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Aims Many patients with suspected non-ST-elevation (NSTE) acute coronary syndromes (ACS) are admitted, even those with initial high-sensitivity cardiac troponins (hs-cTn) values who meet rapid rule-out criteria for myocardial infarction (MI). We examined the clinical outcomes, resource utilization, and diagnostic yield of suspected NSTE-ACS patients, who presented with hs-cTnT values meeting these criteria but were nevertheless hospitalized. Methods and results Applying the 2020 European Society of Cardiology (ESC) rapid rule-out MI criteria, we identified consecutive patients with an initial value of hs-cTnT Conclusion Our findings support a policy of ED discharge of suspected NSTE-ACS patients meeting rapid MI rule-out criteria and subsequent ambulatory evaluation, sparing resource-consuming admissions. In-hospital and ensuing prognosis were better with lower initial hs-cTnT values.

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The pivotal studies that led to the recommendations for emergent reperfusion therapy for ST-elevation myocardial infarction (STEMI) were conducted for the most part over 25 years ago. At that time, contemporary standard treatments including aspirin, statin, and even anticoagulation were not commonly used. The 2013 American College of Cardiology Foundation (ACCF)/American Heart Association (AHA) guidelines and the 2017 European Society of Cardiology guidelines give a class I recommendation (with the level of evidence A) for primary percutaneous coronary intervention (pPCI) in patients with STEMI and ischemic symptoms of less than 12 h. However, if the patient presents to a hospital without pPCI capacity, and it is anticipated that pPCI cannot be performed within 120 min of first medical contact, fibrinolytic therapy is indicated (if there are no contraindications) (class I indication, level of evidence A). Our review of the pertinent literature shows that the current recommendation for inferior STEMI is based on the level of evidence lower than A. We can consider level B even C, supporting the recommendation for fibrinolytic therapy if pPCI is not available for inferior STEMI.

Introduction Based on data from randomized controlled trials, both American and European guidelines recommend treating acute coronary syndrome (ACS) patients with second generation P2Y12 inhibitors.1,2 Direct head-to-head comparison of these agents was scarce until the recent publication of the ISAR-REACT-5 study which demonstrated the superiority of the Irreversible thienopyridine type P2Y12 inhibitor (prodrug) over the reversible P2Y12 inhibitor in terms of 1-year composite of death, myocardial infarction (MI), and stroke.3,4,5 Given the unexpected outcomes of this trial, we sought to perform a comparison of ticagrelor and prasugrel in real-life ACS patients. Purpose To compare the outcomes of ACS (acute coronary syndrome) patients undergoing in-hospital PCI (percutaneous coronary intervention) treated with the Irreversible thienopyridine type P2Y12 inhibitor (prodrug) versus the reversible P2Y12 inhibitor. Methods ACSIS (Acute Coronary Syndrome in Israel) is a national ACS snapshot survey conducted in all 25 cardiology departments in Israel since 2000 over a two-month period, every two to three years. Both the Irreversible thienopyridine type P2Y12 inhibitor (prodrug) and the reversible P2Y12 inhibitor were commercially introduced in Israel in 2010. We therefore considered patients enrolled in ACSIS surveys 2010–2018 for the present analysis. Results Among 7,233 patients enrolled to the ACSIS (Acute Coronary Syndrome in Israel) registry between 2010 and 2018, we identified 1133 eligible patients treated with the Irreversible thienopyridine type P2Y12 inhibitor (prodrug) and 825 with the reversible P2Y12 inhibitor. In hospital complication rates, including rates of stent thrombosis, were roughly similar between groups. Compared to the reversible P2Y12 inhibitor, the Irreversible thienopyridine type P2Y12 inhibitor (prodrug) was associated with lower 1-year death in ST-elevation myocardial infarction (STEMI) patient compared to non-ST-elevation ACS (NSTE-ACS) patients (p for interaction 0.03). In propensity score matched STEMI patients (502 receiving the Irreversible thienopyridine type P2Y12 inhibitor (prodrug), 251 the reversible P2Y12 inhibitor) 30-day re-hospitalization rate (p Conclusion The Irreversible thienopyridine type P2Y12 inhibitor (prodrug) was more effective than the reversible P2Y12 inhibitor in STEMI patients, but not in NSTE-ACS patients. Funding Acknowledgement Type of funding sources: Foundation. Main funding source(s): the Israeli working group on acute cardiac care of the Israel heart society

Background Right heart catheterization (RHC) and echocardiography are both routinely used for pulmonary hypertension (PH) assessment in LT candidates, although this is not mandatory according to guidelines. We aim to describe the correlation between the pulmonary artery systolic pressure (PASP) measured by echocardiography to that measured by RHC in this population. Methods From a retrospective registry of 461 LT candidates, undergoing RHC between 2015–2019, 393 consecutive patients were assessed for the presence of pulmonary hypertension according to two methods – echocardiography and RHC. The primary outcome was the correlation between the estimated PASP measured by echocardiography to that measured by RHC. Secondary outcome was the accuracy of the echocardiographic assessment of PH. Results Patients were predominantly males (63.6%) with a mean age of 61.46±8.33y. The two most common etiologies for lung failure were interstitial lung disease or pulmonary fibrosis (52.2%) and chronic obstructive pulmonary disease (30.5%). Estimated PASP as measured by echocardiography was available in 89.31% of the patients, with a mean value of 49.5±20.02 mmHg. Mean PASP measured by RHC was 42.47±17.96 mmHg. The correlation between the two measurements was moderate (Pearson's correlation: r=0.609, p10 mmHg differences between the two values in 79.9% of the patients. Conclusions In the pre-surgical evaluation of LT candidates, echocardiographic estimation of PASP has moderate correlation with the PASP measured by RHC and relatively poor accuracy. Funding Acknowledgement Type of funding sources: None.

Introduction: We aimed to compare the outcomes of acute coronary syndrome (ACS) patients undergoing in-hospital percutaneous coronary intervention treated with prasugrel versus ticagrelor. Methods: Among 7,233 patients enrolled to the Acute Coronary Syndrome Israeli Survey (ACSIS) between 2010 and 2018, we identified 1,126 eligible patients treated with prasugrel and 817 with ticagrelor. Comparison between the groups was performed separately in ST-elevation myocardial infarction (STEMI) patients, propensity score matched (PSM) STEMI patients, and non-ST-elevation ACS (NSTE-ACS) patients. Results: In-hospital complication rates, including rates of stent thrombosis, were not significantly different between groups. In PSM STEMI patients, 30-day re-hospitalization rate (p < 0.05), 30-day MACE (the composite of death, MI, stroke, and urgent revascularization, p = 0.006), and 1-year mortality rates (p = 0.08) were higher in the ticagrelor group compared to the prasugrel group; in NSTE-ACS patients, outcomes were not associated with drug choice. In Cox regression analysis applied on the entire cohort, prasugrel was associated with lower 1-year mortality in STEMI patients but not in NSTE-ACS patients (p for interaction 0.03). Conclusions: Compared to ticagrelor, prasugrel was associated with superior clinical outcomes in STEMI patients, but not in NSTE-ACS patients.

Heart failure (HF) patients with reduced ejection fraction (HFrEF) are frequently treated with sub-optimal doses of angiotensin converting enzyme-inhibitors (ACE-Is), angiotensin receptor blockers (ARBs), and beta blockers (BBs).To determine factors associated with attaining upper-range doses in patients with HFrEF.We examined treatment in patients with left ventricular ejection fraction (LVEF) ≤ 40% in a community-based, dedicated heart-failure clinic. Upper-range doses were defined as ≥ 75% of target recommended doses by heart failure society guidelines.The majority of the 215 patients were men (82%); median age at presentation 73 years (interquartile range [IQR] 65-78) and LVEF of 30% (IQR 25-35%). Following the up-titration program, 41% and 35% of patients achieved upper-range doses of ACE-Is/ARBs and BBs, respectively. Higher body mass index (BMI) was the only parameter found to be associated with achieving upper-range doses of ACE-I/ARBs (odds ratio [OR] 1.13, 95% confidence interval [95%CI] 1.05-1.22, P = 0.001). More patients achieved this target as BMI increased, with a sharp decline in the highest obesity category (BMI ≥ 40 m2/kg). Attaining upper-range doses of BBs was associated with pre-existing diabetes mellitus (DM) (OR 2.6, 95%CI 1.34-5.19, P = 0.005); women were associated with attaining lower BBs doses (OR 0.34, 95%CI 0.13-0.90, P = 0.031).Achieving upper-range doses of ACE-Is/ARBs and BBs in HFrEF outpatients in a treatment up-titration program were associated with greater BMI and DM, respectively. These findings may serve as benchmarks for up-titration programs.

Background The traditional treatment of acute pericarditis includes non-steroidal anti-inflammatory agents (NSAIDs) or glucocorticoids. The addition of colchicine has been found to reduce the rate of recurrences. Glucocorticoids, however, may attenuate this effect, although the available data are limited. We examined the impact of colchicine on the rate of recurrence of acute idiopathic pericarditis pretreated with prednisone. Methods The frequency of recurrence in patients hospitalized for acute idiopathic pericarditis in a tertiary medical center in 2004–2014 who were treated with glucocorticoids or with non-steroidal therapy was assessed from the computerized hospital database. A retrospective design was used. Results The cohort included 199 patients aged 18–86 years. Sixty-two (31%) were treated with prednisone, 42 with colchicine and 20 without, and 133 with non-steroidal therapy; in 4 patients, therapy was not detailed. Follow-up ranged from 13 to 147 months (median, 48 months). Fifty-three patients (26.6%) experienced at least one recurrence of pericarditis. The recurrence rate was significantly higher in patients who received prednisone and colchicine (17/42, 40.5%) than in patients who received NSAIDs or aspirin and colchicine (8/44, 18.2%, p = 0.03) or any non-steroidal therapy (30/133, 22.6%, p = 0.03). There was no difference between the rate of recurrence in patients who were treated with prednisone alone (5/20, 25%) and those treated with NSAIDs or aspirin and colchicine or with any non-steroidal therapy (p = NS). Baseline characteristics and duration of follow-up were similar in patients with and without recurrence. Hospital stay was longer in patients treated with prednisone alone as compared to patients treated with prednisone and colchicine. There were no other differences in baseline characteristics between these groups. Conclusions The addition of colchicine to prednisone in patients admitted for acute idiopathic pericarditis does not reduce the risk of recurrence. This finding suggests that prednisone blunts the salutary effects of colchicine.

Although typical chest pain is an important clinical feature required for diagnosis of acute coronary syndrome (ACS), many patients present with atypical complaints. The full extent and implication of this presentation is largely unknown. The study aim was to evaluate possible relations and temporal trends between presenting symptoms and outcomes in patients with ACS. Data was obtained from the Acute Coronary Syndrome Israeli Survey on patients presenting with typical chest pain versus atypical complaints, including dyspnea, nonspecific chest pain, palpitations or other. Temporal trends analysis examined the early (2000 to 2006) versus the late (2008 to 2016) period. During 2000 to 2016, 14,722 patients with ACS were enrolled; 11,508 (79%) presented with typical chest pain and 3,214 (21%) with atypical complaints. Patients with atypical complaints were older, majority female, and had more co-morbidities (p

Limited data are available regarding the optimal management of patients with cancer in the acute myocardial infarction (AMI) setting.We studied consecutive patients with AMI included in a national registry (years 2010, 2016) with the diagnosis of past or active malignancy and followed them for 1 year.Our cohort consisted of 2937 cancer-naive patients and 152 patients with cancer, of whom 35% presented with active malignancies. Compared with cancer-naive patients, patients with cancer were older, with female predominance, and presented more often with a history of hypertension and chronic kidney disease (P0.001 for all comparisons). The rate of ST-elevation AMI was comparable (P=0.067). GRACE score more than 140 was more common in the cancer group (P0.001). Most patients with cancer were referred to coronary angiography, though less than cancer-naive patients (87 vs. 93%; P=0.004). The rate of percutaneous coronary intervention was similar (P=0.265). Propensity score matching demonstrated similar rates of in-hospital complications between groups, and no mortality or major cardiac adverse event differences were noted at 30 days. Moreover, short-term mortality was similar between patients with active versus past malignancies, and between patients with solid and nonsolid tumors. However, cancer in patients with AMI was found to predict an increased mortality risk at 1 year by multivariable analysis (hazard ratio=2.52; P0.001).Patients with cancer and AMI have a more complicated clinical presentation, yet their short-term prognosis is similar to cancer-naive patients. Nevertheless, 1-year outcome is worse.

We sought to examine the management and outcomes of ambulatory patients with heart failure and reduced ejection fraction in a community-based, dedicated clinic. Patients with left ventricular ejection fraction (LVEF) ≤40% were actively solicited to attend a community-based, dedicated clinic. Eligible patients who chose to decline constituted our control group. Of 552 patients with LVEF ≤40% (median age 73 years and median LVEF 35%), 304 (55%) agreed to attend the clinic. Patients with worse New York Heart Association class were more likely to attend the clinic (odds ratio 2.07 [1.45, 2.95], p0.001), whereas women were more likely to decline (odds ratio 0.63 [0.42, 0.93], p0.022). During 18 months of follow-up, patients in the dedicated clinic significantly improved their functional capacity (56% New York Heart Association 3 to 4 at baseline vs 27% at follow-up, p0.001) and LVEF (35% [interquartile range 25, 35] at baseline vs 35% (interquartile range 30, 40) at follow-up, p0.001). In comparison with patients managed routinely, patients treated in a dedicated clinic achieved better guideline-recommended pharmacological treatment (65% vs 85% receiving β blockers, p0.001, 65% vs 82% receiving renin-angiotensin inhibitors, p = 0.0006, 31% vs 45% receiving mineralocorticoid receptor antagonists, p0.001). During follow-up, electrical device implantation was similar (6% vs 7% of dedicated-HF-clinic patients, p = 0.700). Furthermore, overall survival was better in patients treated in the clinic (log rank p = 0.0006), even after censoring the first 4 months to account for potential bias (log rank p = 0.0232). In conclusion, management in a community-based, dedicated clinic compared with routine management was associated with augmented guideline-recommended treatment and improved survival.

Background Patients who have had an acute coronary syndrome ( ACS ) are at increased risk of recurrent cardiovascular events; however, paradoxically, high‐risk patients who may derive the greatest benefit from guideline‐recommended therapies are often undertreated. The aim of our study was to examine the management, clinical outcomes, and temporal trends of patients after ACS stratified by the Thrombolysis in Myocardial Infarction (TIMI) risk score for secondary prevention, a recently validated clinical tool that incorporates 9 clinical risk factors. Methods and Results Included were patients with ACS enrolled in the biennial Acute Coronary Syndrome Israeli Surveys ( ACSIS ) between 2008 and 2016. Patients were stratified by the TIMI risk score for secondary prevention to low (score 0–1), intermediate (2), or high (≥3) risk. Clinical outcomes included 30‐day major adverse cardiac events (death, myocardial infarction, stroke, unstable angina, stent thrombosis, urgent revascularization) and 1‐year mortality. Of 6827 ACS patients enrolled, 35% were low risk, 27% were intermediate risk, and 38% were high risk. Compared with the other risk groups, high‐risk patients were older, were more commonly female, and had more renal dysfunction and heart failure ( P P P Conclusions Despite an improvement in the management of high‐risk ACS patients, they are still undertreated with guideline‐recommended therapies. Nevertheless, the outcome of high‐risk patients after ACS has significantly improved in the past decade, thus they should not be denied these therapies.

The current armamentarium for the treatment of chronic ischaemic heart disease includes agents that are used to relieve angina or attenuate ischaemia, as well as agents that are administered regardless of symptom status to ameliorate prognosis. Beta blockers and calcium channel blockers are the mainstay treatments for angina and ischaemia relief. Adjunct therapy includes nitrates, ivabradine, ranolazine, nicorandil, and trimetazidine. Aspirin (alternatively, clopidogrel), statins (possibly with ezetimibe), and angiotensin-converting enzyme inhibitors (alternatively, angiotensin receptor blockers), are the mainstay agents to improve outcomes.

There are limited and conflicting data regarding the prognosis of patients with apical hypertrophic cardiomyopathy (HC) and their risk for sudden cardiac death (SCD). We used data from a single tertiary center for comparing the clinical course and the calculated risk for SCD in patients with nonobstructive apical HC (apical HC) versus patients with nonobstructive, nonapical HC (NONA HC). The 5-year SCD risk was calculated based on the HC risk-SCD tool. A total of 109 patients were included in the cohort of whom 44 (40%) patients were diagnosed with apical HC. The majority of patients were males with a median age at diagnosis of 40 years (interquartile range 26, 59 years). Patients with apical HC had a significant lower calculated 5-year risk for SCD compared with patients with NONA HC (2.65 ± 2.2% vs 4.00 ± 3.5%, respectively, p = 0.017), primarily due to a lower incidence of familial SCD (20% vs 43% respectively, p = 0.014). Only 9% of patients with apical HC had a calculated risk of >6% (implantable cardioverter-defibrillator recommended), as compared with 23% of patients with NONA HC. During a median follow-up of 1,018 days (interquartile range 546, 1449 days), apical HC patients tended to develop less malignant ventricular arrhythmia episodes compared with NONA HC patients (0% vs 7.7%, respectively, p = 0.060). In conclusion, apical HC patients have a lower calculated risk of SCD compared with NONA HC patients, mainly due to a lower incidence of family history of SCD. Thus, apical HC should be considered a form of HC less prone to SCD.

Family history of premature cardiovascular disease (FHpCVD) is a well-established risk factor for development of coronary artery disease. However, little is known about the impact of FHpCVD on the outcome of patients presenting with acute coronary syndrome (ACS). We therefore aimed to evaluate the outcomes of ACS patients grouped by the presence and/or absence of FHpCVD. All patients ≤65 at admission who had an ACS event and were enrolled in the national ACS Israel Survey registry from 2000 to 2013 were included. Patients were grouped by the presence or absence of self-reported FHpCVD. Nearest neighbor propensity score matching was applied to create an evenly matched cohort of patients. Outcomes included 30-day MACE (defined as the composite of death, unstable angina pectoris, myocardial infarction, stroke, stent thrombosis, and urgent revascularization) and its individual components. Of 7,173 ACS patients, 33.9% reported FHpCVD. These patients were younger, with lower prevalence of diabetes, previous cerebrovascular and kidney diseases, but had higher prevalence of smoking and hyperlipidemia (p0.001 for each). The propensity score-matching cohort included 1,793 pairs of evenly matched patients. The rate of 30-day MACE did not differ in the groups, as well as 1-year mortality (2.4% vs 2.2%, with vs without FHpCVD, respectively). During long-term follow-up (median 7.6 years), mortality rate was lower in the FHpCVD group (hazard ratio 0.82, 95% confidence intervals 0.69 to 0.99). In conclusion, we observed no differences in short- and intermediate-term outcomes based on the presence and/or absence of FHpCVD. However, patients with FHpCVD had better long-term survival.

Background Worse renal function, even in the normal or mildly impaired range, is associated with incident cardiovascular disease (CVD). Whether this association exists in both sexes across all ages is not known. Methods A population based cohort of individuals >22 years with no prior CVD and with an eGFR 60–130 ml/min/1.73 m2. eGFR was calculated using the CKD-EPI formula. Incident CVD was defined as either myocardial infarction, unstable angina pectoris, coronary revascularization, or cerebrovascular event. Incident CVD was examined separately in men and women in 3 age-groups (young, 22–40 years; middle-aged, 41–60 years; and elderly, ≥61 years), during a median follow-up of 96.0 months. Results Among 1,341,400 individuals (57% women, mean age 49.2 ± 16.6 years), men had more incident CVD as compared to women (34,968 vs. 23,515 total incident CVD) in all age-groups (0.6% vs. 0.2% in young; 6.2% vs. 2.0% in middle-aged; 13.4% vs. 8.4% in elderly, respectively). After adjustment for CVD risk factors, an increment of 10 units in eGFR was independently associated with a decrease of 5.4%, 3.4% and 5.4% in incident CVD in young, middle-aged and elderly men (p Conclusion Although incident CVD differs in men and women, as well as in different age-groups, a higher eGFR even in the normal or mildly impaired range is associated with lesser incident CVD in men and women of all ages.

There are scarce contemporary data regarding the incidence and prognosis of early postmyocardial infarction pericarditis (PMIP). Thus, we retrospectively analyzed 6,282 patients with ST-segment elevation myocardial infarction (STEMI) enrolled with known PMIP status in the Acute Coronary Syndrome Israeli Survey 2000 to 2013 registry. The primary outcome was the composite of all-cause mortality, nonfatal myocardial infarction, cerebrovascular event, stent thrombosis, or revascularization. The secondary outcomes were mortality and length of stay during the acute hospitalization. Overall, 76 patients with STEMI had PMIP (1.2%). PMIP incidence gradually decreased from 170 per 10,000 in 2000 to 110 per 10,000 in 2013, respectively (35% reduction, p for trend = 0.035). Patients with PMIP were younger (median 58.0 vs 61.0; p = 0.045), had less hypertension, higher cardiac biomarkers, and more frequently reduced left ventricular ejection fraction (87.0% vs 67.0%; p = 0.001). Patients with PMIP had longer time to reperfusion (225 minutes vs 183 minutes; p = 0.016) and length of stay (7.0 vs 5.0 days; p 0.001). The composite end point occurred similarly in patients with and without PMIP (10.5% vs 13.2%, respectively). There was no significant difference in 30-day, 1-year, and 5-year survival. In conclusion, PMIP is a relatively rare complication of STEMI in the coronary reperfusion era, portends worse short-term but not long-term outcomes, and is associated with bigger infarct size.

BackgroundLower estimated glomerular filtration rate, in particular in the significant renal impairment range (estimated glomerular filtration rate 22 years old) without rheumatic heart disease or prosthetic valves and with 60 ml/min/1.73 m2 10 m patient-years of follow-up (∼75% 65,000 individuals had ≥1 atrial fibrillation event (incident atrial fibrillation rate 5.1% and 5.8% excluding or includin...

Concomitant carotid artery disease (CaAD) in patients with coronary artery disease (CAD) is associated with worse cardiac and neurologic outcomes. The reported prevalence and risk factors for concomitant CaAD in CAD patients varied among previous studies.To examine these factors in ambulatory patients with CAD and well-documented cholesterol levels treated with cholesterol-lowering medications.We retrospectively analyzed prospectively collected data from 325 unselected patients with CAD (89 women, mean age 68.8 ± 9.9 years) undergoing routine evaluation at the coronary clinic of our hospital.The low density lipoprotein-cholesterol (LDL-C) was100 mg/dl in 292 patients (90%). Age at onset of CAD symptoms was 59.4 ± 10.8 years. Carotid stenosis ≥ 50% was seen in 83 patients (25.5%) and between 30% and 49% in 55 patients (17%) (duplex method). Carotid stenosis was significantly associated with hypertension (P = 0.032), peripheral arterial disease (P = 0.002) and number of coronary arteries with ≥ 50% stenosis (P = 0.002), and showed a borderline association with age at CAD onset (P = 0.062) and diabetes mellitus (P = 0.053). On linear regression analysis, independent predictors of CaAD were peripheral vascular disease (OR 3.186, 95% CI 1.403-7.236, P = 0.006), number of coronary arteries with ≥ 50% stenosis (OR 1.543, 95% CI 1.136-2.095, P = 0.005), and age at CAD onset (OR 1.028, 95% CI 1.002-1.054, P = 0.003). None of the variables studied predicted freedom from CaAD.Carotid atherosclerosis is very common in stable ambulatory patients with CAD regularly taking statins. The risk is higher in patients with peripheral arterial disease, a greater number of involved coronary arteries, and older age at onset of CAD.

The kinetics of high sensitivity cardiac troponin T (hs-cTnT) levels after elective, biphasic, direct-current cardioversion for persistent atrial fibrillation/flutter remains unknown.We examined hs-cTnT kinetics in 24 patients at baseline and at 2, 6 and 24 hours post-cardioversion, and again at 7 and 30 days. We also examined levels of creatine kinase, aspartate aminotransferase, lactate dehydrogenase, brain natriuretic peptide (BNP), and high sensitivity C-reactive protein (hs-CRP).Median (25th, 75th interquartiles) baseline hs-cTnT concentration was 19.8 (10.4, 35.2) ng/L with 14 patients presenting with levels above the 99th percentile (13 ng/L). Hs-cTnT levels did not change significantly over time although they tended to decrease by 30 days, 18.8 ng/L (12.5, 23.3). There was no significant rise in other markers of myocardial injury. Similarly, BNP and hs-CRP levels were elevated at baseline and tended to decrease over time.Patients with persistent atrial fibrillation/flutter have elevated hs-cTnT levels, as part of a general rise in biomarkers such as BNP and hs-CRP, without a further rise after cardioversion. After cardioversion, there is a gradual non-significant decrease in biomarker levels over time, and thus a rise in hs-cTnT levels should not be attributed to cardioversion.

The association between lower estimated glomerular filtration rate (eGFR) and incident cardiovascular disease is less clear within the normal or mildly impaired range.Using the Chronic Kidney Disease EPIdemiology collaboration (CKD-EPI) and the Modification of Diet in Renal Disease (MDRD) eGFR formulas, we analyzed outpatients ≥ 22 years old from 2004-2006 with 60 mL/min/1.73 m(2)eGFR130 mL/min/1.73 m(2), without prior cardiovascular disease, and with and without proteinuria.During a median follow-up of 96 months and10 million patient-years of follow-up, 103,506 and 104,315 cardiovascular events were recorded using CKD-EPI (n = 1,341,400, mean age 49.2 years, 42.6% male) and MDRD (n = 1,284,762, mean age 50.2 years, 43.4% male) formulas, respectively (incident event rates 4.4% and 4.6%, respectively). Adjusting for age, sex, and major cardiovascular risk factors, a 10-unit eGFR increase was independently associated with a mean decrease of 3.0% and 1.0% in incident cardiovascular events, using CKD-EPI and MDRD, respectively (P.001 for both), with a sharp decrease in events in the 100-mL/min/1.73 m(2)eGFR130 mL/min/1.73 m(2) range in the CKD-EPI, but not the MDRD, cohort. Using net reclassification analysis, CKD-EPI was more accurate in predicting events than MDRD (Net Reclassification Improvement 0.39, P.001 stratifying patients to eGFR deciles and 0.64, P.001 as a continuous variable). Using both formulas, eGFR was predictive of incident cardiovascular disease for patients without proteinuria, but not for the 2.4% with proteinuria (P.001 for interaction).Higher eGFR is associated with fewer cardiovascular events in adults without prior cardiovascular disease and without proteinuria, particularly in the 100-mL/min/1.73 m(2)eGFR130 mL/min/1.73 m(2) range, indicating that eGFR, especially using the CKD-EPI formula, may be an independent risk marker for incident cardiovascular disease.

Aims The aim of this study is to determine the most accurate renal function formula that predicts short- and long-term mortality in a wide spectrum of acute coronary syndrome (ACS) patients. Methods and results We analyzed 8,726 consecutive patients (46.3% ST-elevation myocardial infarction [STEMI] and 53.7% non–ST-elevation ACS [NSTE-ACS]) enrolled in the ACS survey in Israel. Renal function, assessed using 5 formulas as proxies of creatinine clearance or estimated glomerular filtration rate (Cockcroft-Gault, modification of diet in renal disease [MDRD], Chronic Kidney Disease Epidemiology Collaboration, Mayo quadratic, and inulin clearance based), varied in applying the different formulas. For both STEMI and NSTE-ACS patients, the Mayo formula yielded the highest mean value (88.9 ± 27.7 and 81.4 ± 29.2 mL/min per 1.73 m 2 , respectively) and Chronic Kidney Disease Epidemiology Collaboration the lowest (73.0 ± 23.1 and 67.0 ± 24.1 mL/min per 1.73 m 2 , respectively). Using multivariate analysis, worse renal function was independently associated with increased mortality risk by 30% to 40% for each decrement of 10 U of creatinine clearance or estimated glomerular filtration rate in STEMI patients and by 25% to 30% for NSTE-ACS patients, using all 5 formulas. The only formula that more accurately predicted 1-year mortality than the MDRD formula was the Mayo quadratic formula with a 1-year net reclassification index of 0.26 and 0.14 for STEMI and NSTE-ACS patients, respectively, after multivariable adjustment. Conclusion Worse renal function was an independent predictor for short- and long-term mortality using all 5 formulas in a broad spectrum of ACS patients, but only the Mayo quadratic formula had better accuracy in predicting mortality relative to the MDRD, suggesting that it may be the preferred prognosticator among ACS patients.