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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.

Background Everolimus provides effective immune suppression (IS) after heart transplant (HTx). Its pharmacologic properties differentiate everolimus from other IS drugs. A non-invasive immune monitoring (IM) assay test appears to predict the immune state in HTx recipients on standard calcineurin-inhibitor-based IS. The utility of IM in HTx recipients on everolimus-based IS was evaluated. Methods Between June 2005 and June 2011, 34 adult HTx recipients followed up at our center received everolimus and had 381 IM assays that were performed at six months to 16-yr post-transplant. Results of the IM assay were correlated with infection and rejection episodes that occurred during the IM testing. Results In the everolimus-based IS group, there were 18 infectious episodes and four rejection episodes. The average IM score was significantly lower during infection than at steady state (188 ± 122 vs. 338 ± 137 ng/mL ATP, p

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.

2012 focused update of the ESC Guidelines for the management of atrial fibrillation : an update of the 2010 ESC Guidelines for the management of atrial fibrillation: developed with the special contribution of the European Heart Rhythm Association

High on-treatment platelet reactivity (HTPR) despite clopidogrel therapy is associated with adverse cardiac events after acute myocardial infarction (AMI). Most studies to date have assessed clopidogrel response at a single time point before or after percutaneous coronary intervention (PCI). It is unclear, however, whether the HTPR phenotype is stable over time. Therefore, we aimed to examine response to clopidogrel in patients with AMI treated with PCI over a 6-month period. Patients (n = 57) with AMI treated with PCI were assessed for response to clopidogrel at 3 time points: in hospital, 30 days, and 6 months after index hospitalization. Response to clopidogrel was determined by the VerifyNow P2Y12 assay (reported as P2Y12 response units) and multiple electrode aggregometry (MEA; reported as aggregation units). HTPR was defined as ≥235 P2Y12 response units or ≥47 aggregation units. Patients' mean age was 54.5 ± 10.9 years, 91% were men, 19% had diabetes, and 74% were admitted with ST-segment elevation MI. HTPR based on MEA was observed in 22.8% of patients in hospital, 26.3% at 30 days, and 17.5% at 6 months (p = NS). HTPR based on the VerifyNow assay was observed in 38.6% of patients in hospital, 28.1% at 30 days, and 33.3% at 6 months (p = NS). Individual HTPR phenotypic assignment at baseline was stable in 73.7% (based on MEA) and 70.2% (based on VerifyNow) of patients at 6-month follow-up. In conclusion, this is the first study evaluating the stability of clopidogrel response over time after AMI. Rates of HTPR to clopidogrel therapy appear to be relatively stable up to 6 months after AMI.

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.

Background: Current guidelines regarding the use of intravenous morphine (IM) in the management of patients with acute decompensated heart failure (ADHF) are discordant; whereas the American guidelines reserve IM for terminal patients, the European guidelines recommend its use in the early stage of treatment. Our aim was to determine the impact of IM on outcomes of ADHF patients. Methods: Stepwise logistic regression and propensity score analysis of ADHF patients with and without use of IM was performed in a national heart failure survey. Results: Of the 4102 enrolled patients, we identified 2336 ADHF patients, of whom 218 (9.3%) received IM. IM patients were more likely to have acute coronary syndromes, acute rather than exacerbation of chronic heart failure, and diabetes mellitus and dyslipidemia. They had higher heart rate, were less likely to receive diuretics and more likely to receive aspirin and statins. Unadjusted in-hospital mortality rates were 11.5% versus 5.0% for patients who did or did not r...

Background: By and large, prior registries and randomized trials have not distinguished between acute heart failure (AHF) associated with acute coronary syndrome (ACS) versus other causes.Aims: To examine whether the treatments and outcomes of ACS-associated AHF are different from non-ACS-associated AHF.Methods: We examined in a prospective, nationwide hospital-based survey the adjusted outcomes of AHF patients with and without ACS as its principal cause.Results: Of the 4102 patients in our national heart failure survey, 2336 (56.9%) had AHF, of whom 923 (39.5%) had ACS-associated AHF. These patients were more likely to receive intravenous inotropes and vasodilators and to undergo coronary angiography and revascularization, but less likely to receive intravenous diuretics. The unadjusted in-hospital, 30-day, one-year, and four-year mortality rates for AHF patients with or without ACS were 6.5% versus 5.0% (P = 0.13), 10.3% versus 7.5% (P = 0.02), 26.6% versus 31.0% (P = 0.02), and 55.3% versus 63.3% (P = ...

Current guidelines have recommended intravenous narcotics (IVNs) for patients with ST-segment elevation acute coronary syndromes (STEACS) and patients with non-STEACS (NSTEACS), although the safety of IVNs has been challenged. We performed a retrospective analysis of the 30-day outcomes stratified by IVN use among patients enrolled in a national survey, using logistic regression and propensity score analysis. Of the 765 patients with STEACS and 993 patients with NSTEACS, 261 (34.1%) and 97 (9.8%) had received IVNs, respectively. The patients with STEACS who received IVNs were more likely to undergo reperfusion (79.7% vs 55.2%, p0.0001), received it more rapidly (median 59 minutes vs 70 minutes, p = 0.02), and were more likely to undergo coronary angiography and revascularization. No difference was found in hemodynamic status. The patients with NSTEACS who received IVNs were more likely to present with Killip class II-IV (39.2% vs 10.0%, p0.001) and to have left ventricular systolic dysfunction (39.0% vs 17.0%, p0.001). No difference was found in the use of invasive procedures. Using propensity score analysis, of 249 matched STEACS pairs, the rate of 30-day death was lower in the group that had received IVNs (2.4% vs 6.2%, p = 0.04), and this trend persisted after logistic regression analysis (odds ratio 0.40, 95% confidence interval 0.14 to 1.14, p = 0.09). Using propensity score analysis, of 95 matched NSTEACS pairs, no difference was found in the 30-day death rate (2.2% for patients receiving IVNs vs 6.3%, p = 0.16), even after logistic regression analysis (odds ratio 0.56, 95% confidence interval 0.14 to 2.33, p = 0.43). In conclusion, IVNs were commonly used in different scenarios-patients with STEACS were more likely to receive IVNs in the context of prompt reperfusion, and patients with NSTEACS were more likely to receive IVNs in the context of heart failure. In both scenarios, IVN use did not adversely affect the outcomes.

Elevated homocysteine levels are associated with increased risk for mortality in patients with coronary artery disease (CAD). However, the benefit of homocysteine-lowering therapy remains controversial. The aim of this study was to examine the impact of homocysteine-lowering therapy on the long-term outcomes of patients with CAD and its interaction with the methylenetetrahydrofolate reductase genotype. The study sample included 492 patients with early-onset CAD who were genotyped for the C677T mutation in the methylenetetrahydrofolate reductase gene or screened for elevated homocysteine from January 1997 to December 2002. Folic acidor =400 microg/day with or without additional B vitamins was administered at the attending physicians' discretion. There was no difference between treated (n = 140) and untreated patients in age, gender, or prevalence of coronary risk factors. Forty-six patients (9%) died during a median follow-up period of 115 months. Treatment was associated with significantly lower all-cause mortality in patients with homocysteine levels15 micromol/L (4% vs 32%, p0.001) but not in patients with lower levels (5% vs 7%, p0.05). On Cox regression analysis, the following factors were independently associated with all-cause mortality: vitamin therapy (hazard ratio 0.33, 95% confidence interval 0.11 to 0.98, p = 0.046), elevated homocysteine level (hazard ratio 3.5, 95% confidence interval 1.31 to 9.43, p = 0.013), and older age (hazard ratio 1.1, 95% confidence interval 1.04 to 1.14, p0.0001 for an increment of 5 years). The methylenetetrahydrofolate reductase genotype was not associated with outcomes. In conclusion, long-term folate-based vitamin therapy was independently associated with lower all-cause mortality in patients with CAD and elevated homocysteine levels. This association was not observed in patients with lower homocysteine levels.

Objectives This study sought to assess long-term outcome and determine its predictors among 30-day survivors of cardiogenic shock. Background Patients with cardiogenic shock have high in-hospital and 30-day mortality, but there are little data about those who survive beyond 30 days. Methods We analyzed baseline, in-hospital, and survival data from patients in the U.S. with ST-segment elevation myocardial infarction (STEMI) and cardiogenic shock enrolled in the GUSTO (Global Utilization of Streptokinase and Tissue-Type Plasminogen Activator for Occluded Coronary Arteries)-I trial and compared them with patients in the same trial who did not have shock. Results Of 22,883 patients enrolled in the U.S., shock occurred in 1,891 (8.3%); 953 (50.4%) survived 30 days and 527 (27.8%) survived 11 years. Of 20,992 U.S. patients without shock, 20,360 (96.9%) survived 30 days and 14,131 (67.3%) survived 11 years. After the first year, 2% to 4% of patients died each year regardless of whether they had cardiogenic shock. Using Cox proportional hazards models, we were able to predict long-term mortality in all U.S. GUSTO-I 30-day survivors from their baseline demographics and in-hospital complications. The strongest predictors were diabetes mellitus, cardiogenic shock, hypertension, previous myocardial infarction, current smoking, anterior infarct, higher Killip class, higher heart rate, and older age; patients >75 years were at highest risk. Percutaneous revascularization during the index hospitalization was associated with a reduced risk of death. Conclusions Among patients with cardiogenic shock who survive 30 days after STEMI, annual mortality rates of 2% to 4% approximate those of patients without shock.

The treatment of cardiogenic shock complicating the acute coronary syndromes consists of medical therapy, percutaneous revascularization procedures, cardiac surgery, and the implantation of devices. Medical therapy is limited to different positive inotropic and vasoactive drugs, without any firm evidence of survival benefit using these drugs. Several new pharmacologic compounds are at different stages of clinical research, but are not yet routinely approved for the treatment of cardiogenic shock. The only evidence-based therapy with proven survival benefit is timely revascularization. Intra-aortic balloon pump counterpulsation maintains its central role as supportive treatment in cardiogenic shock patients. Anecdotal evidence is available about the use of ventricular assist devices, cardiac resynchronization therapy, and emergent heart transplantation.

Guidelines and Expert Consensus Documents summarize and evaluate all currently available evidence on a particular issue with the aim to assist physicians in selecting the best management strategies for a typical patient, suffering from a given condition, taking into account the impact on outcome, as well as the risk–benefit ratio of particular diagnostic or therapeutic means. Guidelines are no substitutes for textbooks. The legal implications of medical guidelines have been discussed previously. A great number of Guidelines and Expert Consensus Documents have been issued in recent years by the European Society of Cardiology (ESC) as well as by other societies and organizations. Because of the impact on clinical practice, quality criteria for development of guidelines have been established in order to make all decisions transparent to the user. The recommendations for formulating and issuing ESC Guidelines and Expert Consensus Documents can be found on the ESC website (http://www.escardio.org/knowledge/guidelines/rules). In brief, experts in the field are selected and undertake a comprehensive review of the published evidence for management and/or prevention of a given condition. A critical evaluation of diagnostic and therapeutic procedures is performed including assessment of the risk–benefit ratio. Estimates of expected health outcomes for larger societies are included, where data exist. The level of evidence and the strength of recommendation of particular treatment options are weighed and graded according to pre-defined scales, as outlined in Tables 1 and 2 . View this table: Table 1 Classes of recommendations View this table: Table 2 Levels of evidence The experts of the writing panels have provided disclosure statements of all relationships they may have which might be perceived as real or potential sources of conflicts of interest. These disclosure forms are kept on file at the European Heart House, headquarters of the ESC. Any changes in conflict of interest that arise during the writing period must be notified to the …

No-reflow is a frequent event during percutaneous coronary intervention (PCI) for acute myocardial infarction (AMI), and it may affect cardiac prognosis. We evaluated the occurrence of no-reflow as a predictor of outcomes in patients who underwent PCI for AMI. We prospectively collected data from 599 consecutive patients who underwent stent-based PCI for ST-elevation AMI by identifying those with no-reflow (Thrombosis In Myocardial Infarction [TIMI] grade3 flow at completion of the procedure) and analyzing their baseline characteristics and clinical outcomes. Patients with no-reflow (n = 40, 6.7%) were older (67 +/- 13 vs 60 +/- 13 years, p = 0.002) and had longer ischemic times (5.5 +/- 3.7 vs 4.4 +/- 3.0 hours, p = 0.04) with more TIMI grade 0/1 flow at presentation (90% vs 64%, p = 0.001). No-reflow occurred mostly (73%) after stenting and often required intra-aortic balloon pump counterpulsation (30% vs 4.3%, p0.001). Peak creatine kinase level was higher in patients with no-reflow (2,700 +/- 1,900 vs 2,000 +/- 1,800, p = 0.03) and more often associated with moderate or severe left ventricular dysfunction (68% vs 45%, p = 0.006) and increased 6-month mortality (12.5% vs 4.3%, p = 0.04). By multivariate analysis, no-reflow was an independent predictor of long-term mortality (odds ratio 3.4, p = 0.02). In addition, renal failure (odds ratio 4.39, p = 0.0025) and preprocedure TIMI grade 0/1 flow (odds ratio 2.1, p = 0.003) were independent predictors of no-reflow. In conclusion, the association of no-reflow with longer ischemic time and worse initial TIMI flow may indicate the presence of highly organized thrombus burden with higher propensity for distal embolization. Regardless of its mechanism, no-reflow was an independent predictor of increased mortality.

Background/Aims: Physicians’ perception of antecedent physical/cognitive status may account for the suboptimal implementation of acute coronary syndrome (ACS) guidelines. Methods: In an ACS survey of all cardiac wards, physicians’ perception of antecedent physical/cognitive status was prospectively recorded and categorized as either normal, mildly impaired or significantly impaired. We examined the impact of antecedent status on the use of evidence-based medications and procedures and on mortality. Results: Of the 2,021 patients, 1,025 (51%) had ST elevation. Impaired antecedent physical/cognitive status was diagnosed in 417 patients (20.6%), more commonly among non-ST-elevation patients (26.2 vs. 15.2%). Patients with impaired physical/cognitive status, with or without ST elevation, had significantly worse baseline demographic and clinical characteristics. They less often received aspirin, clopidogrel, platelet glycoprotein IIb/IIIa receptor antagonists, statins and β-adrenergic blockers, and significantly less often underwent in-hospital catheterization and revascularization. Reperfusion treatment was given significantly less frequently to ST elevation patients with impaired status (63.0% for normal vs. 50.8% and 33.3% for mildly and significantly impaired status, respectively; p = 0.001). After adjustment for differences in baseline characteristics, impaired antecedent status remained independently associated with lower use of these therapies and higher mortality rates. Conclusions: ACS guideline implementation is significantly influenced by physicians’ perception of antecedent physical/cognitive status, and thus is a crucial parameter for understanding ACS management and outcomes.

Purpose The number of elderly patients with acute myocardial infarction (AMI) is growing rapidly, and their early and postdischarge mortality is high. Several studies have reported a decline in mortality after myocardial infarction; however, the magnitude of the decline among the elderly has not been fully investigated. Methods We assessed trends in management, in-hospital, and long-term outcomes of 1475 elderly patients (aged ≥75 years, 42% women) hospitalized with AMI in all 25 operating coronary care units in Israel between 1992 and 2002, from our prospective nationwide biennial surveys. Results Between 1992 and 2002, a significant increase was observed in the use of acute reperfusion therapy (27%-48%), coronary angiography (6%-47%), percutaneous coronary intervention (3%-33%), coronary bypass (2%-8%), aspirin (53%-88%), beta-blockers (18%-65%), angiotensin-converting enzyme inhibitors (26%-63%), and lipid-lowering drugs (0%-43%). These changes were associated with a 42% reduction in 30-day mortality (27.6%-16.1%; adjusted odds ratio 0.57; 95% confidence interval [CI], 0.36-0.93). One-year cumulative mortality declined by 20% (37%-29%; adjusted odds ratio 0.74; 95% CI, 0.49-1.13). Conclusions The management of elderly patients with AMI changed substantially during the last decade. This change was associated with a significant reduction in early mortality, whereas cumulative 1-year mortality improved only slightly. Better adherence to in-hospital management guidelines and better implementation of postdischarge health policy may further decrease mortality and morbidity in the elderly after AMI.

Heart failure (HF) is associated with poor outcome after acute myocardial infarction (AMI). Women have higher mortality rate than men after AMI, however, it is unknown whether women with HF after AMI have different prognosis than men.To compare the prognosis of men and women with AMI and mild-moderate HF.We analyzed data of 3456 consecutive patients with AMI hospitalized in all cardiac care units in Israel during two nationwide surveys.Among patients with AMI and HF on admission: women were older, had more risk factors, and were less likely to undergo percutaneous coronary angiography/intervention. Women with HF had higher (7-days, 30-days, and 1-year) crude mortality rates than men. However, adjusted mortality rates were not significantly different between genders.Women with AMI complicated by HF had higher crude mortality rate than men that was eliminated after multivariate analysis, suggesting that the higher mortality rate may be attributed to increased prevalence of risk factors and lower rate of revascularization and medical therapies among women. Women with AMI and HF should be considered as a high-risk subgroup with adverse outcome. It remains to be determined whether more intensive management will improve their prognosis.

Increased left ventricular mass index (LVMI) is associated with a greater incidence of acute myocardial infarction (AMI), but there are no data regarding its impact on infarct size.The objective of this study was to determine whether LVMI impacts on infarct size.We analyzed consecutive patients with a first ST-elevation AMI and successful reperfusion of the culprit artery who underwent an echocardiographic assessment of LVMI and regional wall motion score index (RWMSI)72 hours post AMI.Of the 165 patients (76.4% men) with a mean age of 61.0 +/- 13.9 years, 53.9% had anterior wall involvement and 59.3% had increased LVMI. There were no significant differences in baseline characteristics between patients with and without increased LVMI, except for a greater prevalence of hypertension among patients with increased LVMI (44.0% vs 22.4%, P.001). The distributions of anterior wall AMI location and culprit artery involvement were similar between the groups. Patients with increased LVMI were more likely to present with single-vessel coronary artery disease (P = .04) and heart failure upon presentation (P = .03). There was no significant difference between patients with and without increased LVMI in peak creatine kinase (2106.8 +/- 1642.7 vs 2551.2 +/- 2357.4 U/L, P = .16) or RWMSI (1.62 +/- 0.44 vs 1.61 +/- 0.38, P = .91). In addition, no correlation was observed between LVMI as a continuous variable and RWMSI (r = 0.11, P = .18) or peak creatine kinase values (r = 0.02, P = .81).Among patients with a first ST-elevation AMI and successful reperfusion, antecedent increased LVMI was fairly common and did not impact on infarct size.

Right-heart-catheterization and transthoracic echocardiography are routine tests to measure pulmonary artery systolic pressure among lung transplantation candidates. Echocardiography may be as accurate as right-heart-catheterization, without the inherent risks of an invasive test.We examined the correlation between pulmonary pressures estimated by echocardiography versus right-heart-catheterization among lung transplantation candidates and their correlation to measurements during lung transplantation. Our cohort included all lung transplantation candidates during 1997 through 2004 who initially underwent pulmonary pressure evaluation by right-heart-catheterization and echocardiography, as well as measurements during lung transplantation.Of the 106 candidates, evaluation by transthoracic echocardiography was possible in 79 (74.5%). Median pulmonary systolic pressures by right-heart-catheterization was 44.0 [33.2-50.0] mm Hg and by echocardiography 40.0 [32.5-51.5] mm Hg (r = 0.80, p0.0001). In 14 (17.7%) patients the difference between the 2 methods was20 mm Hg. The median time interval between echocardiography and right-heart-catheterization was 65 [40-155] days. The median value of pulmonary systolic pressure measured during lung transplantation in 44 (70.1%) of 62 patients was 39.5 [31.0-50.0] mm Hg. The time interval right-heart-catheterization-to-lung transplantation was 143 [87-339] days and echocardiography-to-lung transplantation 229 [130-367] days. The correlation between measurements during lung transplantation and initial measurements by right-heart-catheterization and echocardiography were r = 0.50 and r = 0.31, respectively, with corresponding p values of p = 0.001 and p = 0.07.For lung transplantation candidates and a suitable transthoracic echocardiography estimate of pulmonary systolic pressure, the need for right-heart catheterization, with its inherent risks for complications, may be foregone. The weak correlation between the initial and intraoperative measurements, probably stemming from the significant time interval, suggests that serial measurements may be needed.

Background: Although clopidogrel and aspirin (dual therapy, DT) are used for acute coronary syndrome (ACS), sometimes treatment with warfarin (triple therapy, TT) is required. Aim: To determine the incidence, complications, and outcomes of TT. Methods: We analyzed Israeli surveys of ACS from 2000 to 2004. Results: In these surveys, 5,706 (96%) were discharged alive from hospital. Post-ACS TT and DT were 76 patients (1.3%) and 2,661 patients (46.7%), respectively. The TT group was older with more prior cardiac disease. During hospitalization, the TT patients received more intravenous anticoagulant and antithrombotic agents, and had more heart failure, arrhythmias, ischemia, and major bleeding (2.6 vs. 0.6%, p = 0.03). There were no differences in adjusted 30-day and 6-month mortality between the 2 groups. Conclusion: TT is feasible among ACS patients who require concomitant warfarin treatment.