I am a postdoctoral fellow in cardiovascular medicine determined to further cardiovascular disease risk prediction using novel methods and to create practices and systems that allow for reductions in the morbidity and mortality of this disease.
- Internal Medicine
- Cardiovascular Medicine
Member (Postdoc), Cardiovascular Institute
Honors & Awards
Profiles of Excellence Award, American College of Physicians, Department of Medicine, Johns Hopkins Hospital (2020)
Norman and Mary Stewart Memorial Award, Department of Medicine, Johns Hopkins Hospital (2018)
Allie S. Freed Award in Preventive Medicine, GWU School of Medicine and Health Sciences (2017)
Medical Alumni Association Award, GWU School of Medicine and Health Sciences (2017)
AΩA Carolyn L. Kuckein Student Research Fellowship, Alpha Omega Alpha (2016)
Kassan Research Presentation Award, GWU School of Medicine and Health Sciences (2016)
MPH Capstone Award, Johns Hopkins University, Bloomberg School of Public Health (2016)
Gold Humanism Honors Society, GWU School of Medicine and Health Sciences (2015)
Chancellor’s Service Award, UCLA Office of the Dean of Students (2011)
Dean’s Prize in Undergraduate Research, UCLA Spring Poster Day (2011)
Special Achievement in the Study of Religion, UCLA Department of Religion (2011)
Distinguished Senior Award, UCLA Alumni Association (2010)
College Honors Student, UCLA Honors Collegium (2007-2011)
Boards, Advisory Committees, Professional Organizations
Member, American Heart Association (2016 - Present)
Board Certification, American Board of Internal Medicine, Internal Medicine (2020)
Residency, Johns Hopkins Hospital, Internal Medicine (2020)
Internship, Johns Hopkins Hospital, Internal Medicine (2018)
Doctor of Medicine, George Washington University, Medicine (2017)
Master of Public Health, Johns Hopkins University, Epidemiology and Biostatistics (2016)
Bachelor of Arts, University of California Los Angeles, Study of Religion (2011)
Coronary Artery Calcium Dispersion and Cause-Specific Mortality.
The American journal of cardiology
2023; 191: 76-83
Coronary artery calcium (CAC) measures subclinical atherosclerosis and improves risk stratification. CAC characteristics-including vessel(s) involved, number of vessels, volume, and density-have been shown to differentially impact risk. We assessed how dispersion-either the number of calcified vessels or CAC phenotype (diffuse, normal, and concentrated)-impacted cause-specific mortality. The CAC Consortium is a retrospective cohort of 66,636 participants without coronary heart disease (CHD) who underwent CAC scoring. This study included patients with CAC >0 (n = 28,147). CAC area, CAC density, and CAC phenotypes (derived from the index of diffusion = 1 - [CAC in most concentrated vessel/total Agatston score]) were calculated. The associations between CAC characteristics and cause-specific mortality were assessed. The participant details included (n = 28,147): mean age 58.3 years, 25% female, 89.6% White, and 66% had 2+ calcified vessels. Diabetes, hypertension, and hyperlipidemia were predictors of multivessel involvement (p <0.001). After controlling for the overall CAC score, those with 4-vessel CAC involvement had more CAC area and less dense calcifications than those with 1-vessel. There was a graded increase in all-cause and cardiovascular disease (CVD)- and CHD-specific mortality as the number of calcified vessels increased. Among those with ≥2 vessels involved (n = 18,516), a diffuse phenotype was associated with a higher CVD-specific mortality and had a trend toward higher all-cause and CHD-specific mortality than a concentrated CAC phenotype. Diffuse CAC involvement was characterized by less dense calcification, more CAC area, multiple coronary vessel involvement, and presence of certain traditional risk factors. There is a graded increase in all-cause and CVD- and CHD-specific mortality with increasing CAC dispersion.
View details for DOI 10.1016/j.amjcard.2022.12.014
View details for PubMedID 36645939
Unfavorable social determinants of health are associated with higher burden of financial toxicity among patients with atherosclerotic cardiovascular disease in the US: findings from the National Health Interview Survey.
Archives of public health = Archives belges de sante publique
2022; 80 (1): 248
Atherosclerotic cardiovascular disease (ASCVD) is a major cause of financial toxicity, defined as excess financial strain from healthcare, in the US. Identifying factors that put patients at greatest risk can help inform more targeted and cost-effective interventions. Specific social determinants of health (SDOH) such as income are associated with a higher risk of experiencing financial toxicity from healthcare, however, the associations between more comprehensive measures of cumulative social disadvantage and financial toxicity from healthcare are poorly understood.Using the National Health Interview Survey (2013-17), we assessed patients with self-reported ASCVD. We identified 34 discrete SDOH items, across 6 domains: economic stability, education, food poverty, neighborhood conditions, social context, and health systems. To capture the cumulative effect of SDOH, an aggregate score was computed as their sum, and divided into quartiles, the highest (quartile 4) containing the most unfavorable scores. Financial toxicity included presence of: difficulty paying medical bills, and/or delayed/foregone care due to cost, and/or cost-related medication non-adherence.Approximately 37% of study participants reported experiencing financial toxicity from healthcare, with a prevalence of 15% among those in SDOH Q1 vs 68% in SDOH Q4. In fully-adjusted regression analyses, individuals in the 2nd, 3rd and 4th quartiles of the aggregate SDOH score had 1.90 (95% CI 1.60, 2.26), 3.66 (95% CI 3.11, 4.35), and 8.18 (95% CI 6.83, 9.79) higher odds of reporting any financial toxicity from healthcare, when compared with participants in the 1st quartile. The associations were consistent in age-stratified analyses, and were also present in analyses restricted to non-economic SDOH domains and to 7 upstream SDOH features.An unfavorable SDOH profile was strongly and independently associated with subjective financial toxicity from healthcare. This analysis provides further evidence to support policies and interventions aimed at screening for prevalent financial toxicity and for high financial toxicity risk among socially vulnerable groups.
View details for DOI 10.1186/s13690-022-00987-z
View details for PubMedID 36474300
View details for PubMedCentralID PMC9727868
Coronary Artery Calcium Score to Refine the Use of PCSK9i in Asymptomatic Individuals: A Multicohort Study.
Journal of the American Heart Association
Background The value of coronary artery calcium (CAC) in the allocation of PCSK9i (proprotein convertase subtilisin/kexin type 9 inhibitors) among individuals without clinically evident atherosclerotic cardiovascular disease (ASCVD) is unknown for indications that do not require confirmed familial hypercholesterolemia. We aimed to assess the ability of CAC to stratify ASCVD risk under 3 non-familial hypercholesterolemia PCSK9i allocation paradigms. Methods and Results We included participants without clinically evident ASCVD from MESA (Multi-Ethnic Study of Atherosclerosis), CARDIA (Coronary Artery Risk Development in Young Adults) study, DHS (Dallas Heart Study), and HNR (Heinz Nixdorf Recall) study. Three PCSK9i eligibility scenarios were defined: a broad scenario informed only by high low-density lipoprotein cholesterol levels (N=567), a restrictive one combining higher low-density lipoprotein cholesterol levels and presence of ≥2 additional risk factors (N=127), and a high-risk scenario where individuals with subclinical organ damage or high estimated risk would be treated to achieve low-density lipoprotein cholesterol <55mg/dL (N=471). The high-risk scenario had the highest ASCVD event rates (27.8% at 10years). CAC=0 was observed in 35% participants in the broad scenario, 25% in the restrictive scenario, and 16% in the high-risk scenario. In all, CAC=0 was associated with the lowest incident ASCVD rates at 5 and 10years, and CAC burden was independently associated with ASCVD events adjusting for traditional risk factors. Conclusions CAC may be used to refine the allocation of PCSK9i, potentially leading to a more conservative use if CAC=0. The value of CAC testing is greater in scenarios that use low-density lipoprotein cholesterol levels and/or traditional risk factors to define PCSK9i eligibility (CAC=0 present in 1 of 3-4 patients), whereas its prevalence is lower when allocation is informed by presence of noncoronary subclinical organ damage.
View details for DOI 10.1161/JAHA.122.025737
View details for PubMedID 35943062
Ten things to know about ten cardiovascular disease risk factors - 2022.
American journal of preventive cardiology
2022; 10: 100342
The American Society for Preventive Cardiology (ASPC) "Ten things to know about ten cardiovascular disease risk factors-2022" is a summary document regarding cardiovascular disease (CVD) risk factors. This 2022 update provides summary tables of ten things to know about 10 CVD risk factors and builds upon the foundation of prior annual versions of "Ten things to know about ten cardiovascular disease risk factors" published since 2020. This 2022 version provides the perspective of ASPC members and includes updated sentinel references (i.e., applicable guidelines and select reviews) for each CVD risk factor section. The ten CVD risk factors include unhealthful dietary intake, physical inactivity, dyslipidemia, pre-diabetes/diabetes, high blood pressure, obesity, considerations of select populations (older age, race/ethnicity, and sex differences), thrombosis (with smoking as a potential contributor to thrombosis), kidney dysfunction and genetics/familial hypercholesterolemia. Other CVD risk factors may be relevant, beyond the CVD risk factors discussed here. However, it is the intent of the ASPC "Ten things to know about ten cardiovascular disease risk factors-2022" to provide a tabular overview of things to know about ten of the most common CVD risk factors applicable to preventive cardiology and provide ready access to applicable guidelines and sentinel reviews.
View details for DOI 10.1016/j.ajpc.2022.100342
View details for PubMedID 35517870
CAC for Risk Stratification Among Individuals With Hypertriglyceridemia Free of Clinical Atherosclerotic Cardiovascular Disease.
JACC. Cardiovascular imaging
OBJECTIVES: In this study, we sought to evaluate whether the coronary artery calcium (CAC) score can enhance current paradigms for risk stratification among individuals with hypertriglyceridemia in primary prevention. The eligibility criteria for icosapent ethyl (IPE) were used as case example.BACKGROUND: Recent trials of atherosclerotic cardiovascular disease (ASCVD) risk-reduction therapies for individuals with hypertriglyceridemia without clinical ASCVD restricted enrollment to participants with diabetes or various other risk factors. These criteria were mirrored in the Food and Drug Administration product label for IPE.METHODS: We pooled 2,345 participants with triglycerides 150 to<500mg/dL (or >178-<500mg/dL if not on a statin) and without clinical ASCVD from MESA, CARDIA, the Dallas Heart Study, and the Heinz Nixdorf Recall study. We evaluated the incidence of ASCVD events overall, by IPE eligibility (as defined in the product label), and further stratified by CAC scores (0, >0-100, >100). The number needed to treat for 5 years (NNT5) to prevent 1 event was estimated among IPE-eligible participants, assuming a 21.8% relative risk reduction with IPE. In exploratory analyses, the NNT5 was also estimated among noneligible participants.RESULTS: There was marked heterogeneity in CAC burden overall (45% CAC 0; 24% CAC >100) and across IPE eligibility strata. Overall, 17% of participants were eligible for IPE and 11.9% had ASCVD events within 5 years. Among participants eligible for IPE, 38% had CAC >100, and their event rates were markedly higher (15.9% vs 7.2%) and the NNT5 2.2-fold lower (29 vs 64) than those of the 25% eligible participants with CAC 0. Among the 83% participants not eligible for IPE, 20% had CAC >100, their 5-year incidence of ASCVD (13.9%) was higher than the overall incidence among IPE-eligible participants.CONCLUSIONS: CAC can improve current risk stratification and therapy allocation paradigms among individuals with hypertriglyceridemia without clinical ASCVD. Future trials of risk-reduction therapies in hypertriglyceridemia could use CAC >100 to enroll a high-risk study sample, with implications for a larger target population.
View details for DOI 10.1016/j.jcmg.2021.10.017
View details for PubMedID 34922873
Development and validation of a polysocial risk score for atherosclerotic cardiovascular disease.
American journal of preventive cardiology
2021; 8: 100251
Objective: To date, the extent to which social determinants of health (SDOH) may help identify individuals with atherosclerotic cardiovascular disease (ASCVD) - beyond traditional risk factors - has not been quantified using a cumulative social disadvantage approach. The objective of this study was to develop, and validate, a polysocial risk score (PsRS) for prevalent ASCVD in a nationally representative sample of adults in the United States (US).Methods: We used data from the 2013-2017 National Health Interview Survey. A total of 38 SDOH were identified from the database. Stepwise and criterion-based selection approaches were applied to derive PsRS, after adjusting for traditional risk factors. Logistic regression models were fitted to assign risk scores to individual SDOH, based on relative effect size magnitudes. PsRS was calculated by summing risk scores for individual SDOH, for each participant; and validated using a separate validation cohort.Results: Final sample comprised 164,696 adults. PsRS included 7 SDOH: unemployment, inability to pay medical bills, low income, psychological distress, delayed care due to lack of transport, food insecurity, and less than high school education. PsRS ranged from 0-20 and exhibited excellent calibration and discrimination. Individuals with the highest PsRS (5th quintile) had nearly 4-fold higher ASCVD prevalence, relative to those with the lowest risk scores (1st quintile). Area under receiver operating curve (AU-ROC) for PsRS with SDOH alone was 0.836. Addition of SDOH to the model with only demographic and clinical risk factors (AU-ROC=0.852) improved overall discriminatory power, with AU-ROC for final PsRS (demographics+clinical+SDOH)=0.862.Conclusions: Cumulatively, SDOH may help identify individuals with ASCVD, beyond traditional cardiovascular risk factors. In this study, we provide a unique validated PsRS for ASCVD in a national sample of US adults. Future study should target development of similar scores in diverse populations, and incorporate longitudinal study designs.
View details for DOI 10.1016/j.ajpc.2021.100251
View details for PubMedID 34553187
Assessment of Coronary Artery Calcium Scoring to Guide Statin Therapy Allocation According to Risk-Enhancing Factors: The Multi-Ethnic Study of Atherosclerosis.
Importance: The 2018 American Heart Association/American College of Cardiology Guideline on the Management of Blood Cholesterol recommends the use of risk-enhancing factor assessment and the selective use of coronary artery calcium (CAC) scoring to guide the allocation of statin therapy among individuals with an intermediate risk of atherosclerotic cardiovascular disease (ASCVD).Objective: To examine the association between risk-enhancing factors and incident ASCVD by CAC burden among those at intermediate risk of ASCVD.Design, Setting, and Participants: The Multi-Ethnic Study of Atherosclerosis is a multicenter population-based prospective cross-sectional study conducted in the US. Baseline data for the present study were collected between July 15, 2000, and July 14, 2002, and follow-up for incident ASCVD events was ascertained through August 20, 2015. Participants were aged 45 to 75 years with no clinical ASCVD or diabetes at baseline, were at intermediate risk of ASCVD (≥7.5% to <20.0%), and had a low-density lipoprotein cholesterol level of 70 to 189 mg/dL.Exposures: Family history of premature ASCVD, premature menopause, metabolic syndrome, chronic kidney disease, lipid and inflammatory biomarkers, and low ankle-brachial index.Main Outcomes and Measures: Incident ASCVD over a median follow-up of 12.0 years.Results: A total of 1688 participants (mean [SD] age, 65 years; 976 men [57.8%]). Of those, 648 individuals (38.4%) were White, 562 (33.3%) were Black, 305 (18.1%) were Hispanic, and 173 (10.2%) were Chinese American. A total of 722 participants (42.8%) had a CAC score of 0. Among those with 1 to 2 risk-enhancing factors vs those with 3 or more risk-enhancing factors, the prevalence of a CAC score of 0 was 45.7% vs 40.3%, respectively. Over a median follow-up of 12.0 years (interquartile range [IQR], 11.5-12.6 years), the unadjusted incidence rate of ASCVD among those with a CAC score of 0 was less than 7.5 events per 1000 person-years for all individual risk-enhancing factors (with the exception of ankle-brachial index, for which the incidence rate was 10.4 events per 1000 person-years [95% CI, 1.5-73.5]) and combinations of risk-enhancing factors, including participants with 3 or more risk-enhancing factors. Although the individual and composite addition of risk-enhancing factors to the traditional risk factors was associated with improvement in the area under the receiver operating curve, the use of CAC scoring was associated with the greatest improvement in the C statistic (0.633 vs 0.678) for ASCVD events. For incident ASCVD, the net reclassification improvement for CAC was 0.067.Conclusions and Relevance: In this cross-sectional study, among participants with CAC scores of 0, the presence of risk-enhancing factors was generally not associated with an overall ASCVD risk that was higher than the recommended treatment threshold for the initiation of statin therapy. The use of CAC scoring was associated with significant improvements in the reclassification and discrimination of incident ASCVD. The results of this study support the utility of CAC scoring as an adjunct to risk-enhancing factor assessment to more accurately classify individuals with an intermediate risk of ASCVD who might benefit from statin therapy.
View details for DOI 10.1001/jamacardio.2021.2321
View details for PubMedID 34259820
Cardiac Computed Tomography for Personalized Management of Patients With Type 2 Diabetes Mellitus.
Circulation. Cardiovascular imaging
2020; 13 (9): e011365
The incidence and prevalence of type 2 diabetes mellitus are increasing in the United States and worldwide. The individual-level risk of atherosclerotic cardiovascular disease events in primary prevention populations with type 2 diabetes mellitus is highly heterogeneous. Accurate risk stratification in this group is paramount to optimize the use of preventive therapies. Herein, we review the use of the coronary artery calcium score as a decision aid in individuals with type 2 diabetes mellitus without clinical atherosclerotic cardiovascular disease to guide the use of preventive pharmacotherapies, such as aspirin, lipid-lowering mediations, and cardiometabolic agents. The magnitude of expected risk reduction for each of these therapies must be weighed against its cost and potential adverse events. Coronary artery calcium has the potential to improve risk stratification in select individuals beyond clinical and laboratory risk factors, thus providing a more granular assessment of the expected net benefit with each therapy. In patients with diabetes mellitus and stable chest pain, coronary computed tomography angiography increases the sensitivity for coronary artery disease diagnoses compared with functional studies because of the detection of nonobstructive atherosclerosis. Most importantly, this anatomic approach may improve cardiovascular outcomes by increasing the use of evidence-based preventive therapies informed by plaque burden. We therefore provide an updated discussion of the pivotal role of coronary computed tomography angiography in the workup of stable chest pain in patients with diabetes mellitus in the context of recent landmark trials, such as PROMISE trial (Prospective Multicenter Imaging Study for Evaluation of Chest Pain), SCOT-HEART trial (Scottish Computed Tomography of the Heart), and ISCHEMIA trial (International Study of Comparative Health Effectiveness with Medical and Invasive Approaches). Finally, we also outline the current role of coronary computed tomography angiography in acute chest pain presentations.
View details for DOI 10.1161/CIRCIMAGING.120.011365
View details for PubMedID 32900225
Summarizing 2019 in Cardiovascular Prevention Using the Johns Hopkins Ciccarone Center for the Prevention of Cardiovascular Disease's 'ABC's Approach.
American journal of preventive cardiology
In 2019, Preventive Cardiology welcomed many exciting discoveries that improve our ability to reduce the burden of cardiovascular disease (CVD) nationwide. Not only did 2019 further clarify how various environmental exposures and innate and acquired risk factors contribute to the development of CVD, but it also provided new guidelines and therapeutics to more effectively manage existing CVD. Cardiovascular disease prevention requires the prioritization of early and effective detection of CVD in order to implement aggressive lifestyle and pharmacologic therapies, which can slow, halt, or even reverse the progression of the disease. To help streamline and simplify the process of CVD prevention, The Johns Hopkins Ciccarone Center for the Prevention of Cardiovascular Disease has historically adopted an 'ABC' approach, which focuses on optimizing individual CVD risk through lifestyle, behavioral, and pharmacologic interventions. Given the practice changing research and innovation from the past year, this article intends to summarize the Ciccarone Center's key takeaways from CVD prevention in 2019 utilizing our expanded 'ABC' approach.
View details for DOI 10.1016/j.ajpc.2020.100027
View details for PubMedID 33575672
View details for PubMedCentralID PMC7874982
Keeping a Low Profile: Insulinoma
AMERICAN JOURNAL OF MEDICINE
2019; 132 (10): 1160–62
View details for DOI 10.1016/j.amjmed.2019.04.017
View details for Web of Science ID 000493949700032
View details for PubMedID 31054830
Coronary Artery Calcium Scoring in 2019: Past, Present, and Future
CURRENT CARDIOVASCULAR IMAGING REPORTS
2019; 12 (9)
View details for DOI 10.1007/s12410-019-9511-7
View details for Web of Science ID 000479211300001
Coronary artery calcium scoring for individualized cardiovascular risk estimation in important patient subpopulations after the 2019 AHA/ACC primary prevention guidelines.
Progress in cardiovascular diseases
2019; 62 (5): 423–30
The 2018 and 2019 American Heart Association and American College of Cardiology (AHA/ACC) guidelines for primary prevention of atherosclerotic cardiovascular disease (ASCVD) recommend consideration of so-called "risk-enhancing factors" in borderline to intermediate risk individuals. These include high-risk race/ethnicity (e.g. South Asian origin), chronic kidney disease, a family history of premature ASCVD, the metabolic syndrome, chronic inflammatory disorders (e.g. rheumatoid arthritis [RA], psoriasis, or chronic human immunodeficiency virus [HIV]), and conditions specific to women, among others. Studies suggest, however, that risk may be highly heterogeneous within these subgroups. The AHA/ACC guidelines also recommend consideration of coronary artery calcium (CAC) scoring for further risk assessment in borderline to intermediate risk individuals in whom management is uncertain. Although the combination of risk enhancing factors and CAC burden (together with Pooled Cohort estimates) may lead to more accurate ASCVD risk assessment, few publications have closely examined the interplay between risk enhancing factors and CAC scoring for personalized risk estimation. Our aim is to review the relevant literature in this area. Although further research is clearly needed, CAC assessment seems a highly valuable option to inform individualized ASCVD risk management in these important, often highly heterogeneous patient subgroups.
View details for DOI 10.1016/j.pcad.2019.10.007
View details for PubMedID 31715194
Validation of the Coronary Artery Calcium Data and Reporting System (CAC-DRS): Dual importance of CAC score and CAC distribution from the Coronary Artery Calcium (CAC) consortium.
Journal of cardiovascular computed tomography
The Coronary Artery Calcium Data and Reporting System (CAC-DRS), which takes into account the Agatston score category (A) and the number of calcified vessels (N) has not yet been validated in terms of its prognostic significance.We included 54,678 patients from the CAC Consortium, a large retrospective clinical cohort of asymptomatic individuals free of baseline cardiovascular disease (CVD). CAC-DRS groups were derived from routine, cardiac-gated CAC scans. Cox proportional hazards regression models, adjusted for traditional CVD risk factors, were used to assess the association between CAC-DRS groups and CHD, CVD, and all-cause mortality. CAC-DRS was then compared to CAC score groups and regional CAC distribution using area under the curve (AUC) analysis.The study population had a mean age of 54.2 ± 10.7, 34.4% female, and mean ASCVD score 7.3% ± 9.0. Over a mean follow-up of 12 ± 4 years, a total of 2,469 deaths (including 398 CHD deaths and 762 CVD deaths) were recorded. There was a graded risk for CHD, CVD and all-cause mortality with increasing CAC-DRS groups ranging from an all-cause mortality rate of 1.2 per 1,000 person-years for A0 to 15.4 per 1,000 person-years for A3/N4. In multivariable-adjusted models, those with CAC-DRS A3/N4 had significantly higher risk for CHD mortality (HR 5.9 (95% CI 3.6-9.9), CVD mortality (HR4.0 (95% CI 2.8-5.7), and all-cause mortality a (HR 2.5 (95% CI 2.1-3.0) compared to CAC-DRS A0. CAC-DRS had higher AUC than CAC score groups (0.762 vs 0.754, P < 0.001) and CAC distribution (0.762 vs 0.748, P < 0.001).The CAC-DRS system, combining the Agatston score and the number of vessels with CAC provides better stratification of risk for CHD, CVD, and all-cause death than the Agatston score alone. These prognostic data strongly support new SCCT guidelines recommending the use CAC-DRS scoring.
View details for DOI 10.1016/j.jcct.2019.03.011
View details for PubMedID 30952612
Dose-dependent effects of lifestyle interventions on blood lipid levels: Results from the PREMIER trial.
Patient education and counseling
2019; 102 (10): 1882–91
To assess the effects of comprehensive lifestyle modification on low-density lipoprotein cholesterol (LDL-C) levels and whether greater participation in counseling sessions was associated with greater LDL-C reductions.Multicenter trial of Pre- or Stage 1 hypertensive adults randomized to: (1)Advice alone, (2)'Established' lifestyle intervention implementing physical activity, sodium reduction, and weight loss, if overweight, or (3)'Established + DASH' lifestyle intervention with DASH diet counseling. Both intervention groups received behavioral counseling. We used generalized estimating equations to model the intervention's effects on lipid outcomes. Analyses of number of sessions and lipids were adjusted for demographics and medical history.Among 756 participants (mean age 49.7, 63.2% women, 34.7% black), both lifestyle interventions reduced LDL-C, triglycerides, and total cholesterol (TC) at six months. Compared to the 'Advice' arm, net mean lipid changes in the Established group were: LDL-C of -5.6 mg/dL (p=0.001) and TC of -7.3 mg/dL (p<0.001). Similarly, changes in the 'Established + DASH' group were: LDL-C of -4.0 mg/dL (p=0.03) and TC of -5.7 mg/dL (p=0.006). In dose-response analyses, for every 10-session increase, LDL-C changed by -6.2 mg/dL (p=0.003).Comprehensive lifestyle modification lowers LDL-C with greater benefit among persons who attend more counseling sessions.Patient engagement is a critical aspect of effective lifestyle interventions.
View details for DOI 10.1016/j.pec.2019.05.005
View details for PubMedID 31153659
View details for PubMedCentralID PMC6716987
Non-statin lipid lowering and coronary plaque composition.
Journal of cardiovascular computed tomography
2019; 13 (6): 301–2
View details for DOI 10.1016/j.jcct.2019.02.002
View details for PubMedID 30803836
Analysis of American College of Cardiology/American Heart Association Guideline Author Self-Disclosure Compared With Open Payments Industry Disclosure.
Circulation. Cardiovascular quality and outcomes
2019; 12 (12): e005613
View details for DOI 10.1161/CIRCOUTCOMES.119.005613
View details for PubMedID 32522012
What Clinicians Need to Know About the Cardiovascular Effects of the Most Recent Classes of Drugs Used for Type 2 Diabetes.
The American journal of medicine
2019; 132 (9): 1027–31
The treatment of cardiovascular disease in patients with diabetes has seen a sea change in recent years with the development of novel antihyperglycemic agents. The impact of sodium-glucose cotransporter-2 (SGLT2) inhibitors and glucagon-like peptide-1 receptor agonists (GLP-1 RAs), two medication classes introduced in the United States in the wake of increased scrutiny by the US Food and Drug Administration on cardiovascular disease and antihyperglycemic agents, highlight this progression. In recent trials, SGLT2 inhibitors have demonstrated significant reductions in admissions for heart failure in patients with established cardiovascular disease and those at risk of cardiovascular disease, as well as significant reductions in major adverse cardiovascular events for those with established cardiovascular disease. GLP-1 RAs have exhibited consistent reductions in major adverse cardiovascular events for patients with established cardiovascular disease. These developments have led the 2019 American Diabetes Association guidelines to recommend considering each patient's cardiovascular history when selecting antihyperglycemic agents. The goal of this article is to review recent updates and provide relevant strategies for providers on SGLT2 and GLP-1 RAs in treating cardiovascular disease in patients with diabetes.
View details for DOI 10.1016/j.amjmed.2019.02.050
View details for PubMedID 30904510
Coronary artery calcium scoring in low risk patients with family history of coronary heart disease: Validation of the SCCT guideline approach in the coronary artery calcium consortium.
Journal of cardiovascular computed tomography
2019; 13 (3): 21–25
The Society of Cardiovascular Computed Tomography (SCCT) recommends consideration of coronary artery calcium (CAC) scoring among individuals with a family history (FH) of coronary heart disease (CHD) and atherosclerotic cardiovascular disease (ASCVD) risk <5%. No dedicated study has examined the prognostic significance of CAC scoring among this population.The CAC Consortium is a multi-center observational cohort study from four clinical centers linked to long-term follow-up for cause-specific mortality. All CAC scans were physician referred and performed in patients without a history of CHD. Our analysis includes 14,169 patients with ASCVD scores <5% and self-reported FH of CHD.This cohort had a mean age of 48.1 (SD 7.4), was 91.3% white, 47.4% female, had an average ASCVD score of 2.3% (SD 1.3), and 59.4% had a CAC = 0. The event rate for all-cause mortality was 1.2 per 1000 person-years, 0.3 per 1000 person-years for CVD-specific mortality, and 0.2 per 1000 person-years for CHD-specific mortality. In multivariable Cox proportional hazard models, those with CAC>100 had a 2.2 (95% CI 1.5-3.3) higher risk of all-cause mortality, 4.3 (95% CI 1.9-9.5) times higher risk of CVD-specific mortality, and a 10.4 (95% CI 3.2-33.7) times higher risk of CHD-specific mortality compared to individuals with CAC = 0. The NNS to detect CAC >100 in this sample was 9.In otherwise low risk patients with FH of CHD, CAC>100 were associated with increased risk of all-cause and CHD mortality with event rates in a range that may benefit with preventive pharmacotherapy. These data strongly support new SCCT recommendations regarding testing of patients with a family history of CHD.
View details for DOI 10.1016/j.jcct.2019.03.012
View details for PubMedID 30935842
View details for PubMedCentralID PMC6663654
High-Goal 'Lytes: Repletion Gone Awry?
Journal of hospital medicine
2019; 14 (12): 785–86
View details for DOI 10.12788/jhm.3274
View details for PubMedID 31339839
Serotonin Syndrome Masquerading as Ventricular Tachycardia Storm
AMERICAN JOURNAL OF MEDICINE
2018; 131 (12): E498–E499
View details for DOI 10.1016/j.amjmed.2018.07.016
View details for Web of Science ID 000451731500005
View details for PubMedID 30077498
Prognostic Implications of Coronary Artery Calcium in Different Age Groups: Cause-Specific Mortality From the CAC Consortium.
LIPPINCOTT WILLIAMS & WILKINS. 2018
View details for Web of Science ID 000528619405074
Extreme Endurance Exercise and Progressive Coronary Artery Disease.
Journal of the American College of Cardiology
2017; 70 (2): 293–95
View details for DOI 10.1016/j.jacc.2017.05.016
View details for PubMedID 28683972
Engaging medical students in problem-based search and study of the biomedical literature.
International journal of medical education
2017; 8: 297–99
View details for DOI 10.5116/ijme.5975.c0bc
View details for PubMedID 28829332
View details for PubMedCentralID PMC5572423
ACC/AHA GUIDELINE AUTHOR SELF-DISCLOSURES AND THE SUNSHINE ACT: CONFLICTING REPORTS OF CONFLICTS OF INTEREST
ELSEVIER SCIENCE INC. 2016: 1967
View details for DOI 10.1016/S0735-1097(16)31968-4
View details for Web of Science ID 000375188702813
The American journal of medicine
2016; 129 (9): e195–6
View details for DOI 10.1016/j.amjmed.2016.04.018
View details for PubMedID 27554955
Author Self-disclosure Compared with Pharmaceutical Company Reporting of Physician Payments.
The American journal of medicine
2016; 129 (1): 59–63
Industry manufacturers are required by the Sunshine Act to disclose payments to physicians. These data recently became publicly available, but some manufacturers prereleased their data since 2009. We tested the hypotheses that there would be discrepancies between manufacturers' and physicians' disclosures.The financial disclosures by authors of all 39 American College of Cardiology and American Heart Association guidelines between 2009 and 2012 were matched to the public disclosures of 15 pharmaceutical companies during that same period. Duplicate authors across guidelines were assessed independently. Per the guidelines, payments <$10,000 are modest and ≥$10,000 are significant. Agreement was determined using a κ statistic; Fisher's exact and Mann-Whitney tests were used to detect statistical significance.The overall agreement between author and company disclosure was poor (κ = 0.238). There was a significant difference in error rates of disclosure among companies and authors (P = .019). Of disclosures by authors, companies failed to match them with an error rate of 71.6%. Of disclosures by companies, authors failed to match them with an error rate of 54.7%.Our analysis shows a concerning level of disagreement between guideline authors' and pharmaceutical companies' disclosures. Without ability for physicians to challenge reports, it is unclear whether these discrepancies reflect undisclosed relationships with industry or errors in reporting, and caution should be advised in interpretation of data from the Sunshine Act.
View details for DOI 10.1016/j.amjmed.2015.06.028
View details for PubMedID 26169886
Teaching and learning of medical biochemistry according to clinical realities: A case study.
Biochemistry and molecular biology education : a bimonthly publication of the International Union of Biochemistry and Molecular Biology
2015; 44 (1): 95–98
To foster medical students to become physicians who will be lifelong independent learners and critical thinkers with healthy skepticism and provide high-quality patient care guided by the best evidence, teaching of evidence-based medicine (EBM) has become an important component of medical education. Currently, the teaching and learning of biochemistry in medical schools incorporates its medical relevance and applications. However, to our knowledge there have been no reports on integrating EBM with teaching and learning medical biochemistry. Here, we present a case study to illustrate the significance of this approach. This case study was based on a biochemistry/nutrition question in a popular board review book about whether a homeless alcoholic man is at risk of developing a deficiency of vitamin E. The possible answers and explanation provided in the book raised a question about the correct answer, which provided us with an opportunity to adapt the philosophy and certain basic EBM principles to find evidence for the clinical applicability of a commonly taught biochemistry topic. The outcome of this case study not only taught us how to conduct an EBM exercise to answer a specific patient question, but also provided us with an opportunity for in-depth teaching and learning of the medical relevance of a specific biochemistry topic based on the best clinical evidence obtained from a systematic research of medical literature.
View details for DOI 10.1002/bmb.20924
View details for PubMedID 26593685
Characteristics of Unselected High-Burden Premature Ventricular Contraction Patients
PACE-PACING AND CLINICAL ELECTROPHYSIOLOGY
2014; 37 (12): 1671-1680
High-burden premature ventricular contractions (PVCs) may be an important determinant of heart failure (HF) in patients presenting for PVC ablation. The prevalence and characteristics of high-burden PVC patients outside this setting remain unknown. We, therefore, sought to determine predictors of high-burden PVCs and, among high-burden PVC patients, predictors of HF.We identified all patients undergoing a 24-48-hour Holter study showing at least 20% PVCs between 2005 and 2013 at the University of California, San Francisco. Three time-matched controls undergoing Holter monitoring were selected for each high-burden PVC patient. Medical records were reviewed and test characteristics of PVC counts from 12-lead electrocardiograms (ECG) as predictors of high-burden PVC Holters were analyzed.Among 5,091 participants, 66 (1.3%) exhibited at least 20% PVCs. After multivariate adjustment, high-burden PVC patients had a three-fold greater odds of HF (odds ratio [OR] 3.15; 95% confidence interval [CI] 1.28-6.50; P = 0.005) and 10-fold greater odds of having a first-degree family member with sudden death (OR 9.97; 95% CI 1.78-60.8; P = 0.011). The C-statistic for the number of PVCs on 12-lead electrocardiogram as a predictor of high-burden PVCs was 0.7949. Among high-burden PVC patients, HF was associated with a history of coronary artery bypass grafting (OR 11.76; 95% CI 1.30-106.49; P = 0.028).Among all undergoing Holter monitoring, 1.3% exhibited high-burden PVCs, a phenomenon associated with HF and a first-degree family history of sudden death. In an analysis restricted to high-burden PVC patients, a history of coronary artery bypass grafting was a predictor of HF.
View details for DOI 10.1111/pace.12476
View details for Web of Science ID 000345996100012
View details for PubMedID 25081578