a mean follow-up of 44 ± 32 months, 12 patients (30%) died (in-hospital death in 3 patients). At multivariate analysis, the presence of an RV fractional area change <35% emerged as an independent predictor of death (OR 3.6, CI 1.06-12.41; P = .04).RV involvement is a common finding in SCM, and may present as either global or focal RV apical involvement. Both older age and lower LVEF are associated with a higher risk of RV involvement, which appears to be a major predictor of death.

  View details for DOI 10.1016/j.cardfail.2015.02.001

  View details for PubMedID 25704104

• Invasive Evaluation of Patients With Angina in the Absence of Obstructive Coronary Artery Disease CIRCULATION Lee, B., Lim, H., Fearon, W. F., Yong, A. S., Yamada, R., Tanaka, S., Lee, D. P., Yeung, A. C., Tremmel, J. A. 2015; 131 (12): 1054-1060

  Abstract

  More than 20% of patients presenting to the cardiac catheterization laboratory with angina have no angiographic evidence of coronary artery disease. Despite a "normal" angiogram, these patients often have persistent symptoms, recurrent hospitalizations, a poor functional status, and adverse cardiovascular outcomes, without a clear diagnosis.In 139 patients with angina in the absence of obstructive coronary artery disease (no diameter stenosis >50%), endothelial function was assessed; the index of microcirculatory resistance, coronary flow reserve, and fractional flow reserve were measured; and intravascular ultrasound was performed. There were no complications. The average age was 54.0±11.4 years, and 107 (77%) were women. All patients had at least some evidence of atherosclerosis based on an intravascular ultrasound examination of the left anterior descending artery. Endothelial dysfunction (a decrease in luminal diameter of >20% after intracoronary acetylcholine) was present in 61 patients (44%). Microvascular impairment (an index of microcirculatory resistance ≥25) was present in 29 patients (21%). Seven patients (5%) had a fractional flow reserve ≤0.80. A myocardial bridge was present in 70 patients (58%). Overall, only 32 patients (23%) had no coronary explanation for their angina, with normal endothelial function, normal coronary physiological assessment, and no myocardial bridging.The majority of patients with angina in the absence of obstructive coronary artery disease have occult coronary abnormalities. A comprehensive invasive assessment of these patients at the time of coronary angiography can be performed safely and provides important diagnostic information that may affect treatment and outcomes.

  View details for DOI 10.1161/CIRCULATIONAHA.114.012636

  View details for PubMedID 25712205

• The relationship between fractional flow reserve and index of microcirculatory resistance: be careful with whom you associate. Catheterization and cardiovascular interventions Kobayashi, Y., Tremmel, J. A. 2015; 85 (4): 593-594

  View details for DOI 10.1002/ccd.25850

  View details for PubMedID 25702909

• Commentary on Highlighted Late Breaking Trials in Interventional Cardiology at ESC, VIVA, TCT, and AHA 2013 CATHETERIZATION AND CARDIOVASCULAR INTERVENTIONS Tremmel, J. A., Patel, R. A., Bhatt, D. L., Cilingiroglu, M., Pinto, D. S., Dean, L. S., Grines, C. L. 2015; 85 (1): 95-103

  Abstract

  With the plethora of clinical trials, it is difficult for busy interventional cardiologists to stay up to date. Therefore, the SCAI publications committee concisely summarizes and provides editorial commentary on the most important trials from recent, large international meetings. The intent is to provide this summary every six months to allow quick assimilation of trial results into interventional practice. © 2014 Wiley Periodicals, Inc.

  View details for DOI 10.1002/ccd.25635

  View details for Web of Science ID 000346479900025

  View details for PubMedID 25115350

• Effect of Sex Differences on Invasive Measures of Coronary Microvascular Dysfunction in Patients With Angina in the Absence of Obstructive Coronary Artery Disease. JACC. Cardiovascular interventions Kobayashi, Y., Fearon, W. F., Honda, Y., Tanaka, S., Pargaonkar, V., Fitzgerald, P. J., Lee, D. P., Stefanick, M., Yeung, A. C., Tremmel, J. A. 2015; 8 (11): 1433–41

  Abstract

  This study investigated sex differences in coronary flow reserve (CFR) and the index of microcirculatory resistance (IMR) in patients with angina in the absence of obstructive coronary artery disease.Coronary microvascular dysfunction is associated with worse long-term outcomes, especially in women. Coronary flow reserve (CFR) and the index of microcirculatory resistance (IMR) are 2 methods of assessing the coronary microcirculation.We prospectively enrolled 117 women and 40 men with angina in the absence of obstructive coronary artery disease. We performed CFR, IMR, fractional flow reserve, and quantitative coronary angiography in the left anterior descending artery. Coronary flow was assessed with a thermodilution method by obtaining mean transit time (Tmn) (an inverse correlate to absolute flow) at rest and hyperemia.All patients had minimal atherosclerosis by quantitative coronary angiography (% diameter stenosis: 23.2 ± 12.3%), and epicardial disease was milder in women (fractional flow reserve: 0.88 ± 0.04 vs. 0.87 ± 0.04; p = 0.04). IMR was similar between the sexes (20.7 ± 9.8 vs. 19.1 ± 8.0; p = 0.45), but CFR was lower in women (3.8 ± 1.6 vs. 4.8 ± 1.9; p = 0.004). This was primarily due to a shorter resting Tmn in women (p = 0.005), suggesting increased resting coronary flow, whereas hyperemic Tmn was identical (p = 0.79). In multivariable analysis, female sex was an independent predictor of lower CFR and shorter resting Tmn.Despite similar microvascular function in women and men by IMR, CFR is lower in women. This discrepancy appears to be due to differences in resting coronary flow between the sexes. The effect of sex differences should be considered in interpretation of physiological indexes using resting coronary flow.

  View details for PubMedID 26404195

• Continuous flow left ventricular assist device placement complicated by aortic valve thrombus and myocardial infarction INTERNATIONAL JOURNAL OF CARDIOLOGY Kim, J. B., Rhee, J., Brenner, D. A., Ha, R., Banerjee, D., Yeung, A. C., Tremmel, J. A. 2014; 176 (3): E102-E103

  View details for DOI 10.1016/j.ijcard.2014.07.248

  View details for Web of Science ID 000343893300011

• Commentary on late breaking trials in interventional cardiology at ESC, VIVA, TCT, AHA (Fall 2012), and ACC 2013 CATHETERIZATION AND CARDIOVASCULAR INTERVENTIONS Tremmel, J. A., Patel, R. A., Bhatt, D. L., Cilingiroglu, M., Pinto, D. S., Dean, L. S., Grines, C. L. 2014; 83 (6): 936-943

  Abstract

  With the plethora of clinical trials, it is difficult for busy interventional cardiologists to stay up to date. Therefore, the Society for Cardiovascular Angiography and Interventions (SCAI) publications committee concisely summarized and provided editorial commentary on the most important trials from recent, large international meetings. The intent is to provide this summary every six months to allow quick assimilation of trial results into interventional practice.

  View details for DOI 10.1002/ccd.25301

  View details for Web of Science ID 000334797900024

  View details for PubMedID 24273219

• Best Practices for Transradial Angiography and Intervention: A Consensus Statement From the Society for Cardiovascular Angiography and Intervention's Transradial Working Group CATHETERIZATION AND CARDIOVASCULAR INTERVENTIONS Rao, S. V., Tremmel, J. A., Gilchrist, I. C., Shah, P. B., Gulati, R., Shroff, A. R., Crisco, V., Woody, W., Zoghbi, G., Duffy, P. L., Sanghvi, K., Krucoff, M. W., Pyne, C. T., Skelding, K. A., Patel, T., Pancholy, S. B. 2014; 83 (2): 228-236

  View details for DOI 10.1002/ccd.25209

  View details for Web of Science ID 000329847600014

• Continuous flow left ventricular assist device placement complicated by aortic valve thrombus and myocardial infarction. International journal of cardiology Kim, J. B., Rhee, J. W., Brenner, D. A., Ha, R., Banerjee, D., Yeung, A. C., Tremmel, J. A. 2014; 176 (3): e102–3

  View details for PubMedID 25183539

• It is Time for Sex Inequality in Patients with ST-elevation Myocardial Infarction. Catheterization and cardiovascular interventions Yong, A. S., Tremmel, J. A. 2013; 82 (1): 27-28

  View details for DOI 10.1002/ccd.25026

  View details for PubMedID 23788384

• Can we bear another bare-metal stent study? Catheterization and cardiovascular interventions Yong, A. S., Tremmel, J. A. 2013; 81 (7): 1095-1096

  View details for DOI 10.1002/ccd.24964

  View details for PubMedID 23704063

• A novel stress echocardiography pattern for myocardial bridge with invasive structural and hemodynamic correlation. Journal of the American Heart Association Lin, S., Tremmel, J. A., Yamada, R., Rogers, I. S., Yong, C. M., Turcott, R., McConnell, M. V., Dash, R., Schnittger, I. 2013; 2 (2)

  Abstract

  Patients with a myocardial bridge (MB) and no significant obstructive coronary artery disease (CAD) may experience angina presumably from ischemia, but noninvasive assessment has been limited and the underlying mechanism poorly understood. This study seeks to correlate a novel exercise echocardiography (EE) finding for MBs with invasive structural and hemodynamic measurements.Eighteen patients with angina and an EE pattern of focal end-systolic to early-diastolic buckling in the septum with apical sparing were prospectively enrolled for invasive assessment. This included coronary angiography, left anterior descending artery (LAD) intravascular ultrasound (IVUS), and intracoronary pressure and Doppler measurements at rest and during dobutamine stress. All patients were found to have an LAD MB on IVUS. The ratios of diastolic intracoronary pressure divided by aortic pressure at rest (Pd/Pa) and during dobutamine stress (diastolic fractional flow reserve [dFFR]) and peak Doppler flow velocity recordings at rest and with stress were successfully performed in 14 patients. All had abnormal dFFR (≤0.75) at stress within the bridge, distally or in both positions, and on average showed a more than doubling in peak Doppler flow velocity inside the MB at stress. Seventy-five percent of patients had normalization of dFFR distal to the MB, with partial pressure recovery and a decrease in peak Doppler flow velocity.A distinctive septal wall motion abnormality with apical sparing on EE is associated with a documented MB by IVUS and a decreased dFFR. We posit that the septal wall motion abnormality on EE is due to dynamic ischemia local to the compressed segment of the LAD from the increase in velocity and decrease in perfusion pressure, consistent with the Venturi effect.

  View details for DOI 10.1161/JAHA.113.000097

  View details for PubMedID 23591827

• A novel stress echocardiography pattern for myocardial bridge with invasive structural and hemodynamic correlation. Journal of the American Heart Association Lin, S., Tremmel, J. A., Yamada, R., Rogers, I. S., Yong, C. M., Turcott, R., McConnell, M. V., Dash, R., Schnittger, I. 2013; 2 (2)

  View details for DOI 10.1161/JAHA.113.000097

  View details for PubMedID 23591827

• The Impact of Sex Differences on Fractional Flow Reserve-Guided Percutaneous Coronary Intervention A FAME (Fractional Flow Reserve Versus Angiography for Multivessel Evaluation) Substudy JACC-CARDIOVASCULAR INTERVENTIONS Kim, H., Tonino, P. A., De Bruyne, B., Yong, A. S., Tremmel, J. A., Pijls, N. H., Fearon, W. F. 2012; 5 (10): 1037-1042

  Abstract

  This study sought to evaluate the impact of sex differences on fractional flow reserve (FFR)-guided percutaneous coronary intervention (PCI).The FAME (Fractional Flow Reserve Versus Angiography for Multivessel Evaluation) study demonstrated that FFR-guided PCI improves outcomes compared with an angiography-guided strategy. The role of FFR-guided PCI in women versus men has not been evaluated.We analyzed 2-year data from the FAME study in the 744 men and 261 women with multivessel coronary disease, who were randomized to angiography- or FFR-guided PCI. Statistical comparisons based on sex were stratified by treatment method.Although women were older and had significantly higher rates of hypertension than men did, there were no differences in the rates of major adverse cardiac events (20.3% vs. 20.2%, p = 0.923) and its individual components at 2 years. FFR values were significantly higher in women than in men (0.75 ± 0.18 vs. 0.71 ± 0.17, p = 0.001). The proportion of functionally significant lesions (FFR ≤ 0.80) was lower in women than in men for lesions with 50% to 70% stenosis (21.1% vs. 39.5%, p < 0.001) and for lesions with 70% to 90% stenosis (71.9% vs. 82.0%, p = 0.019). An FFR-guided strategy resulted in similar relative risk reductions for death, myocardial infarction, and repeat revascularization in men and in women. There were no interactions between sex and treatment method for any outcome variables.In comparison with men, angiographic lesions of similar severity are less likely to be ischemia-producing in women. An FFR-guided PCI strategy is equally beneficial in women as it is in men.

  View details for DOI 10.1016/j.jcin.2012.06.016

  View details for PubMedID 23078733

• Most accurate definition of a high femoral artery puncture: Aiming to better predict retroperitoneal hematoma in percutaneous coronary intervention CATHETERIZATION AND CARDIOVASCULAR INTERVENTIONS Tremmel, J. A., Tibayan, Y. D., O'Loughlin, A. J., Chan, T., Fearon, W. F., Yeung, A. C., Lee, D. P. 2012; 80 (1): 37-42

  Abstract

  Retroperitoneal hematoma (RPH) increases morbidity and mortality in percutaneous coronary intervention (PCI). High femoral arteriotomy is an independent predictor of RPH, but the optimal angiographic criterion for defining a high puncture is unknown.We retrospectively identified 557 consecutive PCI cases with femoral angiograms. Arteriotomy sites were categorized as high based on three angiographic criteria: at or above the proximal third of the femoral head (criterion A), at or above the most inferior border of the inferior epigastric artery (criterion B), and at or above the origin of the inferior epigastric artery (criterion C). Cases of RPH were then identified.Of the 557 PCI patients, 26 had a high femoral arteriotomy by criterion A, 17 by criterion B, and 6 by criterion C. Among these patients with a high arteriotomy, RPH occurred in four with criterion A, in three with criterion B, and in one with criterion C. Of the three criteria, criterion A most strongly correlated with RPH (odds ratio [OR] 96, 95% confidence interval [CI] 10.3-898.4; p < 0.0001) compared with criterion B (OR 58, 95% CI 8.9 to 372.6; p < 0.0001) or C (OR 27, 95% CI 2.6 to 290.1; p = 0.053). All criteria had high specificity (A, 96%; B, 97%; C, 99%), but the sensitivity was higher with criterion A (80%) than criterion B (60%) or C (20%), and statistically, the use of criterion A led to the most accurate risk-stratification for RPH (A, κ = 0.79; B, κ = 0.59; C, κ = 0.19).Among the three common definitions of high arteriotomy, femoral artery puncture at or above the proximal third of the femoral head is the landmark that most accurately risk stratifies PCI patients for development of RPH.

  View details for DOI 10.1002/ccd.23175

  View details for PubMedID 22511409

• Comparison of the Frequency of Coronary Artery Disease in Alcohol-Related Versus Non-Alcohol-Related Endstage Liver Disease AMERICAN JOURNAL OF CARDIOLOGY Patel, S., Kiefer, T. L., Ahmed, A., Ali, Z. A., Tremmel, J. A., Lee, D. P., Yeung, A. C., Fearon, W. F. 2011; 108 (11): 1552-1555

  Abstract

  There are conflicting data as to the prevalence of coronary artery disease (CAD) in patients with end-stage liver disease (ESLD) being assessed for liver transplantation (LT). The aims of this study were to compare the prevalence of CAD in patients with alcohol-related versus non-alcohol-related ESLD and to assess the diagnostic utility of dobutamine stress echocardiography (DSE) in predicting angiographically important CAD. Consecutive patients with ESLD being assessed for LT (n = 420, mean age 56 ± 8 years) were identified and divided into groups of those with alcohol-related ESLD (n = 125) and non-alcohol-related ESLD (n = 295). Demographic characteristics, CAD risk factors, results of DSE, and coronary angiographic characteristics were recorded. There were no significant differences in age or CAD risk factors between groups. The incidence of severe CAD (>70% diameter stenosis) was 2% in the alcohol-related ESLD group and 13% in the non-alcohol-related ESLD group (p <0.005). In the 2 groups, the presence of ≥1 CAD risk factor was associated with significant CAD (p <0.05 for all). Absence of cardiac risk factors was highly predictive in ruling out angiographically significant disease (negative predictive value 100% for alcohol-related ESLD and 97% for non-alcohol-related ESLD). DSE was performed in 205 patients. In the 2 groups, DSE had poor predictive value for diagnosing significant CAD but was useful in ruling out patients without significant disease (negative predictive value 89% for alcohol-related ESLD and 80% for non-alcohol-related ESLD). In conclusion, there was a significantly lower prevalence of severe CAD in patients with alcohol-related ESLD. These findings suggest that invasive coronary angiography may not be necessary in this subgroup, particularly in the absence of CAD risk factors and negative results on DSE.

  View details for DOI 10.1016/j.amjcard.2011.07.013

  View details for PubMedID 21890080

• Quantitative Comparison of Microcirculatory Dysfunction in Patients With Stress Cardiomyopathy and ST-Segment Elevation Myocardial Infarction JOURNAL OF THE AMERICAN COLLEGE OF CARDIOLOGY Kim, H., Tremmel, J. A., Nam, C., Zhou, J., Haddad, F., Vagelos, R. H., Lee, D. P., Yeung, A. C., Fearon, W. F. 2011; 58 (23): 2430-2431

  View details for DOI 10.1016/j.jacc.2011.08.046

  View details for Web of Science ID 000297319700016

  View details for PubMedID 22115653

• Transradial arterial access for coronary and peripheral procedures: Executive summary by the transradial committee of the SCAI CATHETERIZATION AND CARDIOVASCULAR INTERVENTIONS Caputo, R. P., Tremmel, J. A., Rao, S., Gilchrist, I. C., Pyne, C., Pancholy, S., Frasier, D., Gulati, R., Skelding, K., Bertrand, O., Patel, T. 2011; 78 (6): 823-839

  Abstract

  In response to growing U.S. interest, the Society for Coronary Angiography and Interventions recently formed a Transradial Committee whose purpose is to examine the utility, utilization, and training considerations related to transradial access for percutaneous coronary and peripheral procedures. With international partnership, the committee has composed a comprehensive overview of this subject presented here-with.

  View details for DOI 10.1002/ccd.23052

  View details for Web of Science ID 000297111100001

  View details for PubMedID 21544927

• Do Not Be Deceived by the Cunning Jailed Side Branch CATHETERIZATION AND CARDIOVASCULAR INTERVENTIONS Tremmel, J. A. 2011; 78 (5): 727-728

  View details for DOI 10.1002/ccd.23384

  View details for Web of Science ID 000296412800013

  View details for PubMedID 22025473

• Sex Differences in Neointimal Hyperplasia Following Endeavor Zotarolimus-Eluting Stent Implantation AMERICAN JOURNAL OF CARDIOLOGY Nakatani, D., Ako, J., Tremmel, J. A., Waseda, K., Otake, H., Koo, B., Miyazawa, A., Hongo, Y., Hur, S., Sakurai, R., Yock, P. G., Honda, Y., Fitzgerald, P. J. 2011; 108 (7): 912-917

  Abstract

  Inconsistent results in outcomes have been observed between the genders after drug-eluting stent implantation. The aim of this study was to investigate gender differences in neointimal proliferation for the Endeavor zotarolimus-eluting stent (ZES) and the Driver bare-metal stent (BMS). A total of 476 (n = 391 ZES, n = 85 BMS) patients whose volumetric intravascular ultrasound analyses were available at 8-month follow-up were studied. At 8 months, neointimal obstruction and maximum cross-sectional narrowing (CSN) were significantly lower in women than in men receiving ZES (neointimal obstruction 15.5 ± 9.5% vs 18.2 ± 10.9%, p = 0.025; maximum CSN 30.3 ± 13.2% vs 34.8 ± 15.0%, p = 0.007). Conversely, these parameters tended to be higher in women than in men receiving BMS (neointimal obstruction 36.3 ± 15.9% vs 27.5 ± 17.2%, p = 0.053; maximum CSN 54.3 ± 18.6% vs 45.6 ± 18.3%, p = 0.080). There was a significant interaction between stent type and gender regarding neointimal obstruction (p = 0.001) and maximum CSN (p = 0.003). Multivariate linear regression analysis revealed that female gender was independently associated with lower neointimal obstruction (p = 0.027) and maximum CSN (p = 0.004) for ZES but not for BMS. Compared to BMS, ZES were independently associated with a reduced risk for binary restenosis in both genders (odds ratio for women 0.003, p = 0.001; odds ratio for men 0.191, p <0.001), but the magnitude of this risk reduction with ZES was significantly greater in women than men (p = 0.015). In conclusion, female gender is independently associated with decreased neointimal hyperplasia in patients treated with ZES. The magnitude of risk reduction for binary restenosis with ZES is significantly greater in women than in men.

  View details for DOI 10.1016/j.amjcard.2011.05.019

  View details for Web of Science ID 000295863200002

  View details for PubMedID 21784390

• Comparison of Drug-Eluting Versus Bare Metal Stents in Cardiac Allograft Vasculopathy AMERICAN JOURNAL OF CARDIOLOGY Tremmel, J. A., Ng, M. K., Ikeno, F., Hunt, S. A., Lee, D. P., Yeung, A. C., Fearon, W. F. 2011; 108 (5): 665-668

  Abstract

  Although not a definitive treatment, percutaneous coronary intervention offers a palliative benefit to patients with cardiac allograft vasculopathy. Given the superior outcomes with drug-eluting stents (DESs) over bare metal stents (BMSs) in native coronary artery disease, similar improvements might be expected in transplant patients; however, the results have been mixed. Consecutive cardiac transplantation recipients at a single center receiving a stent for de novo cardiac allograft vasculopathy from 1997 to 2009 were retrospectively analyzed according to receipt of a DES versus a BMS. The angiographic and clinical outcomes were subsequently evaluated at 1 year. The baseline clinical and procedural characteristics were similar among those receiving DESs (n = 18) and BMSs (n = 16). Quantitative coronary angiography revealed no difference in the reference diameter, lesion length, or pre-/postprocedural minimal luminal diameter. At the 12-month angiographic follow-up visit, the mean lumen loss was significantly lower in the DES group than in the BMS group (0.19 ± 0.73 mm vs 0.76 ± 0.97 mm, p = 0.02). The DES group also had a lower rate of in-stent restenosis (12.5% vs 33%, p = 0.18), as well as a significantly lower rate of target lesion revascularization (0% vs 19%, p = 0.03). At 1 year, DESs were associated with a lower composite rate of cardiac death and nonfatal myocardial infarction (12% vs 38%, p = 0.04). In conclusion, DESs are safe and effective in the suppression of neointimal hyperplasia after percutaneous coronary intervention for cardiac allograft vasculopathy, resulting in significantly lower rates of late lumen loss and target lesion revascularization, as well as a reduced combined rate of cardiac death and nonfatal myocardial infarction.

  View details for DOI 10.1016/j.amjcard.2011.04.014

  View details for PubMedID 21684511

• Stress-induced cardiomyopathy associated with a transfusion reaction: A case of potential crosstalk between the histaminic and adrenergic systems EXPERIMENTAL & CLINICAL CARDIOLOGY Zhou, J. Q., Choe, E., Ang, L., Schnittger, I., Rockson, S. G., Tremmel, J. A., Haddad, F. 2011; 16 (1): 30-32

  Abstract

  The adrenergic and histaminergic systems have been reported to have analogous effects on the heart. A case of transient ventricular dysfunction with echocardiographic findings characteristic of stress-induced cardiomyopathy (also known as takotsubo cardiomyopathy) in a patient who had an urticarial transfusion reaction is described. The effect of histamine on ventricular function and its interaction with the adrenergic system are discussed.

  View details for Web of Science ID 000300518800008

  View details for PubMedID 21523205

  View details for PubMedCentralID PMC3076164

• Images in intervention. Intramural hematoma appearing as a new lesion after coronary stenting. JACC. Cardiovascular interventions Tremmel, J. A., Koizumi, T., O'Loughlin, A., Yeung, A. C. 2011; 4 (1): 129-130

  View details for DOI 10.1016/j.jcin.2010.07.019

  View details for PubMedID 21251640

• Launching a successful transradial program. journal of invasive cardiology Tremmel, J. A. 2009; 21 (8): 3A-10A

  Abstract

  There is an increasing interest in performing transradial (TR) procedures in the United States, but with so few experienced operators, developing a TR program often means figuring out a lot on one's own. Certain necessary fundamentals - including a good reason for doing procedures transradially, getting adequate training, gaining the support of cath lab staff, using the right equipment, and having patience and perseverance through learning and change - improve the chances of success. In discussing each of these fundamentals, this article reviews the advantages of a radial approach compared with a femoral approach; describes ways to acquire TR training; stresses the importance of involving nurses, technicians, administrators, and colleagues in the process; encourages the use of designated radial equipment for enhancing success; and demonstrates the learning curve by describing a single operator experience during the first year of launching a TR program.

  View details for PubMedID 19734568

• Predictive value of the index of microcirculatory resistance in patients with ST-segment elevation myocardial infarction JOURNAL OF THE AMERICAN COLLEGE OF CARDIOLOGY Fearon, W. F., Shah, M., Ng, M., Brinton, T., Wilson, A., Trernmel, J. A., Schnittger, I., Lee, D. P., Vagelos, R. H., Fitzgerald, P. J., Yock, P. G., Yeung, A. C. 2008; 51 (5): 560-565

  Abstract

  The objective of this study is to evaluate the predictive value of the index of microcirculatory resistance (IMR) in patients undergoing primary percutaneous coronary intervention (PCI) for ST-segment elevation myocardial infarction (STEMI).Despite adequate epicardial artery reperfusion, a number of patients with STEMI have a poor prognosis because of microvascular damage. Assessing the status of the microvasculature in this setting remains challenging.In 29 patients after primary PCI for STEMI, IMR was measured with a pressure sensor/thermistor-tipped guidewire. The Thrombolysis In Myocardial Infarction (TIMI) myocardial perfusion grade, TIMI frame count, coronary flow reserve, and ST-segment resolution were also recorded.The IMR correlated significantly with the peak creatinine kinase (CK) (R = 0.61, p = 0.0005) while the other measures of microvascular dysfunction did not. In patients with an IMR greater than the median value of 32 U, the peak CK was significantly higher compared with those having values 32 U compared with

  View details for DOI 10.1016/j.jacc.2007.08.062

  View details for PubMedID 18237685

• Ischemic heart disease in women: An appropriate time to discriminate REVIEWS IN CARDIOVASCULAR MEDICINE Tremmel, J. A., Yeung, A. C. 2007; 8 (2): 61-68

  Abstract

  Although cardiovascular mortality for men has been declining, the number of women dying from cardiovascular disease has slightly increased. Differences between women and men have been identified throughout the entire spectrum of ischemic heart disease, from risk factors to presentation and from diagnosis to treatment and outcomes. In the setting of an acute coronary syndrome or acute myocardial infarction, women are significantly more likely than men to report multiple non-chest pain symptoms, including dyspnea, nausea/vomiting, abdominal pain, back pain, neck pain, and jaw pain. Investigations into the pathophysiology of ischemic heart disease in women have broken away from the traditional thinking that coronary artery disease simply equals epicardial stenosis. In women, the new paradigm of coronary artery disease also focuses on diffuse atherosclerosis, endothelial dysfunction, and microvascular disease. Further research focusing on sex differences in cardiovascular disease is needed, but enough is currently known to offer a sex-based approach, which may ultimately lead to improved outcomes.

  View details for Web of Science ID 000247793600003

  View details for PubMedID 17603424

• Selective renal arterial infusion of fenoldopam for the prevention of contrast-induced nephropathy. Journal of interventional cardiology Ng, M. K., Tremmel, J., Fitzgerald, P. J., Fearon, W. F. 2006; 19 (1): 75-79

  Abstract

  Contrast-induced nephropathy (CIN) remains an important complication of angiographic procedures, particularly among patients with significant renal impairment. To date, vasodilator therapies such as fenoldopam have failed to prevent CIN, possibly because significant hypotension as a result of systemic infusion has limited the ability to deliver adequate drug levels to the renal vasculature. We present a case of averted CIN after multivessel coronary intervention in a diabetic patient with severe renal insufficiency, potentially due to bilateral renal arterial infusion of fenoldopam. Our subsequent experience with intrarenal fenoldopam in nine additional procedures in eight other high risk patients resulted in one case of asymptomatic transient CIN. Further studies are warranted to evaluate the efficacy of intrarenal administration of vasodilator therapies such as fenoldopam for the prevention of CIN.

  View details for PubMedID 16483344

• Risk factors for the development of retroperitoneal hematoma after percutaneous coronary intervention in the era of glycoprotein IIb/IIIa inhibitors and vascular closure devices JOURNAL OF THE AMERICAN COLLEGE OF CARDIOLOGY Farouque, H. M., Tremmel, J. A., Shabari, F. R., Aggarwal, M., Fearon, W. F., Ng, M. K., Rezaee, M., Yeung, A. C., Lee, D. P. 2005; 45 (3): 363-368

  Abstract

  We sought to determine the incidence, clinical features, and risk factors for retroperitoneal hematoma (RPH) after percutaneous coronary intervention (PCI).Little is known about the clinical features, outcomes, and determinants of this serious complication in the contemporary era of PCI.A retrospective analysis yielded 26 cases of RPH out of 3,508 consecutive patients undergoing PCI between January 2000 and January 2004. Cases were compared with a randomly selected sample of 50 control subjects without RPH.The incidence of RPH was 0.74%. Features of RPH included abdominal pain (42%), groin pain (46%), back pain (23%), diaphoresis (58%), bradycardia (31%), and hypotension (92%). The mean systolic blood pressure nadir was 75 mm Hg. The hematocrit dropped by 11.5 +/- 5.1 points from baseline in RPH patients, as compared with 2.3 +/- 3.3 points in controls (p < 0.0001). The mean hospital stay was longer in RPH patients (2.9 +/- 3.8 days vs. 1.7 +/- 1.5 days, p = 0.06). The following variables were found to be independent predictors of RPH: female gender (odds ratio [OR] 5.4, p = 0.005), low body surface area (BSA <1.73 m(2); OR 7.1, p = 0.008), and higher femoral artery puncture (OR 5.3, p = 0.013). There was no association between RPH and arterial sheath size, use of glycoprotein IIb/IIIa inhibitors, or deployment of a vascular closure device.Female gender, low BSA, and higher femoral artery puncture are significant risk factors for RPH. Awareness of the determinants and clinical features of RPH may aid in prevention, early recognition, and prompt treatment.

  View details for DOI 10.1016/j.jacc.2004.10.042

  View details for PubMedID 15680713

• Is the obesity paradox for real? The effect of body mass index on mortality following percutaneous coronary intervention for those presenting with an ST elevation myocardial infarction. Circulation Tremmel J, Shaw RE, Lee DP 2005; 112 ((17, supp)): II-695
• The influence of body mass index on mortality following percutaneous coronary intervention in those presenting with unstable angina or non-ST elevation myocardial infarction: is there an obesity paradox? Am J Cardiol Tremmel J, Shaw RE, Lee DP 2005; 96 (7,supp1): 106H
• "Tako-tsubo-like left ventricular dysfunction": a clinical entity mimicking acute myocardial infarction with a favorable prognosis. American journal of geriatric cardiology Farouque, H. M., Kaltenbach, T., Ako, J., Tremmel, J. A., Fearon, W. F., Yeung, A. C., Vagelos, R. H. 2004; 13 (6): 323-326

  Abstract

  An emotionally-distressed, elderly Caucasian woman presented with chest pain and hypertension. Electrocardiogram showed inferior ST-segment elevation, and an urgent cardiac catheterization was performed. Coronary angiography revealed normal appearing coronary arteries; however, left ventriculography showed extensive left ventricular apical akinesis. The patient had a mild rise in cardiac enzyme levels indicative of myocardial injury. She was discharged after an uncomplicated in-hospital course. One month later, the left ventricular wall motion abnormality had improved. In this report, the authors discuss this compilation of findings known as tako-tsubo-like left ventricular dysfunction.

  View details for PubMedID 15538070

• Women remain at higher risk for retroperitoneal hematoma after percutaneous coronary intervention in the era of glycoprotein IIb/IIIa inhibitors and vascular closure devices 53rd Annual Scientific Session of the American-College-of-Cardiology Farouque, H. M., Tremmel, J. A., Aggarwal, M., Shabari, F. R., Fearon, W. F., Rezaee, M., Yeung, A. C., Lee, D. P. ELSEVIER SCIENCE INC. 2004: 63A–63A

  View details for Web of Science ID 000189388500266

• Direct-to-consumer advertisements for prescription drugs: what are Americans being sold? LANCET Woloshin, S., Schwartz, L. M., Tremmel, J., Welch, H. G. 2001; 358 (9288): 1141-1146

  Abstract

  Pharmaceutical companies spent US$1.8 billion on direct-to-consumer advertisements for prescription drugs in 1999. Our aim was to establish what messages are being communicated to the public by these advertisements.We investigated the content of advertisements, which appeared in ten magazines in the USA. We examined seven issues of each of these published between July, 1998, and July, 1999.67 advertisements appeared a total of 211 times during our study. Of these, 133 (63%) were for drugs to ameliorate symptoms, 54 (26%) to treat disease, and 23 (11%) to prevent illness. In the 67 unique advertisements, promotional techniques used included emotional appeals (45, 67%) and encouragement of consumers to consider medical causes for their experiences (26, 39%). More advertisements described the benefit of medication with vague, qualitative terms (58, 87%), than with data (9, 13%). However, half the advertisements used data to describe side-effects, typically with lists of side-effects that generally occurred infrequently. None mentioned cost.Provision of complete information about the benefit of prescription drugs in advertisements would serve the interests of physicians and the public.

  View details for Web of Science ID 000171399000011

  View details for PubMedID 11597668