Person: Kinlay, Scott
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Kinlay
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Kinlay, Scott
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Publication Prognosis of patients with secondary mitral regurgitation and reduced ejection fraction(BMJ Publishing Group, 2018) Mowakeaa, Samer; Dwivedi, Aeshita; Grossman, Jason R; Parikh, Gaurav; Curillova, Zelmira; Aragam, Krishna; Elmariah, Sammy; Kinlay, Scott; Aragam, JayashriObjective: The impact of the severity of secondary mitral regurgitation (MR) on the risk of death and heart failure (HF) hospitalisations in patients with reduced left ventricular (LV) systolic function is poorly defined. The study sought to identify the incremental risk of secondary MR in patients with reduced LV systolic function. Methods: We studied 615 consecutive patients with LV ejection fraction ≤35% by transthoracic echocardiography at a single medical centre. Patients were divided into three groups of no MR, mild, or moderate to severe MR. The median follow-up was 2.9 years. The primary endpoint was a composite of death or HF hospitalisations. Results: Compared with patients with no MR, the risk of death or HF hospitalisations was higher for mild MR (HR 1.7, P=0.003) and moderate to severe MR (HR 2.7, P<0.001). The risk was also higher for the component endpoints of HF hospitalisations (mild MR: HR 2.3, P=0.001; moderate to severe MR: HR 3.5, P<0.001) and death (mild MR: HR 1.6, P=0.033; moderate to severe MR: HR 2.6, P<0.001). After adjustment for other covariates, MR was no longer significantly associated with death or HF hospitalisations, or death alone, but remained significantly associated with HF hospitalisations (mild MR: HR 1.7, P=0.028; moderate to severe MR: HR 2.2, P=0.002). Conclusions: In patients with reduced LV systolic function, secondary MR is associated with an increased risk of HF hospitalisations but not death.Publication Management of Left Main Coronary Artery Disease(John Wiley and Sons Inc., 2018) Ramadan, Ronnie; Boden, William E.; Kinlay, ScottPublication Physician Accuracy in Interpreting Potential ST‐Segment Elevation Myocardial Infarction Electrocardiograms(Blackwell Publishing Ltd, 2013) McCabe, James M.; Armstrong, Ehrin J.; Ku, Ivy; Kulkarni, Ameya; Hoffmayer, Kurt S.; Bhave, Prashant D.; Waldo, Stephen W.; Hsue, Priscilla; Stein, John C.; Marcus, Gregory M.; Kinlay, Scott; Ganz, PeterBackground: With adoption of telemedicine, physicians are increasingly asked to diagnose ST‐segment elevation myocardial infarctions (STEMIs) based on electrocardiograms (ECGs) with minimal associated clinical information. We sought to determine physicians' diagnostic agreement and accuracy when interpreting potential STEMI ECGs. Methods and Results: A cross‐sectional survey was performed consisting of 36 deidentified ECGs that had previously resulted in putative STEMI diagnoses. Emergency physicians, cardiologists, and interventional cardiologists participated in the survey. For each ECG, physicians were asked, “based on the ECG above, is there a blocked coronary artery present causing a STEMI?” The reference standard for ascertaining the STEMI diagnosis was subsequent emergent coronary arteriography. Responses were analyzed with generalized estimating equations to account for nested and repeated measures. One hundred twenty‐four physicians interpreted a total of 4392 ECGs. Among all physicians, interreader agreement (kappa) for ECG interpretation was 0.33, reflecting poor agreement. The sensitivity to identify “true” STEMIs was 65% (95% CI: 63 to 67) and the specificity was 79% (95% CI: 77 to 81). There was a 6% increase in the odds of accurate ECG interpretation for every 5 years of experience since medical school graduation (OR 1.06, 95% CI: 1.02 to 1.10, P=0.01). After adjusting for experience, there was no significant difference in the odds of accurate interpretation by specialty—Emergency Medicine (reference), General Cardiology (AOR 0.97, 95% CI: 0.79 to 1.2, P=0.80), or Interventional Cardiology physicians (AOR 1.24, 95% CI: 0.93 to 1.7, P=0.15). Conclusions: There is significant physician disagreement in interpreting ECGs with features concerning for STEMI. Such ECGs lack the necessary sensitivity and specificity to act as a suitable “stand‐alone” diagnostic test.Publication The Effect of Salsalate Therapy on Endothelial Function in a Broad Range of Subjects(Blackwell Publishing Ltd, 2014) Nohria, Anju; Kinlay, Scott; Buck, J. Stewart; Redline, Whitney; Copeland‐Halperin, Robert; Kim, Sora; Beckman, Joshua A.Background: Inflammation is fundamental to the development of atherosclerosis. We examined the effect of anti‐inflammatory doses of salicylate on endothelium‐dependent vasodilation, a biomarker of cardiovascular risk, in a broad range of subjects. Methods and Results: We performed a randomized, double‐blind, placebo‐controlled crossover trial evaluating the effects of 4 weeks of high‐dose salsalate (disalicylate) therapy on endothelium‐dependent flow‐mediated and endothelium‐independent vasodilation. Fifty‐eight subjects, including 17 with metabolic syndrome, 13 with atherosclerosis, and 28 healthy controls, were studied. Among all subjects, endothelium‐dependent flow‐mediated vasodilation decreased after salsalate compared with placebo therapy (P=0.01), whereas nitroglycerin‐mediated, endothelium‐independent vasodilation was unchanged (P=0.97). Endothelium‐dependent flow‐mediated vasodilation after salsalate therapy was impaired compared with placebo therapy in subjects with therapeutic salicylate levels (n=31, P<0.02) but not in subjects with subtherapeutic levels (P>0.2). Conclusions: Salsalate therapy, particularly when therapeutic salicylate levels are achieved, impairs endothelium‐dependent vasodilation in a broad range of subjects. These data raise concern about the possible deleterious effects of anti‐inflammatory doses of salsalate on cardiovascular risk. Clinical Trial Registration URL: www.clinicaltrials.gov. Unique Identifiers: NCT00760019 and NCT00762827.Publication Relationship of antihypertensive treatment to plasma markers of vascular inflammation and remodeling in the Comparison of Amlodipine versus Enalapril to Limit Occurrences of Thrombosis study(Elsevier BV, 2012) Zamani, Payman; Ganz, Peter; Libby, Peter; Sutradhar, Santosh C.; Rifai, Nader; Nicholls, Stephen J.; Nissen, Steven E.; Kinlay, ScottBackground Antihypertensive agents lower the risk of cardiovascular events, but whether they affect pathways important in inflammation and plaque remodeling in atherosclerosis is uncertain. We assessed whether 2 commonly used antihypertensive agents affected plasma biomarkers reflecting specific inflammatory and remodeling processes over 2 years in the Comparison of Amlodipine versus Enalapril to Limit Occurrences of Thrombosis (CAMELOT) study. Methods The study was a randomized controlled trial of 2 antihypertensives (amlodipine and enalapril) compared with placebo in patients with coronary artery disease and diastolic blood pressure less than 100 mm Hg. In 196 subjects who had baseline and 2-year intravascular coronary ultrasound examinations, we measured plasma interleukin 18, interleukin 1 receptor antagonist, matrix metalloproteinase 9, neopterin, and C-reactive protein. Results for both treatment groups were pooled and compared with placebo. Results Antihypertensive treatment with either agent significantly lowered diastolic blood pressure (−4.7 vs placebo 1.3 mm Hg, P = .002) and progression of coronary atheroma (Δ percent atheroma volume 0.6 vs placebo 2.1, P = .031). Antihypertensive therapy did not affect plasma biomarkers of inflammation or plaque remodeling in the 135 subjects with baseline and 2-year biomarker samples. Progression in percent atheroma volume was significantly less in subjects taking statins at baseline (−2.5%, P = .0008). Conclusions In patients with coronary artery disease and well-controlled risk factors, antihypertensive therapy lowered blood pressure and progression of coronary atherosclerosis but did not affect plasma biomarkers of inflammation and remodeling. Antihypertensives may decrease atheroma progression by mechanisms other than those reflected by these plasma biomarkers.Publication Endogenous tissue plasminogen activator and risk of recurrent cardiac events after an acute coronary syndrome in the MIRACL study(Elsevier BV, 2009) Kinlay, Scott; Schwartz, Gregory; Olsson, Anders G.; Rifai, Nader; Bao, Weihang; Libby, Peter; Ganz, PeterObjective To examine the relationship of baseline tissue plasminogen activator (t-PA) to early cardiovascular risk after an acute coronary syndrome, and the effect of intensive statin therapy. Methods We measured plasma t-PA in 2860 of the 3086 (93%) subjects in the MIRACL study, an international randomized trial of atorvastatin 80 mg daily versus placebo in patients with acute coronary syndromes. The relationship of t-PA to death, non-fatal acute myocardial infarction, cardiac arrest, or worsening angina over 16 weeks was assessed by Cox Proportional Hazards. D-dimer was measured in a random sample of 395 subjects. Results Higher baseline t-PA was significantly related to the risk of recurrent events (HR = 1.25, p = 0.0014). This relationship was unaffected by adjustment for age, sex, troponin, hsCRP, and lipids (HR = 1.17, p = 0.029), but was attenuated by adjustment including body mass index and smoking (HR = 1.14, p=0.08). D-dimer and t-PA concentrations were not related. Atorvastatin reduced the risk of recurrent events, but did not affect t-PA or D-dimer concentrations or the relationship of t-PA to outcomes. Conclusion In patients with acute coronary syndromes, increasing t-PA concentration was related to a higher early risk of recurrent events, paradoxically reflecting impaired endogenous fibrinolysis. This relationship is due in part to the association of t-PA with age, body mass index and smoking. Although statins lower the risk of recurrent events after acute coronary syndromes, it is unlikely that this benefit is achieved through thrombolytic and fibrinolytic pathways.Publication Improved characterization of atherosclerotic plaques by gadolinium contrast during intravascular magnetic resonance imaging of human arteries(Elsevier BV, 2008) Larose, Eric; Kinlay, Scott; Selwyn, Andrew; Yeghiazarians, Yerem; Yucel, E. Kent; Kacher, Daniel F.; Libby, Peter; Ganz, PeterObjectives To determine whether gadolinium-DTPA (Gd-DTPA) facilitates discrimination of fibrous, lipid or calcified constituents during intravascular magnetic resonance imaging (IVMRI) of human atherosclerotic arteries. Background Atherosclerotic plaques that cause fatal thrombosis due to rupture have high content of lipid relative to fibrous tissue. We recently demonstrated that IVMRI identifies lipid, fibrous, and calcified components within atherosclerotic human arteries with favorable sensitivity and specificity. Gd-DTPA, a T1-shortening agent, selectively amplifies the signal from fibrous tissue on T1 weighted (T1w) surface MRI. Methods A 0.030 in. diameter receiver coil coupled to a 1.5T MR scanner was positioned in iliac arteries of nine subjects with atherosclerosis. Previously validated multi-parametric analysis of T1w and moderate T2w images identified 137 fibrous, lipid and calcified regions of interest within 37 arterial segments. T1w imaging was repeated following 0.1 mmol/kg IV Gd-DTPA infusion. Results Computer-derived mean gray value in fibrous regions increased by 34.2% with Gd-DTPA (95% CI 24.3–43.5%, p = 0.0001) while lipid and calcified regions showed only a non-significant increase of 4.3% (95% CI −0.6 to 9.2%, p = 0.0825) and 3.8% (95% CI −1.1 to 7.7%, p = 0.103), respectively. The increase in mean gray value with Gd-DTPA was greater for fibrous than for lipid or calcified regions (p = 0.0001). Conclusions Gd-DTPA selectively enhances signal intensity of fibrous constituents during IVMRI of human atherosclerotic arteries and thus identifies key tissue characteristics associated with plaque stability. These findings have important implications for the assessment of plaque-stabilizing therapies and ultimately for reducing cardiovascular events.Publication Prevalence and Factors Associated With False-Positive ST-Segment Elevation Myocardial Infarction Diagnoses at Primary Percutaneous Coronary Intervention–Capable Centers(American Medical Association (AMA), 2012) McCabe, James M.; Armstrong, Ehrin J.; Kulkarni, Ameya; Hoffmayer, Kurt S.; Bhave, Prashant D.; Garg, Sonia; Patel, Ateet; MacGregor, John S.; Hsue, Priscilla; Stein, John C.; Kinlay, Scott; Ganz, PeterBackground Rapid activation of the cardiac catheterization laboratory for primary percutaneous coronary intervention (PCI) improves outcomes for ST-segment elevation myocardial infarction (STEMI), but selected emphasis on minimizing time to reperfusion may lead to a greater frequency of false-positive activations. Methods We analyzed consecutive patients referred for primary PCI for a possible STEMI at 2 centers from October 2008 to April 2011. “False-positive STEMI activation” was defined as lack of a culprit lesion by angiography or by assessment of clinical, electrocardiographic, and biomarker data in the absence of angiography. Clinical and electrocardiographic factors associated with false-positive activations were evaluated in a backward stepwise selection bootstrapped logistic regression model. Results Of 411 STEMI activations by emergency physicians, 146 (36%) were deemed to be false-positive activations. Structural heart disease and heart failure were the most common diagnoses among false-positive activations. Electrocardiographic left ventricular hypertrophy (adjusted odds ratio [AOR], 3.15; 95% CI, 1.55-6.40; P = .001), a history of coronary disease (AOR, 1.93; 95% CI, 1.04-3.59; P = .04), or prior illicit drug abuse (AOR, 2.67; 95% CI, 1.13-6.26; P = .02) independently increased the odds of false-positive STEMI activations. Increasing body mass index decreased the odds of a false-positive activation (AOR, 0.91; 95% CI, 0.86-0.97; P = .004), as did angina at presentation (AOR, 0.28; 95% CI, 0.14-0.57; P < .001). Conclusions More than a third of patients referred for primary PCI from the emergency department did not have a STEMI. Multiple patient-level characteristics were significantly associated with an increased odds of false-positive STEMI activation. Reperfusion therapy with percutaneous coronary intervention (PCI) is recommended for treatment of ST-segment elevation myocardial infarction (STEMI) when readily available.1 One strategy that was found to facilitate a more rapid administration of PCI is autonomous STEMI team activation by emergency department (ED) physicians without routine cardiology consultation.2- 7 Appropriate STEMI care and national health care quality metrics emphasize the timeliness of reperfusion therapy, but patient safety and health care costs demand thoughtful and judicious implementation of emergency coronary angiography. Nevertheless, inaccurate STEMI diagnoses with so-called false-positive activations of the cardiac catheterization team for emergent cardiac angiography are not only anticipated, they are readily accepted in an effort to preferentially emphasize diagnostic sensitivity. However, acceptable rates of false-positive activations are not established. Furthermore, current STEMI diagnosis accuracy remains uncertain owing to discrepancies in defining a false-positive STEMI diagnosis,8,9 temporal trends in primary PCI availability at nontertiary care centers,10,11 and potential reclassification bias within national angiographically based STEMI registries. The objective of this study was to determine the prevalence of false-positive STEMI diagnoses among emergency physicians at primary PCI-capable centers. We also assessed the relationship between false-positive activations and clinical and electrocardiographic (ECG) factors available at the time of diagnosis.Publication Attitudes of developing world physicians to where medical research is performed and reported(Springer Nature, 2003) Page, John; Heller, Richard F; Kinlay, Scott; Lim, Lynette L-Y; Qian, Wang; Suping, Zheng; Kongpatanakul, Supornchai; Akhtar, Murtaza; Khedr, Salah; Macharia, WilliamBackground Little is known about the influence of the site of research or publication on the impact of the research findings on clinical practice, particularly in developing countries. The International Clinical Epidemiology Network (INCLEN) is dedicated to improving the quality of health research in the Developing World through institutional capacity building for evidence based medicine, and provided the opportunity to examine the likely impact of research location and journal location on physicians' practice in a number of the participating countries. Methods Physicians from secondary and tertiary hospitals in six cities located in China, Thailand, India, Egypt and Kenya were enrolled in a cross-sectional questionnaire survey. The primary outcome measures were scores on a Likert scale reflecting stated likelihood of changing clinical practice depending on the source of the research or its publication. Results Overall, local research and publications were most likely to effect change in clinical practice, followed by North American, European and regional research/publications respectively, although there were significant variations between countries. The impact of local and regional research would be greater if the perceived research quality improved in those settings. Conclusion Conducting high quality local research is likely to be an effective way of getting research findings into practice in developing countries.Publication Choice of anticoagulant affects measurement of plasma fibrinogen.(American Association for Clinical Chemistry, 1993) Gleeson, M; Kinlay, Scott