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AIMS Although routine echocardiographic parameters as ejection fraction are used to risk stratify for death in patients referred for echocardiography, they have limited predictive value. We speculated that non-invasive hemodynamic echocardiographic data, assessing left ventricular (LV) filling pressure and output, stratified based on the clinical Killip score, may have additive prognostic value on top of routine echocardiographic parameters. We created an echocardiographic correlate of this classification, using diastolic grade and stroke volume index (SVI) as indicators of pulmonary congestion and systemic perfusion, respectively, and evaluated the prognostic value of this correlate. METHODS A retrospective study of consecutive patients (hospitalized or not) referred for echocardiography for a range of cardiac diagnoses in a tertiary medical center. We included patients in sinus rhythm who were evaluated by 2 sonographers, and reviewed by a single cardiologist, 565 patients were included. Patients with normal filling pressures and normal SVI (>35ml/m2) were defined as eKillip class-1. Patients with pseudo-normal or restrictive diastolic patterns and normal SVI were ascribed to eKillip class-2 or 3, respectively. Those with pseudo-normal or restrictive diastolic patterns and a sub-normal SVI were defined as eKillip class-4. RESULTS EKillip class-1 was present in 382 (68%) patients, 115 (20%), 26 (5%) and 42 (7%) were in eKillip classes 2-4 respectively. Median follow-up time was 1056 days (IQR 729-1390). A total of 105 deaths occurred, in a univariate Cox regression analysis showed eKillip class was associated with all-cause mortality, hazard ratio (HR) and 95%CI were - 2.73[1.67-4.48], 3.19[1.42-7.17] and 4.79[2.58-8.89] for each eKillip class above 1, respectively (p

Patients undergoing percutaneous coronary interventions (PCIs) are prone to a wide range of complications; one complication that is constantly correlated with a worse prognosis is acute kidney injury (AKI). Gender as an independent risk factor for said complications has raised some interest; however, studies have shown conflicting results so far. We aimed to investigate the possible relation of gender to the occurrence of AKI in STEMI patients undergoing PCI. This retrospective observational study cohort included 2967 consecutive patients admitted with STEMI between the years 2008 and 2019. Their renal outcomes were assessed according to KDIGO criteria (AKI serum creatinine ≥ 0.3 mg/dL from baseline within 48 h from admission), and in-hospital complications and mortality were reviewed. Our main results show that female patients were older (69 vs. 60, p < 0.001) and had higher rates of diabetes (29.2% vs. 23%, p < 0.001), hypertension (62.9% vs. 41.3%, p < 0.001), and chronic kidney disease (26.7% vs. 19.3%, p < 0.001). Females also had a higher rate of AKI (12.7% vs. 7.8%, p < 0.001), and among patients with AKI, severe AKI was also more prevalent in females (26.1% vs. 14.5%, p = 0.03). However, in multivariate analyses, after adjusting for the baseline characteristics above, the female gender was a non-significant predictor for AKI (adjusted OR 1.01, 95% CI 0.73–1.4, p = 0.94) or severe AKI (adjusted OR 1.65, 95% CI 0.80–1.65, p = 0.18). In conclusion, while females had higher rates of AKI and severe AKI, gender was not independently associated with AKI after adjusting for other confounding variables. Other comorbidities that are more prevalent in females can account for the difference in AKI between genders.

Transcatheter aortic valve replacement (TAVR) has become the mainstay of treatment for patients with severe AS. Since the TAVR population and patients’ outcomes have dramatically changed over the last decade, updated data regarding contemporary practice and trends are pertinent to clinical use. We performed a retrospective observational analysis of consecutive patient who underwent TAVR for symptomatic severe AS between the years 2009 and 2021 in a single high-volume center. Patients were divided into four equal time groups based on the procedure date (2009–2012, 2013–2015, 2016–2018 and 2019–2021). A total of 1988 patients were included in this study and divided into four groups, with 321, 482, 565 and 620 patients in groups 1–4, respectively. Significant trends were seen in baseline characteristics of a few parameters, including lower age, lower procedural risk and reduced rates of comorbidity (p for trend < 0.0001 for all factors mentioned above). A shift was seen in the procedural technique with lower balloon pre-dilatation and higher device success rates (p for trend < 0.0001). The post-procedural period changed over the years with fewer pacemaker placements (p < 0.0001) and reduced rates of AKI and post-procedural bleed (p value 0.02 and

Physicians use Holter electrocardiography (ECG) monitoring to evaluate some patients with syncope in the internal medicine department. We questioned whether Holter ECG should be used in the presented setting. Included were all consecutive patients admitted with syncope to one of our nine internal medicine departments who had completed a 24 h Holter ECG between 2018 and 2021. A diagnostic Holter was defined as one which altered the patient’s treatment and met ESC/ACC/AHA diagnostic criteria. A total of 478 Holter tests were performed for syncope evaluation during admission to an internal medicine department in the study period. Of them, 25 patients (5.2%) had a diagnostic Holter finding. Sinus node dysfunction was the most frequent diagnostic recording (13 patients, 52%). In multivariant analysis, predictors for diagnostic Holter were older age (OR 1.35, 95% CI 1.08–1.68), heart failure with preserved ejection fraction (OR 4.1, 95% CI 1.43–11.72), and shorter duration to Holter initiation (OR 0.73, 95% CI 0.56–0.96). There was a positive correlation between time from admission to Holter and hospital stay, r(479) = 0.342, p < 0.001. Our results suggest that completing a 24 h Holter monitoring during admission to the internal medicine department should be restricted to patients with a high pre-test probability to avoid overuse and possible harm.

Neutrophil-to-lymphocyte ratio (NLR) is a simple and cost-effective marker of inflammation. This marker has been shown to predict cardiac arrhythmias, progression of valvular heart disease, congestive heart failure decompensation, acute kidney injury, and mortality in cardiovascular patients. The pathologic process of aortic stenosis includes chronic inflammation of the valve and therefore biomarkers of inflammation might offer additive prognostic value.To evaluate NLR and its association with long term mortality in transcatheter aortic valve implantation (TAVI) patients.We evaluated data of 1152 consecutive patient from the Tel Aviv Medical Center TAVI registry who underwent TAVI. Data included baseline clinical, demographic, and echocardiographic findings; procedural complications; and post-procedure mortality. Patients were compared by using the median NLR value (4.1) and evaluated for long-term mortality.Patients with NLR above the median had higher mortality rates (26.4% vs. 16.3%, P0.001) at 3 years post-procedure. A multivariable analysis found NLR to be an independent risk factor for mortality (hazard ratio = 1.47, 95% confidence interval 1.09-1.99, P = 0.013). In addition, high NLR was linked to complicationsduring and after the procedure.NLR is an independent prognostic marker among TAVI patients. This marker may represent an increased inflammatory response and should be added to previous known prognostic factors.

Mortality from acute ST elevation myocardial infarction (STEMI) was significantly reduced with the introduction of percutaneous catheterization intervention (PCI) but remains high in patients who develop acute kidney injury (AKI). Previous studies found overweight to be protective from mortality in patients suffering from STEMI and AKI separately but not as they occur concurrently. This study aimed to establish the relationship between AKI and mortality in STEMI patients after PCI and whether body mass index (BMI) has a protective impact. Between January 2008 and June 2016, two thousand one hundred and forty-one patients with STEMI underwent PCI and were admitted to the Tel Aviv Medical Center Cardiac Intensive Care Unit. Their demographic, laboratory, and clinical data were collected and analyzed. We compared all-cause mortality in patients who developed AKI after PCI for STEMI and those who did not. In total, 178 patients (10%) developed AKI and had higher mortality (p < 0.001). Logistic regression analysis was performed to determine the relationship between AKI, BMI, and mortality. AKI was significantly associated with both 30-day and overall mortality, while BMI had a significant protective effect. Survival analysis found a significant difference in 30-day and overall survival between patients with and without AKI with a significant protective effect of BMI on survival at 30 days. AKI presents a major risk for mortality and poor survival after PCI for STEMI, yet a beneficial effect of increased BMI modifies it.

Tricuspid regurgitation (TR) is associated with adverse prognosis in various patient populations but currently no data is available about the prevalence and prognostic implication of TR in ST-segment elevation myocardial infarction (STEMI) patients.To investigate the possible implication of TR among STEMI patients.We conducted a retrospective study of STEMI patients undergoing primary percutaneous coronary intervention (PCI), and its relation to major clinical and echocardiographic parameters. Patient records were assessed for the prevalence and severity of TR as well as the relation to the clinical profile, key echocardiographic parameters, in-hospital outcomes, and long-term mortality. Patients with previous myocardial infarction or known previous TR were excluded.The study included 1071 STEMI patients admitted between September 2011 and May 2016 (age 61 ± 13 years; predominantly male). A total of 205 patients (19%) had mild TR while another 32 (3%) had moderate or greater TR. Patients with significant TR demonstrated worse echocardiographic parameters, were more likely to have in-hospital complications, and had higher long-term mortality (28% vs. 6%, P0.001). Following adjustment for significant clinical and echocardiographic parameters, mortality hazard ratio of at least moderate to severe TR remained significant (2.44, 95% confidence interval 1.06-5.6, P = .036) for patients with moderate to severe TR.Among STEMI patients after primary PCI, the presence of moderate to severe TR was independently associated with adverse outcomes and significantly lower survival rate.

Recent practice guidelines recommended the use of new stress, functional, and damage biomarkers in clinical practice to prevent and manage acute kidney injury (AKI). Biomarkers are one of the tools used to define various AKI phenotypes and provide prognostic information regardless of an acute decline in renal function. We investigated the incidence and possible implications of AKI phenotypes among ST elevation myocardial infarction patient treated with primary coronary intervention. We included 281 patients with STEMI treated with PCI. Neutrophil gelatinase associated lipocalin (NGAL) was utilized to determine structural renal damage and functional AKI was determined using the KDIGO criteria. Patients were stratified into four AKI phenotypes: no AKI, subclinical AKI, hemodynamic AKI, and severe AKI. Patients were assessed for in-hospital adverse events (MACE). A total of 46 patients (44%) had subclinical AKI, 17 (16%) had hemodynamic AKI, and 42 (40%) had severe AKI. We observed a gradual and significant increase in the occurrence of MACE between the groups being highest among patients with severe AKI (10% vs. 19% vs. 29% vs. 43%; p < 0.001). In a multivariable regression model, any AKI phenotype was independently associated with MACE with an odds ratio of 4.15 (95% CI 2.1–8.3, p < 0.001,) for subclinical AKI, 4.51 (95% CI 1.61–12.69; p = 0.004) for hemodynamic AKI, and 12.9 (95% CI 5.59–30.1, p < 0.001) for severe AKI. In conclusion, among STEMI patients, AKI is a heterogeneous condition consisting of distinct phenotypes, addition of novel biomarkers may overcome the limitations of sCr-based AKI definitions to improve AKI phenotyping and direct potential therapies.

Background Routine, short-term use of inotropic agents is still applied in advanced heart failure (HF) patients either as a bridge to definitive treatment or as a mean to improve quality of life, despite the paucity of scientific evidence. Intermittent levosimendan was shown to be efficacious compared to placebo in advanced HF patients, however no prospective data comparing it to other inotropes and in particular, to milrinone are available. We aimed to assess the clinical effects of intermittent levosimendan in a small group of milrinone-treated advanced HF patients. Methods This was a prospective, un-blinded study. Consecutive ambulatory advanced HF patients intermittently treated with ≥ 4 cycles of once-weekly 6-hours 0.25–0.5 mg/kg/min milrinone at our HF outpatient clinic, were switched to levosimendan. All patients were evaluated using B-natriuretic peptide (BNP) levels, echocardiography, cardio-pulmonary exercise test and HF questionnaire before and after 4 weeks of intermittent once-weekly 6-hours therapy with levosimendan 0.1–0.2 mcg/kg/min. Results The cohort included 11 patients, 10 men, mean age 76±12 years. After 4 weeks of levosimendan therapy, Vo2 max improved by a mean of 2.28 ml/kg [95% CI -0.22-3.38, p = 0.05], BNP levels decreased from a median of 1015 ng/l [261–1035] to 719 ng/l [294–739], (p

Background: Tricuspid regurgitation (TR) is associated with adverse prognosis in various patient populations but currently no data is available about the prevalence and prognostic implication of TR in ST-segment elevation myocardial infarction (STEMI) patients. We investigated the possible implication of TR among STEMI patients. Methods: We conducted a retrospective study of STEMI patients undergoing primary percutaneous coronary intervention (PCI), and its relation to major clinical and echocardiographic parameters. Patients records were assessed for the prevalence and severity of TR, its relation to the clinical profile, key echocardiographic parameters, in-hospital outcomes, and long-term mortality. Patients with previous myocardial infarction or known previous TR were excluded. Results: The study included 1071 STEMI patients admitted between September 2011 and May 2016 (age 61 ± 13 years; predominantly male). A total of 205 patients (19%) had mild TR while another 32 (3%) had moderate or greater TR was 3% (n = 32). Patients with significant TR demonstrated worse echocardiographic parameters, more likely to have in-hospital complications and had higher long-term mortality (28% vs. 6%; p

SummaryIt was the study objective to evaluate whether chewing a 180 mg loading dose of ticagrelor versus an equal dose of traditional oral administration, enhances inhibition of platelet aggregation 1 hour (h) after administering a ticagrelor loading dose in non-ST elevation myocardial infarction (NSTEMI) patients. Dual anti-platelet therapy represents standard care for treating NSTEMI patients. Ticagrelor is a direct acting P2Y12 inhibitor and, unlike clopidogrel and prasugrel, does not require metabolic activation. Fifty NSTEMI patients were randomised to receive either a chewing loading dose of 180 mg ticagrelor or an equal standard oral dose of ticagrelor. Platelet reactivity was evaluated by VerifyNow at baseline, 1 and 4 h post-loading dose. Results are reported in P2Y12 reaction units. Patients then continued to receive standard 90 mg oral ticagrelor twice daily. Baseline characteristics did not differ between the two groups. P2Y12 reaction units in the chewing group compared with the standard group at 0, 1 and 4 h after ticagrelor loading dose were: 245 vs 239 (p=0.59), 45 vs 130 (p=0.001) and 39 vs 60 (p=0.12), respectively, corresponding to a relative inhibition of platelet aggregation of 83 % vs only 47 % at 1 h (p< 0.001), and 84 % vs 77 % (p=0.59) at 4 h. Major adverse cardiac and cardiovascular events at 30 days were low (2 %), occurring in only one patient in the standard group. In conclusion, chewing a 180 mg ticagrelor loading dose is feasible and facilitates both faster and improved early inhibition of platelet aggregation in NSTEMI patients, compared with a standard oral-loading dose.Supplementary Material to this article is available online at www.thrombosis-online.com.