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Background: Nonagenarians are a fast-growing age group among acute coronary syndrome (ACS) patients. While new therapeutic options have improved outcomes of ACS patients, data regarding very elderly ACS patients are limited. We aimed to evaluate temporal trends in the treatment and outcomes of nonagenarian ACS patients., Methods: Included were ACS patients aged below 90 years enrolled in ACS Israeli Survey. Patients were divided into two groups according to enrolment period: early (2000-2010) and recent (2012-2021). The primary endpoints were 30-day major adverse cardiovascular events and all-cause mortality. Secondary outcomes included in-hospital and 1-year all-cause mortality., Results: Included were 316 elderly ACS patients. Of them, 184 were enrolled in the early and 132 in recent surveys. Patients enrolled in the recent period were more commonly referred for an invasive strategy and more commonly received guideline-based medical therapy. All-cause mortality at 30 days was significantly lower in the recent group compared with the early group (12.5 and 26.1%, respectively, P  = 0.005). Rates of 30-day major adverse cardiovascular events were also significantly lower in the recent group (21.9 and 35.9%, respectively, P  = 0.012). Patients in the recent group received more aggressive medical therapy in discharge but at 30-day follow-up, no difference in medical treatment was observed in the two groups. There were no significant differences in 1-year mortality rates., Conclusions: Treatment of nonagenarians with ACS has improved over the past decade. Treatment improvement was associated with a significant improvement in 30-day outcomes without any effect in 1 year. Nevertheless, even with contemporary treatment, nonagenarians with ACS remain a high-risk group with high mortality rates., (Copyright © 2024 Wolters Kluwer Health, Inc. All rights reserved.)

Background: Patients with mechanical prosthetic heart valves must be treated with vitamin K antagonists (VKA) due to an increased risk of valve thrombosis and systemic embolism., Objectives: To assess the effects of the COVID-19 pandemic on VKA treatment control in patients with mechanical prosthetic heart valves., Methods: We conducted a retrospective nationwide cohort study using the Clalit Health Services database. The cohort included patients who underwent either aortic or mitral valve replacement using a prosthetic mechanical valve. The primary outcomes included the overall time in therapeutic range (TTR) and the percent of patients with a TTR < 50% during the first year of the COVID-19 pandemic compared to preceding year., Results: The cohort included 2381 patients. The percentage of patients who had at least two international normalized ratio (INR) tests during the first year of the COVID-19 pandemic was significantly lower compared to the year preceding the pandemic (81% and 87%, respectively, P < 0.001). In both years, the percentage of patients without any documented INR test was high (31.5% in the first COVID-19 pandemic year and 28.9% in the preceding year, P < 0.001). TTR was significantly lower during the 1st year of the COVID-19 pandemic compared to the preceding year (68.1% ± 26 and 69.4% ± 24, P = 0.03). A TTR > 50% was demonstrated in 78% and 81% during the pandemic and the preceding year, P = 0.009., Conclusions: We noted overall poor VKA control in patients with mechanical heart valves. During the COVID-19 pandemic, VKA control became even worse as reflected by significantly lower TTR and INR tests rates.

Non-invasive characterization of powders may take one of two approaches: imaging and counting individual particles; or relying on scattered light to estimate the particle size distribution (PSD) of the ensemble. The former approach runs into practical difficulties, as the system must conform to the working distance and other restrictions of the imaging optics. The latter approach requires an inverse map from the speckle autocorrelation to the particle sizes. The principle relies on the pupil function determining the basic sidelobe shape, whereas the particle size spread modulates the sidelobe intensity. We recently showed that it is feasible to invert the speckle autocorrelation and obtain the PSD using a neural network, trained efficiently through a physics-informed semi-generative approach. In this work, we eliminate one of the most time-consuming steps of our previous method by engineering the pupil function. By judiciously blocking portions of the pupil, we sacrifice some photons but in return we achieve much enhanced sidelobes and, hence, higher sensitivity to the change of the size distribution. The result is a 60 × reduction in total acquisition and processing time, or 0.25 seconds per frame in our implementation. Almost real-time operation in our system is not only more appealing toward rapid industrial adoption, it also paves the way for quantitative characterization of complex spatial or temporal dynamics in drying, blending, and other chemical and pharmaceutical manufacturing processes., (© 2024. The Author(s).)

Background: Statin therapy is well-established for treating hyperlipidemia and ischemic heart disease (IHD), but its role in Acute Decompensated Heart Failure (ADHF) remains less clear. Despite varying clinical guidelines, the actual utilization and impact of statin therapy initiation in patients with ADHF with an independent indication for statin therapy have not been thoroughly explored., Methods: We conducted a retrospective observational study on 5978 patients admitted with ADHF between January 1st, 2007, and December 31st, 2017. Patients were grouped based on their statin therapy status at admission and discharge. We performed multivariable analyses to identify independent predictors of short-term, intermediate-term, and long-term mortality. A sensitivity analysis was also conducted on patients with an independent indication for statin therapy but who were not on statins at admission., Results: Of the total patient cohort, 73.9% had an indication for statin therapy. However, only 38.2% were treated with statins at admission, and 56.1% were discharged with a statin prescription. Patients discharged with statins were younger, predominantly male, and had a higher prevalence of IHD and other comorbidities. Statin therapy at discharge was an independent negative predictor of 5-year all-cause mortality (hazard ratio 0.80, 95% confidence interval 0.76-0.85). The sensitivity analysis confirmed these findings, demonstrating higher mortality rates in patients not initiated on statins during admission., Conclusions: The study highlights significant underutilization of statin therapy among patients admitted with ADHF, even when there's an independent indication for such treatment. Importantly, initiation of statin therapy during hospital admission was independently associated with improved long-term survival., Competing Interests: The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (© 2024 The Author(s).)

Background: The use of proprotein convertase subtilisin/kexin type 9 monoclonal antibodies (PCSK9 mAbs) is emerging for lowering low-density lipoprotein cholesterol (LDL-C). However, real-world data is lacking for their use among elderly patients., Objectives: To define the characteristics of elderly patients treated with PCSK9 mAbs and to evaluate the efficacy and tolerability compared with younger patients., Methods: We conducted a retrospective cohort study of elderly patients (≥ 75 years at enrollment) treated with PCSK9 mAbs for primary and secondary cardiovascular prevention. Data were retrieved for demographic and clinical characteristics; indications for treatment; agents and dosages; concomitant lipid lowering treatment; LDL-C levels at baseline, 6, 12 months, and at the end of follow up. Data also included achieving LDL-C target levels and adverse effects., Results: The cohort included 91 elderly patients and 92 younger patients, mean age 75.2 ± 3.76 and 58.9 ± 7.4 years (P < 0.0001). Most patients (82%, 80%) were in high/very high-risk categories. For almost all (98%, 99%), the indication was statin intolerance, with PCSK9 mAb monotherapy the most prevalent regimen. The average follow-up was 38.1 ± 20.5 and 30.9 ± 15.8 months (P = 0.0258). Within 6 months the LDL-C levels were reduced by 57% in the elderly group and by 59% in the control group (P = 0.2371). Only 53% and 57% reached their LDL-C target levels. No clinically significant side effects were documented., Conclusions: PCSK9 mAbs have similar effects and are well tolerated among elderly patients as in younger patients.

Introduction: Individuals with chronic kidney disease (CKD) are at increased risk of thrombotic events and bleeding. Acetylsalicylic acid (ASA), an effective antiplatelet agent, is one of the most frequently used medications for both primary and secondary prevention of cardiovascular disease (CVD). However, it can also contribute to bleeding events due to its inherent antiplatelet effect. The objective of this study was to determine the characteristics of CKD patients at increased risk of bleeding under ASA therapy., Methods: This retrospective analysis included patients with non-dialysis-dependent CKD who were treated with ASA for primary prevention of CVD for at least 3 consecutive months and did not receive anti-coagulants or anti-platelets. Data were collected from electronic medical records from January 2014 to December 2018. CKD diagnosis was based on an estimated glomerular filtration rate of <60 mL/min/1.73 m2. CKD patients who experienced major bleeding events during ASA therapy (bleeding group) versus all others (control group) were compared. Additional outcomes included first documented nonfatal cardiovascular event and all-cause mortality., Results: Of the 900 adult CKD patients included in this analysis, 82 (9.1%) had a major bleeding event during 31.6 ± 25.9 months of follow-up. The most common bleeding site was gastrointestinal (52 cases, 63.4% of major bleeding events). Patients who had a major bleeding event were older (76.5 ± 10 vs. 74 ± 10.3 years, p = 0.038). On multivariate analysis, age was the most important predictor of major bleeding event (odds ratio: 1.029, 95% confidence interval: 1.004-1.056)., Conclusions: Given its controversial efficacy in primary prevention of CVD in CKD patients, characterizing those at increased risk of bleeding under ASA therapy is important in the era of tailored medicine. Age, CKD stage, and cardiovascular risk are key factors to consider regarding the safety and effectiveness of ASA for CKD patients., (© 2024 The Author(s). Published by S. Karger AG, Basel.)

Introduction: The ridaforolimus-eluting stent (RES) system uses a novel cobalt alloy-based coronary stent with a durable elastomeric polymer eluting ridaforolimus., Aim of Study: To assess the safety and efficacy of small diameter (2.25 mm) RES (EluNIR) in small coronary artery disease., Methods: A prospective, multicenter, single-arm, open-label clinical trial. Clinical follow-up was performed at 30 days, 6 months, and 1 year after the procedure. Target lesions were located in native coronary arteries or bypass graft conduits, with visually estimated diameter of ≥2.25 mm to ≤2.5 mm. The primary endpoint was combined device success, defined as final in-stent residual diameter stenosis <30%, without 30-day major adverse cardiovascular events (MACE)., Results: A total of 81 patients were enrolled in the study. Twenty-three patients (28%) had acute coronary syndrome (ACS) at presentation and 37 (46%) had prior myocardial infarction (MI). Most of the target lesions were located in the circumflex coronary artery (44%) and were classified as B2/C grade according to the American Heart Association/American College of Cardiology classification. The final mean minimal lumen diameter, mean reference vessel diameter, and mean residual percent diameter stenosis were 2.0 ± 0.2 mm, 2.3 ± 0.1 mm, and 14 + 6.6%, respectively. The primary endpoint of device success without 30-day MACE was achieved in 98.8% of the patients. Target lesion failure (TLF) at 6 months was 1.2%. Thirty-day and 1-year MACE rates were 1.2% and 2.5%, respectively., Conclusion: The EluNIR 2.25 mm stent shows excellent results in small coronary artery disease and adds another tool in the treatment of this complex lesion type., (© 2023 The Authors. Catheterization and Cardiovascular Interventions published by Wiley Periodicals LLC.)

Cardiac rehabilitation improves cardiovascular outcomes in patients after acute coronary syndrome (ACS). Recently there has been a growing interest in remote cardiac rehabilitation (RCR) programs. We aimed to evaluate the effectiveness of RCR compared with center-based cardiac rehabilitation (CBCR). This is an observational study including patients after hospital admission for ACS. The study group included patients at low-to-moderate risk for cardiovascular complications who were referred for RCR. The control group included patients at similar risk who participated in CBCR. The primary end points were the improvement of at least 10% to 25% in exercise capacity after 6 months of cardiac rehabilitation. Included were 305 patients who completed 6 months of cardiac rehabilitation. Of them, 107 patients participated in RCR and 198 in CBCR. RCR patients were younger and more frequently males. Improvement of ≥10% in exercise capacity after 6 months was achieved more frequently in patients participating in RCR compared with CBCR (69.3% and 55% respectively, p = 0.03). A similar trend was observed for improvement of ≥25% in exercise capacity after 6 months (33.8% and 22.7% in RCR and CBCR, respectively, p = 0.05). While weight reduction and the increase in muscle mass were similar in the 2 groups, fat percent reduction was significantly greater in the RCR compared with the CBCR (2.5% and 1.4% respectively, p <0.005). We conclude that RCR program is an effective and safe option for low-risk patients after hospital admission for ACS. It enables optimizing the utilization of this important service for patients with coronary artery disease., Competing Interests: Declaration of Competing Interest The authors have no competing interests to declare., (Copyright © 2023 Elsevier Inc. All rights reserved.)

Background: COVID-19 vaccination has been associated with reduced risk of acute coronary syndrome (ACS); however, several studies have reported cardiovascular complications following vaccination. We aimed to investigate the effect of COVID-19 vaccination status on the treatment and outcome of ACS patients., Methods: The study was based on the 2021 Acute Coronary Syndrome Israeli Survey. Patients were stratified into two groups according to COVID-19 vaccination status, vaccinated compared to unvaccinated. Patients who had received at least 2 vaccination doses up to 1 week prior to ACS hospitalization were considered vaccinated. The primary endpoint was 1-year all-cause mortality., Results: A total of 1261 patients with ACS were included, of whom 990 (78.5%) were vaccinated. Vaccinated patients were older and less frequently smokers. There were no significant differences in coronary reperfusion rates and treatment with guideline-based medical therapy during hospital stay and at discharge. The primary endpoint of 1-year all-cause mortality occurred in 38 (3.8%) and 14 (5.2%) patients in the vaccinated and unvaccinated groups respectively (P = 0.42). 30-day MACE occurred in 94 (9.5%) in the vaccinated patients compared to 31 (11.5%) in the unvaccinated group (P = 0.39). These results remained similar following adjustment for confounders., Conclusion: There was no association between COVID-19 vaccination status and the outcomes of patients with ACS. Our findings provide support for the cardiovascular safety of COVID-19 mRNA vaccines in patients at high cardiovascular risk., (Copyright © 2023 Wolters Kluwer Health, Inc. All rights reserved.)

Speckle noise has long been an extensively studied problem in medical imaging. In recent years, there have been significant advances in leveraging deep learning methods for noise reduction. Nevertheless, adaptation of supervised learning models to unseen domains remains a challenging problem. Specifically, deep neural networks (DNNs) trained for computational imaging tasks are vulnerable to changes in the acquisition system's physical parameters, such as: sampling space, resolution, and contrast. Even within the same acquisition system, performance degrades across datasets of different biological tissues. In this work, we propose a few-shot supervised learning framework for optical coherence tomography (OCT) noise reduction, that offers high-speed training (of the order of seconds) and requires only a single image, or part of an image, and a corresponding speckle-suppressed ground truth, for training. Furthermore, we formulate the domain shift problem for OCT diverse imaging systems and prove that the output resolution of a despeckling trained model is determined by the source domain resolution. We also provide possible remedies. We propose different practical implementations of our approach, verify and compare their applicability, robustness, and computational efficiency. Our results demonstrate the potential to improve sample complexity, generalization, and time efficiency, for coherent and non-coherent noise reduction via supervised learning models, that can also be leveraged for other real-time computer vision applications.

Background: Chronic kidney disease (CKD) is associated with a high burden of coronary artery disease (CAD), which remains the leading cause of death in CKD patients. Despite the high cardiovascular risk, ACS patients with renal dysfunction are less commonly treated with guideline-based medical therapy and are less frequently referred for coronary revascularization., Summary: The management of CAD is more challenging in patients with CKD than in the general population due to concerns regarding side effects and renal toxicity, as well as uncertainty regarding clinical benefit of guideline-based medical therapy and interventions. Patients with advanced CKD and especially those receiving dialysis have not traditionally been represented in randomized trials evaluating either medical or revascularization therapies. Thus, only scant data from small prospective studies or retrospective analyses are available. Recently published studies suggest that there are significant opportunities to substantially improve both cardiovascular and renal outcomes of patients with CAD and CKD, including new medications and interventions. Thus, the objective of this review is to summarize the current evidence regarding the management of CAD in CKD patients, in particular with respect to improvement of both cardiovascular and renal outcomes., Key Messages: Adequate medical therapy and coronary interventions using evidence-based strategies can improve both cardiac and renal outcomes in patients with CAD and CKD., Competing Interests: The authors have no conflicts of interest to declare., (© 2023 The Author(s). Published by S. Karger AG, Basel.)

The statistical supervised learning framework assumes an input-output set with a joint probability distribution that is reliably represented by the training dataset. The learning system is then required to output a prediction rule learned from the training dataset's input-output pairs. In this work, we investigate the relationship between the sample complexity, the empirical risk and the generalization error based on the asymptotic equipartition property (AEP) (Shannon, 1948). We provide theoretical guarantees for reliable learning under the information-theoretic AEP, with respect to the generalization error and the sample size in different settings., Competing Interests: Declaration of competing interest The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (Copyright © 2023 Elsevier Ltd. All rights reserved.)

Frailty has been associated with poor outcomes in patients with cardiovascular diseases (CVDs). We aimed to assess the accuracy of the Eyeball test for frailty assessment in elderly patients with CVD. This is a prospective study including stable patients ≥75 years old who were followed-up in a cardiology clinic. Frailty assessment was performed separately through the Eyeball test and the Fried test in a blinded way. Cardiologists were asked to rate the frailty status of participants based on their routine clinical assessment and grade frailty on a Fried-type scale (1 to 5, with frailty defined as a score ≥3). Each patient then underwent formal frailty assessment using the Fried test. Included were 300 consecutive patients with a mean age of 81 ± 6 years. Frailty was diagnosed in 109 (36%) and 125 patients (41%) according to the Fried and Eyeball tests, respectively. The Eyeball test demonstrated 86% sensitivity and 82% specificity for the diagnosis of frailty. A receiver operating characteristics curve analysis demonstrated an area under the curve of 0.82 for the diagnosis of frailty. The Eyeball test demonstrated a very high negative predictive value of 90% and a modest positive predictive value of 73% for frailty assessment. Similar results were observed after subgroup analysis according to age and gender. In conclusion, the Eyeball test is an accurate method to rule out frailty in elderly patients with CVD. However, when frailty is suspected based on the Eyeball test, a formal tool such as the Fried test should be used to confirm the diagnosis., Competing Interests: Declaration of Competing Interest The authors have no competing interests to declare., (Copyright © 2023 Elsevier Inc. All rights reserved.)

Background: Conflicting evidence exists regarding the association between marital status and outcomes in patients with heart failure (HF). Further, it is not clear whether type of unmarried status (never married, divorced, or widowed) disparities exist in this context., Hypothesis: We hypothesized that marital status will be associated with better outcomes in patients with HF., Methods: This single-center retrospective study utilized a cohort of 7457 patients admitted with acute decompensated HF (ADHF) between 2007 and 2017. We compared baseline characteristics, clinical indices, and outcomes of these patients grouped by their marital status. Cox regression analysis was used to explore the independency of the association between marital status and long-term outcomes., Results: Married patients accounted for 52% of the population while 37%, 9%, and 2% were widowed, divorced, and never married, respectively. Unmarried patients were older (79.8 ± 11.5 vs. 74.8 ± 11.1 years; p < 0.001), more frequently women (71.4% vs. 33.2%; p < 0.001), and less likely to have traditional cardiovascular comorbidities. Compared with married patients, all-cause mortality incidence was higher in unmarried patients at 30 days (14.7% vs. 11.1%, p < 0.001), 1 year, and 5 years (72.9% vs. 68.4%, p < 0.001). Nonadjusted Kaplan-Meier estimates for 5-year all-cause mortality by sex, demonstrated the best prognosis for married women, and by marital status in unmarried patients, the best prognosis was demonstrated in divorced patients while the worst was recorded in widowed patients. After adjustment for covariates, marital status was not found to be independently associated with ADHF outcomes., Conclusions: Marital status is not independently associated with outcomes of patients admitted for ADHF. Efforts for outcomes improvement should focus on other, more traditional risk factors., (© 2023 The Authors. Clinical Cardiology published by Wiley Periodicals LLC.)

Background and objectives : Dyslipidemia is one of the most important modifiable risk factors in the pathogenesis of cardiovascular disease in the general population, but its importance in the hemodialysis (HD) population is uncertain. Materials and Methods : This retrospective cohort study includes HD patients hospitalized due to acute coronary syndrome (ACS) in the period 2015-2020 with lipid profile data during ACS. A control group with preserved kidney function was matched. Risk factors for 30-day and 1-year mortality were assessed. Results : Among 349 patients included in the analysis, 246 were HD-dependent ("HD group"). HD group patients had higher prevalence of diabetes, hypertension, and heart disease than the control group. At ACS hospitalization, lipid profile and chronic statin treatment were comparable between groups. Odds ratios for 30-day mortality in HD vs. control group was 5.2 (95% CI 1.8-15; p = 0.002) and for 1-year, 3.4 (95% CI 1.9-6.1; p <0.001). LDL and LDL < 70 did not change 30-day and 1-year mortality rates in the HD group ( p = 0.995, 0.823, respectively). However, survival after ACS in HD patients correlated positively with nutritional parameters such as serum albumin (r = 0.368, p < 0.001) and total cholesterol (r = 0.185, p < 0.001), and inversely with the inflammatory markers C-reactive protein (CRP; r = -0.348, p < 0.001) and neutrophils-to-lymphocytes ratio (NLR; r = -0.181, p = 0.019). Multivariate analysis demonstrated that heart failure was the only significant predictor of 1-year mortality (OR 2.8, p = 0.002). LDL < 70 mg/dL at ACS hospitalization did not predict 1-year mortality in the HD group. Conclusions : Despite comparable lipid profiles and statin treatment before and after ACS hospitalization, mortality rates were significantly higher among HD group. While malnutrition-inflammation markers were associated with survival of dialysis patients after ACS, LDL cholesterol was not. Thus, our study results emphasize that better nutritional status and less inflammation are associated with improved survival among HD patients.

Background: Direct oral anticoagulants (DOACs) are the treatment of choice for patients with non-valvular atrial fibrillation; however, bleeding risk remains significant. We reported a single-center experience with 11 patients who presented with hemorrhagic cardiac tamponade while treated with DOACs., Objectives: To evaluate the characteristics and clinical outcomes of patients under DOACs with cardiac tamponade., Methods: We retrospectively identified 11 patients treated with DOACs admitted with pericardial tamponade in our cardiology unit during 2018-2021., Results: The mean age was 84 ± 4 years; 7 males. Atrial fibrillation was the indication for anticoagulation in all cases. DOACs included apixaban (8 patients), dabigatran (2 patients), and rivaroxaban (1 patient). Urgent pericardiocentesis via a subxiphoid approach under echocardiography guidance was successfully performed in 10 patients. One patient was treated with urgent surgical drainage with a pericardial window. Reversal of anticoagulation using prothrombin complex concentrate and idarucizumab was given before the procedure to 6 patients treated with apixaban and one patient treated with dabigatran. One patient, initially treated with urgent pericardiocentesis, underwent pericardial window surgery due to re-accumulation of blood in the pericardium. The pericardial fluid analysis demonstrated hemopericardium. Cytology tests were negative for malignant cells in all cases. Discharge diagnoses regarding the cause of hemopericardium included pericarditis (3 patients) and idiopathic (8 patients). Medical therapy included non-steroidal anti-inflammatory drugs (1 patient), colchicine (3 patients), and steroids (3 patients). No patient died during hospitalization., Conclusions: Hemorrhagic cardiac tamponade is a rare complication of DOACs. We found good short-term prognosis following pericardiocentesis.

Background: Cardiac rehabilitation improves prognosis and symptoms in cardiac patients. In 2020, due to the COVID-19 pandemic, cardiac rehabilitation services were temporarily suspended between April and August. We aimed to investigate the effect of cardiac rehabilitation suspension during the COVID-19 pandemic on patients' exercise capacity and metabolic parameters., Methods: Included were patients undergoing cardiac rehabilitation following hospital admission for ACS. Exercise capacity, weight and body fat percentage were compared between baseline, pre- and post-lockdown visits., Results: A total of 281 patients participated in the cardiac rehabilitation program prior to its suspension. Of them, only 198 (70%) patients returned to the program on its renewal and were included in the analysis. Exercise capacity improved significantly in the pre-lockdown stress test compared to baseline. However, there was a significant decrease in exercise capacity in the post compared to pre-lockdown test (8.1±6.3 and 7.1±2.1 METs in pre- and post-lockdown measurements, respectively, p<0.001). Of the 99 (50%) of patients that demonstrated at least 10% improvement in exercise capacity in the pre-lockdown test, 48(48.5%) patients returned to their baseline values in the post-lockdown test. Post-lockdown assessment demonstrated a significant weight gain (80.3 and 81.1kg, in pre- and post-lockdown measurements, respectively, p<0.001) as well as an increase in visceral fat level and body fat percentage., Conclusions: Cardiac rehabilitation suspension for 4 months during COVID-19 pandemic caused a significant reduction in exercise capacity and increased weight and body fat percent. These findings highlight the importance of remote cardiac rehabilitation services that can continue uninterrupted in times of pandemic., Competing Interests: The authors have declared that no competing interests exist., (Copyright: © 2022 Haskiah et al. This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.)

(1) Background: left atrial appendage occlusion (LAAO) is considered an effective and relatively safe treatment for the prevention of thromboembolic events in patients with atrial fibrillation and a contra-indication for anticoagulation. We present a large multicenter real-world experience of transcatheter LAAO implementation in patients with atrial fibrillation who cannot be treated with chronic anti-coagulation; (2) Methods: included were atrial fibrillation patients who underwent transcatheter LAAO between 1 January 2016 and 30 June 2021. The study was conducted using the electronic health record database of Clalit Health Services (CHS). The primary outcomes included hemorrhagic and ischemic stroke following LAAO; (3) Results: included were 389 atrial fibrillation patients. During a median follow-up of 2.1 years, 13% patients had ischemic cerebrovascular accident (CVA), and 4.4% patients had hemorrhagic CVA. While the risk of ischemic stroke increased gradually over time, the risk of hemorrhagic CVA was highest during the first 3 months following the procedure. Moreover, previous ischemic stroke was the only significant predictor for both hemorrhagic and ischemic stroke following LAAO; (4) Conclusions: while the annual performance rate of transcatheter LAAO has increased significantly over the past years, post procedural long-term prognosis remains poor with a substantial risk of both thrombotic and bleeding events.

Chronic kidney disease is associated with an increased risk for cardiovascular and bleeding events. Data regarding the effectiveness and risks of aspirin therapy for primary prevention in the high-risk group of patients with chronic kidney disease are scant and controversial. This retrospective study included patients with chronic kidney disease. Participants were divided according to aspirin use. Outcomes included non-fatal cardiovascular events, major bleeding events and all-cause mortality. Among 10,303 patients, 2169 met the inclusion criteria and 1818 were included after 1:1 propensity-score matching. Our final cohort included patients with mean age of 73.4 ± 11.6 years, estimated glomerular filtration rate of 31.5 ± 10.5 ml/min/1.73m 2 with follow up of 4.9 ± 1.5 years. There were no significant differences in all-cause mortality and bleeding events (odds ratio = 1.03, confidence interval [0.62, 1.84], p = .58 and odds ratio = 1.09, confidence interval [0.65, 1.72], p = .87 respectively). The incidence of cardiovascular events was higher in aspirin users versus non-users on univariate analysis (p < 0.01) and was comparable after controlling for possible risk-factors (OR = 1.05, CI [0.61, 3.14], p = .85). Chronic aspirin use for primary prevention of cardiovascular disease was not associated with lower mortality, cardiovascular events or increased bleeding among patients with chronic kidney disease. Those results were unexpected and should prompt further research in this field., (© 2022. The Author(s).)

Patients with atrial fibrillation (AF) are at increased cardiovascular risk. The CHA 2 DS 2 -VASc score (congestive heart failure, hypertension, age ≥ 75 years, diabetes mellitus, previous stroke, vascular disease, age 65 to 74 years, female gender) has been used to predict thromboembolic risk in patients with nonvalvular AF. We aimed to evaluate the association between the CHA 2 DS 2 -VASc score and the risk of acute myocardial infarction (AMI) and all-cause mortality in patients with AF treated with direct oral anticoagulants (DOACs). The study was based on the Clalit Health Services database. Included were 21,129 patients with nonvalvular AF treated with DOACs. Patients were stratified into four groups according to the CHA 2 DS 2 -VASc score. 1-9 The primary end point was the occurrence of AMI and all-cause mortality. During 21,129 patient-years, there were 1,253 incidents (5.9%) of AMI. A higher CHA 2 DS 2 -VASc score was associated with a significantly increased risk of AMI (7.8, 14.9, 23.9, and 35.3 cases per 1,000 person-years, for patients with CHA 2 DS 2 -VASc score of 1 to 2, 3 to 4, 5 to 6, and 7 to 9, respectively, p <0.001). Each 1-point increase in the CHA 2 DS 2 -VASc score was associated with a 27% increased risk of AMI. A higher CHA 2 DS 2 -VASc score was also associated with a significantly increased ll-cause mortality rate (21.7, 60.2, 103.9, 162.6 cases per 1,000 person-years, for patients with CHA 2 DS 2 -VASc score of 1 to 2, 3 to 4, 5 to 6, 7 to 9, respectively, p <0.001). All associations remained statistically significant after a multivariate analysis. In conclusion, among patients with nonvalvular AF treated with DOACs, the CHA 2 DS 2 -VASc score was associated with increased risk of AMI and all-cause mortality., Competing Interests: Disclosures The authors have no conflicts of interest to declare., (Copyright © 2022 Elsevier Inc. All rights reserved.)

(1) Background: High bleeding risk is associated with adverse outcomes in ACS patients. We aimed to evaluate temporal trends in treatment and outcomes of ACS patients according to bleeding risk. (2) Methods: Included were ACS patients enrolled in ACSIS surveys. Patients were divided into three groups according to enrolment period: early (2002−2004), mid (2006−2010) and recent (2012−2018). Each group was further stratified into three subgroups according to CRUSADE bleeding risk score. The primary endpoints were 30-day MACE and 1-year all-cause mortality. (3) Results: Included were 13,058 ACS patients. High bleeding risk patients were less frequently treated with guideline-based medications and coronary revascularization. They also had higher rates of 30-day MACE and 1-year all-cause mortality regardless of the enrollment period. Among patients enrolled in early period, 30-day MACE rates were 10.8%, 17.5% and 24.3% (p < 0.001) and 1-year all-cause mortality rates were 2%, 7.7% and 23.6% (p < 0.001) in the low, moderate and high bleeding risk groups, respectively. Among patients enrolled in mid period, 30-day MACE rates were 7.7%, 13.4% and 23.5% (p < 0.001) and 1-year all-cause mortality rates were 1.5%, 7.2% and 22.1% (p < 0.001) in low, moderate and high bleeding risk groups, respectively. For patients enrolled in recent period, 30-day MACE rates were 5.7%, 8.6% and 16.2%, (p < 0.001) and 1-year all-cause mortality rates were 2.1%, 6% and 22.4%, (p < 0.001) in low, moderate and high bleeding risk groups, respectively. These differences remained significant following a multivariate analysis. (4) Conclusions: The percentage of patients at high bleeding risk has decreased over the last years. Despite recent improvements in the treatment of ACS patients, high bleeding risk remains a strong predictor of adverse outcomes.

Aims: To describe the extent of prisoner/detainee cuffing and characterize cuffing methods., Background: Thousands of prisoners and detainees receive medical treatment in Israeli hospitals every year. According to the Israeli law, cuffing during hospital stay should be an exceptional measure, to be considered only in cases of real threat of violence or escape, based on individual assessment. There is no documentation of cuffing rates in hospitals., Methods: A multi-center study in 12 hospitals was performed during 2020-2021. Data were collected prospectively or retrieved retrospectively from security records, when available., Results: A total of 1857 prisoners/detainees were documented, of whom 1794 (96.6%) were cuffed. Of the 241 hospitalized patients, 230 (95.4%) were cuffed. Details regarding cuffing methods were available for 185 hospitalized patients, revealing that at least 63 patients (68% of patients for whom details regarding cuffing to bed were available) were cuffed to the bed with opposite arm and leg in a cross position. Cuffing rates of prisoners under custody of the Prisons Authority, police and the Israeli Defense Forces, were 98.5%, 96.6%, and 83%, respectively. Impaired mobility for medical reasons was documented in 64 cases, of whom 85.9% were cuffed regardless., Conclusions: Cuffing of prisoners/detainees in Israeli hospitals is performed non-selectively, in violation of the law. During hospitalization, cuffing is usually performed in a cross position, severely impairing mobility. Our findings highlight the need for routine documentation of cuffing due to its medical consequences and the responsibility of medical staff towards patients according to rules of ethics and regulations.

Aims: Atrial fibrillation and renal dysfunction are associated with increased cardiovascular risk. We examined the association between renal function and incident ischaemic stroke or myocardial infarction in patients with atrial fibrillation treated with direct oral anticoagulants (DOACs)., Methods and Results: This study was conducted using a large health record database. Included were 19 713 patients with first time diagnosis of non-valvular atrial fibrillation treated with DOACs between 2010 and 2018. Patients were categorized into four groups according to the estimated glomerular filtration rate (eGFR) (<30, 30-59, 60-89, and ≥90 mL/min/1.73 m2). Ischaemic stroke and acute myocardial infarction rates were compared between the groups. During 55 086 person-years of follow-up, there were 2295 (11.6%) cases of ischaemic stroke and 1158 (5.9%) cases of acute myocardial infarction. There was a significant inverse association between eGFR and the risk of myocardial infarction. A multivariate analysis using the group with eGFR ≥90 mL/min/1.73 m2 as a reference demonstrated an increased risk of myocardial infarction with lower eGFR [hazard ratio (HR) = 1.2 95% confidence interval (CI) 0.9-1.4, HR = 1.4, 95% CI 1.2-1.7, and HR = 2.5, 95% CI 1.8-3.4 for patients with eGFR 60-89, 30-59, and <30 mL/min/1.73 m2, respectively, P < 0.001]. Each 10 mL decrease in eGFR was associated with an 8% increase in the risk of myocardial infarction. There was no association between eGFR and the risk of ischaemic stroke (HR = 0.9 95% CI 0.8-1.1, HR = 0.93, 95% CI 0.8-1.1, and HR = 1.1, 95% CI 0.8-1.4 for patients with eGFR 60-89, 30-59, and <30 mL/min/1.73 m2, respectively, P = 0.325)., Conclusions: Renal dysfunction is associated with an increased risk of myocardial infarction but not of ischaemic stroke among patients with atrial fibrillation treated with DOACs., (Published on behalf of the European Society of Cardiology. All rights reserved. © The Author(s) 2021. For permissions, please email: journals.permissions@oup.com.)

Despite advances in percutaneous coronary interventions (PCI), a subgroup of acute coronary syndrome (ACS) patients are still managed medically by a conservative approach. We sought to characterize a contemporary, large-scale, real-world cohort of ACS patients treated conservatively via pharmacological management, without PCI. Data was gathered from the ACS Israeli Survey (ACSIS) between 2000 and 2016, encompassing all consecutive patients admitted to cardiology wards with an ACS diagnosis. Included were 3,543 conservatively managed patients with non-ST elevation ACS (NSTE-ACS). Patients with ST elevation MI or those who underwent any coronary revascularization (PCI or bypass surgery) were excluded. Primary endpoints were 30-day major adverse cardiovascular events (MACE) and 1-year mortality. The study cohort was divided to 4 time-periods. Over 2 decades, medically managed NSTE-ACS patients remained of similar age (67 ± 13 years, p = 0.78), but had more atherosclerotic risk-factors and comorbidities. During time, patients were more often referred to diagnostic angiography and treated with statins, ACE-I/ARBs, and P2Y12 inhibitors (p < 0.001 for each). Over time, there were less in-hospital complications such as kidney injury and heart failure. The rate of 30-day MACE decreased (from 20.7% to 10.3%, earliest to latest period, p < 0.001). Compared with the earliest period, the latest period was associated with a reduction in 1-year mortality (14.7% to 11.6%; adjusted HR 0.65, 95% CI 0.47 to 0.90). In conclusion, Over 2 decades, in medically managed NSTE-ACS patients, short term prognosis has significantly improved while 1-year mortality demonstrated improvement only recently, likely due to incremental benefits of medical management., (Copyright © 2021 Elsevier Inc. All rights reserved.)

Background: Non-Vitamin K antagonist oral anticoagulants (NOACs) emerged as an alternative with comparable or superior efficacy and safety to vitamin K antagonists (VKAs) for stroke prevention in patients with non-valvular atrial fibrillation (AF)., Objectives: The aim of the current study was to investigate the patterns, predictors, timelines and temporal trends of shifting from VKAs to NOACs., Methods: In this retrospective observational study, the computerized database of a large healthcare provider in Israel, Maccabi Healthcare Services, was searched to identify patients with AF for whom either a VKA or NOAC was prescribed between 2012 and 2015. Time from diagnosis to therapy initiation and to shifting between therapies was evaluated., Results: Out of 6987 eligible AF incident patients, 2338 (33.4%) initiated treatment with a VKA and 2221 (31.7%) with a NOAC. In addition, 5259 prevalent patients were analyzed. During the study period, NOAC prescriptions proportion among the newly diagnosed cases increased from 32 to 68.4% (p for trend <  0.001). The median time from diagnosis to first dispensing was greater in NOAC than VKA and decreased among patients treated with NOAC during the study period (2012: 1.9 and 0.3 months, 2015: 0.7 and 0.2 months, respectively). During follow-up, 3737 (49%) patients (54.3% and 47.1% of the incident and prevalent cases, respectively), shifted from a VKA to a NOAC, after a median of 22 months and 39 months in the incident and prevalent cases, respectively, decreasing throughout the study period. Female gender, younger age, southern district, higher CHADS 2 and CHA 2 DS 2 -VASC score, non-smoking, and treatment with antiplatelets were associated with a greater likelihood for therapy shift. Shifting from a NOAC to a VKA decreased over time from 8 to 4.5% in 2012 to 0.5% and 0.7% in 2015 in the incident and prevalent groups, p <  0.001 respectively., Conclusions: Shifting from VKA to NOAC occurred in 50% of the cases, more frequently among incident cases, and younger patients with greater stroke risk. Shifting from a NOAC to a VKA was much less frequent, yet it occurred more often in incident cases and decreased over time. A socially and economically sensitive program to optimize the initiation of OAC therapy upon diagnosis is warranted., (© 2021. The Author(s).)

Background: Obesity is a major public health concern. We sought to investigate temporal trends in characteristics and outcomes of acute coronary syndrome patients according to body mass index., Methods: The study population consisted of patients who were included in the Acute Coronary Syndromes Israeli Surveys during 2000-2016. Patients were categorised into three groups according to body mass index: below 25 kg/m2, 25-30 kg/m2 (overweight) and above 30 kg/m2 (obese). Among each body mass index group the outcomes of two time frames were compared - early (2000-2006) versus late (2008-2016)., Results: Overall 12,167 patients were included. Between the years 2000 and 2016, the percentage of obese patients increased from 20% to 30%. Obese patients were more frequently selected for an invasive approach, and had the lowest all-cause mortality rates. A significant reduction in 1-year mortality in recent compared to early surveys among patients with body mass index less than 25 kg/m2 and in obese patients but not for overweight patients was shown. Multivariable analysis showed that body mass index greater than 25 kg/m2 was associated with 30% lower 1-year mortality (hazard ratio 0.70, 95% confidence interval 0.55-0.90, P=0.005)., Conclusion: The prevalence of obesity among acute coronary syndrome patients has increased over the past two decades. A reduction of all-cause mortality was mainly seen in lean and obese patients., (Published on behalf of the European Society of Cardiology. All rights reserved. © The Author(s) 2019. For permissions, please email: journals.permissions@oup.com.)

Background: Chest-pain patients with no evidence of acute coronary syndrome might still be at risk for adverse outcomes. Adding renal function to the classic scoring of CHADS and CHA 2 DS 2 VASC may improve risk stratification of chest-pain patients discharged from internal medicine wards after acute coronary syndrome (ACS) rule-out., Methods: We accessed medical records of patients admitted to internal medicine wards during 2010-2016 and discharged following ACS rule-out. A R 2 CHA 2 DS 2 -VASc score model that included higher scores as kidney function deteriorated was calculated and compared to CHADS and CHA 2 DS 2 VASC scores. The primary endpoint was the composite of 30-day ACS and mortality. One-year ACS and 1-year mortality were the secondary endpoints. The study included 12,449 patients, stratified into three risk groups according to their R 2 CHA 2 DS 2 -VASc score., Results: Participants were stratified into 3 groups according to R 2 CHA 2 DS 2 -VASc score. R 2 CHA 2 DS 2 -VASc score predicted better the composite outcome of ACS and 30-day and 1-year mortality after discharge (OR: 4, 95%, CI 2.3-7, p < 0.01 and OR: 13.3, 95% CI 7.8-22.7, p < 0.01, respectively). Receiver operating characteristic curve analysis showed better risk stratification of the R 2 CHA 2 DS 2 -VASc compared with both CHADS and CHA 2 DS 2 VASC score., Conclusions: The R 2 CHA 2 DS 2 -VASc score is a better predictor of short- and long-term cardiovascular morbidity and mortality after hospital discharge., (Copyright © 2020. Published by Elsevier Ltd.)

Background: Atrial fibrillation confers higher risk of ischemic stroke, but the contribution of low-density lipoprotein cholesterol (LDL-C) levels to this risk remains unclear. We examined the association between LDL-C levels and incident stroke in patients with atrial fibrillation treated with direct oral anticoagulants (DOACs)., Methods: This study was conducted using the electronic database of Clalit Health Services in Israel. Included were 21,229 patients with first-time diagnosis of nonvalvular atrial fibrillation treated with DOACs between 2010 and 2017. Patients were categorized into 4 groups according to the CHA 2 DS 2 -VASc (congestive heart failure, hypertension, age ≥75 years [doubled], type 2 diabetes, previous stroke or transient ischemic attack [doubled], vascular disease, age 65-74 years, and sex category) score (1-2, 3-4, 5-6, 7-9). Each group was further stratified to 4 sub-groups according to LDL-C levels (<70, 70-99, 100-130, >130 mg/dL). Ischemic stroke rates were compared among the 4 LDL-C subgroups of each CHA 2 DS 2 -VASc category., Results: During 56,467 person-years of follow-up, there were 2481 incidents of ischemic stroke. Higher CHA 2 DS 2 -VASc score was associated with significantly increased risk of ischemic stroke (17.5, 26.9, 46.3, 94.9 cases per 1000 person-years, for patients with CHA 2 DS 2 -VASc score of 1-2, 3-4, 5-6, and 7-9, respectively; P < .001). However, there was no association between LDL-C levels and incident ischemic stroke within each CHA 2 DS 2 -VASc score group, even following a multivariate adjustment. Subanalyses of patients with previous stroke and those treated with statins also failed to show any association between LDL-C levels and incident ischemic stroke., Conclusions: Unlike the general population, LDL-C levels were not associated with ischemic stroke risk among patients with atrial fibrillation treated with DOACs. The findings support the noninclusion of dyslipidemia in ischemic stroke risk stratification of patients with atrial fibrillation., (Copyright © 2020 Elsevier Inc. All rights reserved.)

Background: Efforts to mitigate the risk for perioperative cardiac events focus on both patient's and operation's risk and often include a preprocedural electrocardiogram (ECG). The merits of postprocedural ECG for detection of occult cardiac events occurring during surgery are unknown. We aim to explore the incidence of pre, and new postprocedural ECG pathologies in an intermediate-high risk population undergoing non-cardiac surgery., Methods: This single-center, prospective, observational study, included patients older than 18 years with at least two cardiovascular risk factors who were scheduled for non-cardiac surgery. All patients had pre, and postprocedural ECG. The ECG was analyzed and coded according to the Minnesota criteria. A multivariable logistic regression analysis was performed for indices associated with new postoperative ECG pathologies., Results: A total of 217 patients were enrolled. Preoperative pathologic ECG changes were recorded in 62.2% of the patients. Postoperatively, new ECG pathologies were documented in 49.8% of patients, most commonly T-wave changes (36.4% of changes). Pathologic ECG changes at baseline (OR 3.15, 95% CI [1.61-6.17]; P<0.01), diabetes (OR 1.93, 95% CI [1.02-3.64]; P=0.04), history of ischemic heart disease (OR 2.14, 95% CI [1.03-4.47]; P=0.04), higher volumes of fluid replacement (OR 1.70, 95% CI [1.10-2.61]; P=0.01) and higher levels of preoperative hemoglobin (OR 1.24, 95% CI [1.04-1.47]; P=0.01) were all independently associated with postoperative ECG changes., Conclusions: Pre-, but most importantly, postoperative ECG changes are common in intermediate-high risk surgical patients. Postoperative ECG may be valuable to disclose silent cardiovascular events that occurred during surgery.

Introduction: Atrial fibrillation (AF) is a major increasing public health problem worldwide, with clinical and epidemiological differences between men and women. However, contemporary population-level data on incidence and survival are scarce., Aim: To evaluate sex-specific contemporary trends in the incidence, prevalence, and long-term survival of non-valvular AF in a real-world setting., Methods: AF patients diagnosed between 2007-2015, insured by a large, state-mandated health organization in Israel (Maccabi Healthcare Services) were included. AF was diagnosed based on registered diagnoses. Patients with valvular disease, active malignancy, cardiac surgery ≤ 6 months, or recent pregnancy, were excluded. Annual incidence rate, period prevalence, and 5-year survival for each calendar year during the study period, were calculated., Results: A total of 15,409 eligible patients (8,288 males, 7,121 females) were identified. Males were more likely to be younger, have higher rates of underlying diseases (ischemic heart disease, heart failure, and chronic obstructive pulmonary disease), but with lower rates of hypertension and chronic kidney diseases as compared to female patients. During the study period, age-adjusted incidence decreased both in men: (-0.020/1,000-person year, p-for trend = 0.033) and, women (-0.025/1,000 person-year p = 0.009). The five-year survival rate was significantly higher among men vs. women (77.1% vs. 71.5%, respectively, p<0.001). Age-adjusted prevalence increased significantly among men (+0.102 per year, p-for trend<0.001) yet decreased among women (-0.082 per year, p-for trend = 0.005). A significant trend toward improved long-term survival was observed in women and not in men., Conclusions: The current study shows significant sex-related disparities in the incidence, prevalence, and survival of AF patients between 2007-2015; while the adjusted incidence of both has decreased over-time, prevalence and mortality decreased significantly only in women., Competing Interests: A. Shiyovich received an honorarium (consultation fees) from Pfizer Pharmaceuticals Israel ltd. M. Tirosh is an employee of Pfizer Israel. The remaining authors declare no conflict of interest. This does not alter our adherence to PLOS ONE policies on sharing data and materials.

Aims: Efforts are constantly made to decrease the rates of readmission after acute decompensated heart failure (ADHF). ADHF admissions to internal medicine departments (IMD) were previously associated with higher risk for readmission compared with those admitted to cardiology departments (CD). It is unknown if the earlier still applies after recent advancement in care over the last decade. This contemporary cohort compares characteristics and outcomes of ADHF patients admitted to IMD with those admitted to CD., Methods and Results: The data for this single-centre, retrospective study utilized a cohort of 8332 ADHF patients admitted between 2007 and 2017. We compared patients' baseline characteristics and clinical and laboratory indices of patients admitted to CD and IMD with the outcome defined as 30 day readmission rate. In comparison with those admitted to CD, patients admitted to IMD (89.5% of patients) were older (79 [70-86] vs. 69 [60-78] years; P < 0.001) and had a higher incidence of co-morbidities and a higher ejection fraction. Readmission rates at 30 days were significantly lower in patients admitted to CD (15.9% vs. 19.6%; P = 0.01). Conflicting results of three statistical models failed to associate between the admitting department and 30 day readmission (odds ratio for 30 day readmission in CD: forced and backward stepwise logistic regression 0.8, 95% confidence interval 0.65-0.97, P = 0.02; stabilized inverse probability weights model odds ratio 1.0, confidence interval 0.75-1.37, P = 0.96)., Conclusions: This contemporary analysis of ADHF patient cohort demonstrates significant differences in the characteristics and outcomes of patients admitted to IMD and CD. Thus, focusing strategies for readmission prevention in patients admitted to IMD may be beneficial., (©2020 The Authors. ESC Heart Failure published by John Wiley & Sons Ltd on behalf of the European Society of Cardiology.)

Background: Calcium deposits on heart valves are considered a local manifestation of atherosclerosis and are associated with poor cardiovascular outcomes. The clinical significance of cardiac calcifications among heart failure (HF) patients, as assessed by echocardiography, is unknown. This study evaluated associations of cardiac calcifications with mortality and hospital admissions in this specific population., Methods: Medical records of all patients who initiated ambulatory surveillance at our HF clinic during 2011-2018 were reviewed. Calcifications in the aortic valve, aortic root, or the mitral valve were evaluated. Patients with moderate to severe regurgitation or stenosis of the aortic or mitral valves were excluded. The primary endpoint was the composite of long-term all-cause mortality and HF hospitalizations. Secondary endpoints were long-term all-cause mortality and more than one hospitalization due to HF., Results: This retrospective study included 814 patients (mean age 70.9 ± 13 years, 63.2% male). Of the total cohort, 350 (43%) had no cardiac calcifications and 464 (57%) had at least 1 calcified site. Considering the patients with no calcification as the reference group yielded a higher adjusted odds ratios for the composite endpoint, all-cause death, and recurrent HF hospitalizations, among patients with any cardiac calcification (OR = 1.68, 95%CI = 1.1-2.5, p = 0.01, OR=1.61, 95%CI = 1.1-2.3, p < 0.01, and OR = 1.50, 95%CI = 1.1-2.2, p < 0.01, respectively)., Conclusions: We found an independent association between cardiac calcifications and the risk of death and HF hospitalizations among ambulatory HF patients. Cardiac calcifications evaluated during routine echocardiography may contribute to the risk stratification of patients with HF., (Copyright © 2020. Published by Elsevier Ltd.)

Background: The importance of differences in baseline low-density lipoprotein cholesterol (LDL-C) levels and pretreatment with statins on the temporal improvement in outcome of acute coronary syndrome (ACS) patients has not been studied yet., Methods: Patients were divided into two groups according to baseline LDL-C levels: LDL-C <130 mg/dl and LDL-C ≥130 mg/dl. Baseline characteristics, clinical data and outcomes were compared for each LDL-C group between patients enrolled in early (2000-2006), mid (2008-2010) and recent (2013-2016) surveys., Results: The study population was comprised of 8343 patients. Patients with LDL-C <130 mg/dl were older and were more commonly pretreated with aspirin and statins compared to patients with LDL-C ≥130 mg/dl. Patients included in recent surveys were more frequently selected for an invasive strategy with coronary angiography and subsequent revascularization, and were more commonly treated with guideline-based medical therapy. For patients with a LDL-C ≥130 mg/dl, the temporal improvements in therapy were associated with lower 1-year mortality rates (7.2, 4.4 and 3.5% for patients in early, mid and late surveys, respectively, P = 0.006). That temporal improvement in outcomes existed only in statin-naïve patients. For patients with LDL-C <130 mg/dl, temporal improvement in treatment was not accompanied by a reduction in 30 day or 1-year mortality rates., Conclusion: Treatment of ACS patients has improved over the past decades regardless of LDL-C levels. This improvement was accompanied by lower mortality rates in ACS patients with LDL-C ≥130 mg/dl, but not in patients with LDL-C <130 mg/dl.

Background: Hyponatremia is the most common electrolyte abnormality observed in clinical practice. Among patients with acute coronary syndrome (ACS), serum sodium levels are inversely associated with mortality risk. We assessed associations of serum sodium level with ACS and mortality in patients with chest pain., Methods: This retrospective cohort study used clinical data from a large, academic hospital. All adults admitted with chest pain and without hypernatremia and discharged after ACS rule-out from January 2010 through June 2016 were included. The primary endpoint was the composite of 30-day ACS and mortality. Secondary endpoints were a hospital admission due to ACS and mortality in the first year following discharge., Results: Included were 12 315 patients (mean age 58.2 ± 13 years, 60% male). Patients were classified according to the serum sodium (Na) level: hyponatremia, defined as less than 135 mEq/L (n = 289, 2.3%); 140 > Na ≥ 135 mEq/L (n = 8066, 65.5%), and 145 > Na ≥ 140 mEq/L (n = 3960, 32.2%). Patients with serum sodium more than 145 mEq/L were excluded. Among patients with hyponatremia, low-normal, and high-normal levels, rates of the composite outcome of unadjusted 30-day all-cause mortality and ACS admission were 4.5, 1.0, and 0.7%, respectively (P < 0.001). Unadjusted one-year ACS rates were 3.8, 1.5, and 1.4%, respectively (P < 0.01)., Conclusion: Hyponatremia is associated with higher mortality and ACS risk among patients with chest pain who were discharged from internal medicine wards following ACS-rule-out. Sodium level may be included in the risk stratification of patients with chest pain.

Background: Patients with end-stage renal disease (ESRD) undergoing chronic hemodialysis are at high mortality and cardiovascular risk. This study was aimed to assess whether the CHA2DS2-VASc score may be used for risk stratification of this population., Methods: Included were patients undergoing chronic hemodialysis at Meir Medical Center. The CHA2DS2-VASc score was calculated for each patient at the initiation of hemodialysis. Patients were classified into 3 groups according to the CHA2DS2-VASc score: 0-3 (low), 4-5 (intermediate), and ≥6 (high). The primary endpoint was the composite of all-cause mortality, myocardial infarction, and stroke during the first year of hemodialysis., Results: Of the 457 patients with ESRD, 181 (40%) had low, 193 (42%) intermediate, and 83 (18%) high CHA2DS2-VASc scores. During the first year of hemodialysis, 109 (23.8%) patients died, 17 (3.7%) had a stroke, and 28 (6.1%) had a myocardial infarction. Compared to patients in the low CHA2DS2-VASc score group, those in the intermediate and high score groups had higher risk for the composite endpoint (OR: 2.6, 95% CI: 1.6-4.2, p < 0.01 and OR: 4.2, 95% CI: 2.3-7.5, p < 0.01, respectively). Each 1-point increase in CHA2DS2-VASc score was associated with a 38% increased risk for the composite endpoint, a 19% increased risk for 1-year myocardial infarction, and a 29% increased risk for 1-year stroke., Conclusions: Patients with ESRD are at an extremely high mortality and cardiovascular risk within the first year of hemodialysis. The CHA2DS2-VASc score was strongly associated with adverse outcomes and may be used for risk stratification of these patients., (© 2020 S. Karger AG, Basel.)

Background: Readmissions following acute myocardial infarction are associated with poor outcomes and a heavy economic burden. There are few evidence-based data on the characteristics and outcomes of patients readmitted following acute coronary syndrome. We explored the incidence and outcomes of patients readmitted after an acute coronary syndrome in the past decade., Methods: The study population comprised all acute coronary syndrome patients who were enrolled and prospectively followed up in the biennial Acute Coronary Syndrome Israeli Survey from 2000 to 2013. Multivariate analysis identified factors independently associated with readmission and long-term mortality., Results: There were 13,010 study patients, of whom 556 (4.2%) had an unplanned readmission within 30 days of the index event. Stent thrombosis during the index hospitalisation (odds ratio (OR) 8.43; 95% confidence interval (CI) 4.11-16.07; P <0.001), female sex (OR 1.34; 95% CI 1.1-1.63; P =0.003), older age (>65 years; OR 1.28; 95% CI 1.06-1.55; P =0.011), and lack of dual-antiplatelet therapy (OR 1.52; 95% CI 1.25-1.86; P <0.001) were independently associated with readmission. Readmitted patients were less likely to have been treated with guideline-directed medical therapy during hospitalisation and at discharge, and were less likely to have undergone coronary angiography. A strong trend towards decline in readmission rates following acute coronary syndrome was observed between 2000 and 2013 ( P <0.001). However, the association between readmission and poor long-term outcome was more pronounced among patients readmitted during more recent years (2008-2013)., Conclusions: Patients readmitted to hospital following acute coronary syndrome comprise an undertreated, high-risk cohort. Our findings indicate that despite a significant decline in readmission rates following acute coronary syndrome over the past decade, readmission within 30 days following acute coronary syndrome still portends a grave outcome.

High serum levels of phosphate are associated with uremia-induced calcific aortic valve disease (CAVD). However, it is not clear whether hyperphosphatemia is required in all phases of the process. Our aim was to determine the effects of phosphate and phosphate depletion at different phases of valve disease. The experimental design consisted of administering a uremia-inducing diet, with or without phosphate enrichment, to rats for 7 wk. Forty-two rats were fed with a phosphate-enriched uremic regimen that caused renal insufficiency and hyperphosphatemia. Another 42 rats were fed with a phosphate-depleted uremic regimen, which induces similar severity of renal insufficiency, but without its related mineral disorder. Aortic valves were evaluated at several points during the time of diet administration. In the second part, additional 54 rats were fed a phosphate-enriched diet for various time periods and were then switched to a phosphate-depleted diet to complete 7 wk of uremic diet. Osteoblast-like phenotype, inflammation, and eventually valve calcification were observed only in rats that were fed with a phosphate-enriched regimen. Significant valve calcification was observed only in rats that were fed a phosphate-enriched diet for at least 4 wk. Valve calcification was observed only when the switch to a phosphate-depleted regimen occurred after osteoblast markers and activation of Akt and ERK intracellular signaling pathways had already been found in the valve. Phosphate is essential for the initiation of the calcification process. However, when osteoblast markers are already expressed in valve tissue, phosphate depletion will not halt the disease. NEW & NOTEWORTHY High serum levels of phosphate are associated with uremia-induced calcific aortic valve disease. However, it is not clear whether hyperphosphatemia is required in all phases of the process. Our aim was to determine the effects of phosphate and phosphate depletion at different phases of valve disease. Our findings indicated that phosphate is essential for the initiation of the process that includes macrophage accumulation and osteoblast phenotype. Furthermore, hyperphosphatemia is dispensable beyond a certain phase of the process, a point of "no return" after which phosphate depletion does not prevent calcification. This point is relatively early in the course of calcification, when no calcification is apparent, but the inflammation, osteoblast markers, and activation of ERK and Akt pathways have already been identified. Our findings emphasize the complexity of the calcification process and suggest that different mediators might be required during different phases and that the role of phosphate precedes the actual calcification.

Background: Red blood cell distribution width (RDW) is a measure of the degree of heterogeneity of erythrocyte volume. Higher RDW levels are associated with increased mortality among patients with acute coronary syndrome (ACS), heart failure and other cardiovascular diseases. The association between RDW levels and clinical outcomes in patients admitted for further evaluation of chest pain is not known. Methods: A retrospective analysis of patients hospitalised with chest pain 2010-2016 was conducted. Patients diagnosed with ACS in the emergency department (ED) were excluded. Patients were divided into tertiles according to baseline ED RDW levels (≤13.1%, 13.1%13.9%). Study endpoints were diagnosis of ACS during the index hospitalisation and ACS and all-cause mortality during a median follow-up of 3.3 ± 1.9 years. Results: Included were 13,018 patients (mean age 58 ± 13 years, 61% male). Increased RDW levels were associated with higher rates of ACS in the index hospitalisation (6.1%, 6.6% and 8.1% for 1st, 2nd and 3rd tertiles, respectively, p  < .01), ACS during follow-up (8.6%, 10.1% and 13.4%, respectively, p  < .01), and with all-cause mortality during follow-up (2.5%, 4.6% and 15.4%, respectively, p  < .01). In multivariate analysis, RDW levels >13.9% (vs. ≤13.1%) were associated with ACS in the index hospitalisation (adjusted OR 1.25, 95% CI 1.04-1.51, p  = .02), ACS during follow-up (adjusted OR 1.35, 95% CI 1.05-1.73, p  = .02) and with all-cause mortality (adjusted HR 2.41, 95% CI 1.94-2.99, p  < .01). Conclusion: In this retrospective study of patients hospitalised with chest pain, higher RDW levels were associated with future ACS and long-term mortality.

Background: Intradialytic blood pressure (BP) measurement is currently the main parameter used for monitoring hemodynamics during hemodialysis (HD). Since BP is dependent on cardiac output and total peripheral resistance, knowledge of these parameters throughout the HD treatment would potentially be valuable., Methods: The use of a novel non-invasive monitoring system for profiling hemodynamic response patterns during HD was explored: a whole-body bio-impedance system was used to assess cardiac index (CI), total peripheral resistance index (TPRI), cardiac power index (CPI) among other parameters in chronic HD patients from 4 medical centers. Measurements were made pre, during and post dialysis. Patients were grouped into 5 hemodynamic profiles based on their main hemodynamic response during dialysis i.e. high TPRI; high CPI; low CPI; low TPRI and those with normal hemodynamics. Comparisons were made between the groups for baseline characteristics and 1-year mortality., Results: In 144 patients with mean age of 67.3 ± 12.1 years pre-dialysis hemodynamic measurements were within normal limits in 35.4% but only 6.9% overall remained hemodynamically stable during dialysis. Intradialytic BP decreased in 65 (45.1%) in whom, low CPI (47 (72.3%)) and low TPRI (18 (27.7%) were recorded. At 1-year follow-up, mortality rates were highest in patients with low CPI (23.4%) and low TPRI (22.2%)., Conclusions: Non-invasive assessment of patients' response to HD provides relevant hemodynamic information that exceeds that provided by currently used BP measurements. Use of these online analyses could potentially improve the safety and performance standards of dialysis by guiding appropriate interventions, particularly in responding to hypertension and hypotension.

Background: Currently, there are no clinical scores for risk stratification of low-risk patients with chest pain. We aimed to examine the association between mean platelet volume (MPV) and risk for adverse clinical outcomes in patients with chest pain discharged from internal medicine wards following acute coronary syndrome (ACS) rule-out., Patients and Methods: Included were patients who were admitted to internal medicine wards and were discharged following an ACS-rule-out during 2010-2016. The primary endpoint was the composite of all-cause mortality and hospital admission due to ACS at 30-days following hospital discharge., Results: Included in the study were12 440 patients who were divided into three groups according to MPV. The composite endpoint of 30-day all-cause mortality and hospital admission for ACS occurred more frequently among patients with high MPV. Each one-point increase in MPV was associated with an 18% increase in the risk for the composite endpoint (P = 0.02). Considering patients with MPV less than 7.8 fl as the reference group yielded adjusted hazard ratios for the composite endpoint that was significantly higher in patients in the high MPV tertile ( > 8.8 fl) (hazard ratio 1.6; 95% confidence interval = 1.1-2.5; P = 0.04). Each one-point increase in MPV was associated with an 11% increase in the risk for 1-year all-cause mortality (P = 0.01) and a 10% increase in the risk for 1-year ACS (P = 0.04)., Conclusion: We found an independent association between high MPV and the risk of death and ACS among patients with chest pain who were discharged from internal medicine wards following an ACS-rule-out. MPV may be combined in the risk stratification of patients with chest pain.

Aims: To demonstrate the association between small left atria (LA) and outcome in a relatively large heterogeneous population of hospitalized patients., Methods and Results: In a single-centre retrospective study, all inpatients that underwent an echocardiographic assessment between 2011 and 2016 and had an available left atrial volume index (LAVI) measurement were included. The cohort consisted of 17 343 inpatients who had an available LAVI measurement, 288 with small LA (LAVI <16 mL/m2), 7531 patients had LAVI within normal limits (16-34 mL/m2) divided into low normal (16-24.9 mL/m2; n = 2636) and high normal (25-34 mL/m2; n = 4895), 4720 patients had large LAVI (34.1-45 mL/m2) and 4804 had very large LAVI (>45 mL/m2). Median follow-up time was 2.4 years. After adjustments for age, gender, and baseline characteristics with a P-value <0.2 in univariable analyses (body mass index, haemoglobin, ischaemic heart disease, valvulopathy, atrial fibrillation, diabetes mellitus, hypertension, hyperlipidaemia, smoking, renal dysfunction, lung disease, and malignancy) small LA was associated with a higher risk for in-hospital mortality (odds ratio 2.9, 95% confidence interval (CI) 1.4-5.7; P = 0.002] and all-cause mortality [hazard ratio (HR) 2.1, 95% CI 1.6-2.8; P < 0.001] compared with high normal LA. For every mL/m2 decrease below high normal LA size the risk for in-hospital and long-term all-cause mortality increased by 10% (HR 1.1, 95% CI 1.02-1.18; P = 0.005) and 8% (HR 1.08, 95% CI 1.05-1.12; P < 0.001), respectively., Conclusion: Small LA are independently associated poorer short- and long-term mortality. LA volume should be referred to as J-shaped in terms of mortality., Helsinki Committee Approval Number: 0170-17-TLV., (Published on behalf of the European Society of Cardiology. All rights reserved. © The Author(s) 2019. For permissions, please email: journals.permissions@oup.com.)

Background Marriage is one of the common forms of social support. Conflicting evidence exists about the impact of marital status on the outcomes of patients with acute coronary syndrome ( ACS ). It is further not clear if sex disparity exists in the outcome of married and nonmarried patients with ACS. Methods and Results Data from the ACS Israeli Survey, collected between 2004 and 2016, were used to compare baseline characteristics, clinical indexes, and outcomes of married and nonmarried patients with ACS. Cox regression analysis and propensity score matching were used to explore if marital status was independently associated with long-term outcome. Of 7233 patients included with reported marital status, 5643 (78%) were married. Married patients were younger (62.69±12.07 versus 68.47±14.84 years; P<0.001), more frequently men (83.1% versus 54.8%; P<0.001), and less likely to be hypertensive (61.1% versus 69.3%; P<0.001). All-cause mortality incidence at 30 days and at 1 year was lower in married patients (3.1% versus 7.6% [ P<0.001]; and 7.1% versus 15.3% [ P<0.001], respectively). After adjusting for multiple covariates, the hazard ratio for 5-year all-cause mortality for married patients was 0.74 (95% CI , 0.62-0.88). Similar results were observed after propensity score matching. Kaplan-Meier estimates for all-cause mortality at 5 years demonstrated the best prognosis for married men and the worst for nonmarried women. Conclusions Marriage is independently associated with better short- and long-term outcomes across the spectrum of ACS . Attempts to intensify secondary prevention measures should focus on nonmarried patients and especially nonmarried women.

Global Registry of Acute Coronary Events (GRACE) risk score has been routinely used for risk stratification of acute coronary syndrome (ACS) patients. We aimed to examine whether the addition of the CHA2DS2-VASc score to the GRACE score improves risk stratification. Included were patients with ACS who were divided into high (>140), intermediate (110< GRACE score ≤140) and low (<110) GRACE score. Each group was further divided into 3 subgroups categorized according to their CHA2DS2-VASc score: 0-1, 2-3, and ≥4. Management and Outcomes were compared for each GRACE score group and CHA2DS2-VASc score subgroups. Included 6,854 ACS patients, of them 3596 (52.5%) were classified as low risk, 1,937 (28.3%) were at intermediate risk and 1,321 (19.3%) were high-risk patients. In the intermediate risk group, patients with a higher CHA2DS2-VASc score more frequently underwent percutaneous coronary revascularization. For low risk patients, 30-day mortality rates were 0.8%, 1.5%, and 1.3% (p = 0.02), and 1-year all-cause mortality rates were 1.3%, 3%, and 2.6% (p = 0.002) for CHA2DS2-VASc score 0-1, 2-3, ≥4, respectively. For intermediate risk patients, 30-day mortality rates were 2.9%, 3.4%, and 3.8% (p = 0.8), and 1-year all-cause mortality rates were 6.4%, 7.8%, and 11.2% (p = 0.01) for CHA2DS2-VASc score 0-1, 2-3, ≥4, respectively. Among patients with a GRACE score <140, each 1 point increase in the CHA2DS2-VASc score was associated with a 57% increase in 1-year mortality rates. In conclusion, the addition of the CHA2DS2-VASc score to the GRACE risk score in ACS patients improves risk stratification of patients with low and intermediate risk., (Copyright © 2019 Elsevier Inc. All rights reserved.)

Anthropometric indices of obesity (e.g. body mass index, waist circumference and neck circumference) are associated with poor long-term cardiovascular outcome. Prior studies have associated neck circumference and central body adiposity. We explored the association between neck fat volume (NFV) and long-term cardiovascular outcome. The study provides a retrospective analysis of all patients undergoing computerized tomography angiography for suspected cerebrovascular accident between January and December 2013. NFV was assessed by three dimensional reconstructions and was adjusted to height to account for differences in body sizes, thus yielding the NFV/height ratio (NHR). Univariate and multivariate analysis were utilized to explore the association between various indices including NHR and all-cause mortality. The analysis included 302 patients. The average age was 61.9±14.3 years, 60.6% of male gender. Diabetes mellitus, hypertension and cardiovascular disease were frequent in 31.5%, 69.9%, and 72.2% of patients, respectively. The median NHR was 492.53cm2 [IQR 393.93-607.82]. Median follow up time was 41.2 months, during which 40 patients (13.2%) died. Multivariate analysis adjusting for age, sex, and diabetes mellitus indicated an independent association between the upper quartile of NHR and all-cause mortality (hazard ratio = 2.279; 95% CI = 1.209-4.299; p = .011). NHR is a readily available anthropometric index which significantly correlated with poor long-term outcome. Following validation in larger scale studies, this index may serve a risk stratifying tool for cardiovascular disease and future outcome., Competing Interests: HSM is the owner of Visionary Corp., in Toronto, Canada, and MMK is affiliated with this organization. Visionary Corp received a grant from NVIDIA Corporation, but had no influence in the current study. The authors' affiliation with Visionary Corp is completely independent of the current study. HSM, MMK, and ST have a patent pending related to another study conducted at the same institution; this is completely independent of and had no influence over the current study. These do not alter the authors' adherence to PLOS ONE policies on sharing data and materials. There are no patents, products in development or marketed products associated with this research to declare.

Background: Small scale cohorts demonstrated an association between body mass index (BMI) and diastolic function in a metabolically healthy population. We aimed to characterize the relation between BMI and diastolic function in a relatively large cohort of metabolically healthy obese with preserved ejection fraction., Methods and Results: Echocardiograms of metabolically healthy patients between 2011 and 2016, who had no significant valvulopathies or atrial fibrillation, and had preserved ejection fraction, were retrospectively identified and analyzed. Metabolically healthy was defined as lack of known diabetes mellitus, hypertension, and hyperlipidemia. Patients were categorized into 4 groups according to BMI - normal BMI 18.5-25, overweight 25.01-30, obese 30.01-35, morbidly obese >35 kg/m 2 . The cohort consisted of 7057 individuals, 54.9% males, with a mean age 54 years. Patients in higher BMI groups more commonly demonstrated abnormalities in most echocardiographic parameters associated with diastolic dysfunction, including left atrial volume index>34 ml/m 2 , E/e'>14, e' lateral<10 cm/s, e' septal<7 cm/s, tricuspid regurgitation velocity>2.8 m/s and systolic pulmonary artery pressure≥36 mmHg (p<0.01 for all comparisons). Morbidly obese carried the highest risk compared to those with normal BMI. There were no significant differences between the groups in rates of readmission due to heart failure., Conclusion: High BMI is associated with increased risk of diastolic dysfunction even in metabolically healthy patients. Additional trials are needed in order to evaluate whether these echocardiographic findings translate into clinical implications., (Copyright © 2018 Elsevier B.V. All rights reserved.)

Studies performed in controlled laboratory conditions have shown that environmental thermal application may induce various circulatory changes. We aimed to demonstrate the effect of local climate on hemodynamics according to echocardiography. Echocardiographic studies conducted in ambulatory patients, 18 yr of age or older, between January 2012 and July 2016, at our medical center, for whom climate data on the day of the echocardiogram study were available, were retrospectively included in case climate data. Discomfort index, apparent temperature, temperature-humidity index, and thermal index were computed. Echocardiograms conducted in hotter months (June-November) were compared with those done in colder months (December-May). The cohort consisted of 11,348 individuals, 46.2% women, and mean age of 57.9 ± 18.1 yr. Climate indexes correlated directly with stroke volume ( r = 0.039) and e' (lateral r = 0.047; septal r = 0.038), and inversely with systolic pulmonary artery pressure (SPAP; r = -0.038) (all P values < 0.05). After adjustment for age and sex, echocardiograms conducted during June-November had a lower chance to show e' septal < 7 cm/s (odds ratio 0.88, 95% confidence interval 0.78-0.98, P = 0.017) and SPAP > 40 mmHg (odds ratio 0.81, 95% confidence interval 0.67-0.99, P = 0.04) compared with those conducted in other months. The authors concluded that climate may affect hemodynamics, according to echocardiographic assessment in ambulatory patients. NEW & NOTEWORTHY In the present study, we examined 11,348 individuals who underwent ambulatory echocardiography. Analyses of the echocardiographic studies demonstrated that environmental thermal stress, i.e., climate, may affect hemodynamics. Most notably were the effects on diastolic function. Higher values of mitral e', stroke volume, as well as ejection fraction, and lower values of systolic pulmonary artery pressure and tricuspid regurgitation were demonstrated on hotter days and seasons.

Data on anti-platelet therapy (APT) for prevention of atherothrombotic events in thrombocytopaenic cancer patients is lacking. We aimed to identify patient and physician characteristics associated with APT management in thrombocytopaenic patients with haematological malignancy. A clinical vignette-based experiment was designed. Eleven haematologists were interviewed, identifying five variable categories. Next, 18 hypothetical vignettes were generated. Each physician received three vignettes and chose to: hold all APT; continue APT without platelet transfusion support; or continue APT with platelet transfusion support. The survey was distributed to haematologists and thrombosis specialists in three countries. Multivariate cluster robust Poisson regression models were used to calculate relative risks (RRs) of using one management option (over the other) for each variable in comparison to a reference variable. A total of 145 physicians answered 434 cases. Clinicians were more likely to hold APT in case of 20,000/µL platelets (vs. 40,000/µL; RR for continuing: 0.82 [95% confidence interval: 0.75-0.91]), recent major gastrointestinal bleeding (vs. none; RR 0.81 [0.72-0.92]) and when the physician worked at a university-affiliated community hospital (vs. non-academic community hospital; RR 0.84 [0.72-0.98]). Clinicians were more likely to continue APT in ST elevation myocardial infarction with dual APT (vs. unstable angina with single APT; RR 1.31 [1.18-1.45]) and when there were institutional protocols guiding management (vs. none; RR 1.15 [1.03-1.27]). When APT was continued, increased platelet transfusion targets were used in 34%. In summary, the decision process is complex and affected by multiple patient and physician characteristics. Platelet transfusions were frequently chosen to support APT, although no evidence supports this practice., Competing Interests: None declared., (Georg Thieme Verlag KG Stuttgart · New York.)