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Limited data exist regarding the significance of peripheral arterial disease (PAD) in patients with acute coronary syndrome (ACS).We evaluated 16,922 consecutive ACS patients who were prospectively included in a national ACS registry. The co-primary endpoint included 30 days major adverse cardiovascular event (MACE) (re-infarction, stroke, and/or cardiovascular death) and 1-year mortality.PAD patients were older (70±11 vs 63±13; p0.01), male predominance (80% vs 77%; p=0.01), and more likely to sustain prior cardiovascular events. PAD patients were less likely to undergo coronary angiography (69% vs 83%; p0.001) and revascularisation (80% vs 86%; p0.001). Patients with PAD were more likely to sustain 30-day MACE (22% vs 14%; p0.001) and mortality (10% vs 4.4%; p0.001), as well as re-hospitalisation (23% vs 19%; p=0.001). After adjusting for potential confounders, PAD remained an independent predictor of 30-day MACE (odds ratio [OR], 1.6 [95% confidence interval (CI), 1.24-2.06]). Patients with compared to those without PAD had 2.5 times higher 1-year mortality rate (22% vs 9%; p0.001). Co-existence of PAD remained an independent predictor of 1-year mortality after adjustment for potential confounders by multivariable regression analysis (OR, 1.62; 95% CI, 1.4-1.9). PAD was associated with a significant higher 1-year mortality rate across numerous sub-groups of patients including type of myocardial infarction (ST-elevation myocardial infarction vs non-ST-elevation myocardial infarction), and whether the patient underwent revascularisation.Acute coronary syndrome with concomitant PAD represents a high-risk subgroup that warrants special attention and a more tailored approach.

Background An association between diffuse idiopathic skeletal hyperostosis (DISH) and a history of coronary artery disease (CAD) was previously reported. Purpose To investigate the association between DISH and CAD as assessed using the coronary artery calcification score (CACS) and the CAD-Reporting and Data System (CAD-RADS) score in patients with symptomatic chest pain. Material and Methods Consecutive cardiac CT scans performed before and after IV contrast administration were evaluated for CACS (Agatston method), CAD-RADS, and the presence of DISH. The association of DISH with the presence and extent of CACS/CAD-RADS scores was analyzed with and without adjustment for known atherosclerotic risk factors. Results The study cohort included 268 individuals (157 men, 111 women; median age = 54 years). DISH was present in 65 (24.3%) individuals. CACS was significantly higher in the DISH group compared to the non-DISH group in the univariate analysis (median CACS DISH = 2, range = 0–80.5 vs. median CACS non-DISH = 0, range = 0–11; P Conclusion No independent association was found between the presence of DISH and CACS and CAD-RADS scores. Our findings suggest a more complex and possibly non-causal relationship between coronary artery disease and DISH.

Background Various prognostic models for mortality prediction following ST-segment elevation myocardial infarction (STEMI) have been developed over the past two decades. Our group has previously demonstrated that machine learning (ML)-based models can outperform known risk scores for 30-day mortality post-STEMI. The study aimed to redevelop an ML-based random forest prediction model for 30-day mortality post-STEMI and externally validate it on a large cohort. Methods This was a retrospective, supervised learning, data mining study developed on the Acute Coronary Syndrome Israeli Survey (ACSIS) registry and the Myocardial Ischemia National Audit Project (MINAP) for external validation. Patients included received reperfusion therapy for STEMI between 2006 and 2016. Discrimination and calibration performances were assessed for two developed models and compared with the Global Registry of Acute Cardiac Events (GRACE) score. Results The ACSIS cohort (2,782 included /15,212 total) and MINAP cohort (22,693 included/735,000 total) were significantly different in most variables, yet similar in 30-day mortality rate (4.3–4.4%). Random forest models were developed on the ACSIS cohort with a full model including all 32 variables and a simple model including the 10 most important ones. Features’ importance was calculated using the varImp function measuring how much each feature contributes to the data's homogeneity. Applying the optimized models on the MINAP validation cohort showed high discrimination of area under the curve (AUC) = 0.804 (0.786–0.822) for the full model, and AUC = 0.787 (0.748–0.780) using the simple model, compared with the GRACE risk score discrimination of AUC = 0.764 (0.748–0.780). All models were not well calibrated for the MINAP data. Following Platt scaling on 20% of the MINAP data, the random forest models calibration improved while the GRACE calibration did not change. Conclusions The random forest predictive model for 30-day mortality post STEMI, developed on the ACSIS national registry, has been validated in the MINAP large external cohort and can be applied early at admission for risk stratification. The model performed better than the commonly used GRACE score. Furthermore, to the best of our knowledge, this is the first externally validated ML-based model for STEMI.

Background Severe acute respiratory syndrome coronavirus 2 infection is responsible for the coronavirus disease 2019 (COVID-19) pandemics. Omicron (B.1.1.529) variant is the cause for the surge of the COVID-19 pandemics of the end of 2021 and the beginning of 2022, although its subvariants are responsible for the following daily increase of COVID-19 cases in July 2022. Early reports of Omicron variant confirmed patients indicated less severe disease course compared with the disease caused by previously encountered variants with absence of data regarding cardiac involvement by Omicron. Case summary A 42-year-old male who tested positive for Omicron was admitted on January 2022 with chest pain and ST-segment elevation in the inferior leads. Coronary angiography revealed non-significant coronary artery disease. Cardiac magnetic resonance imaging demonstrated features consistent with myocarditis with involvement of 22% of the left ventricular mass by late gadolinium enhancement involving both the lateral and the septal walls. The second patient is a 60-year-old male presented following syncope and palpitations after he was confirmed with Omicron infection. Upon emergency department arrival he had ventricular tachycardia of 250 beats/minute and underwent urgent cardioversion. During his hospitalization, there was no recurrence of malignant arrhythmia, coronary angiography revealed non-obstructive disease. Cardiac magnetic resonance imaging demonstrated imaging features suggesting acute myocarditis with involvement of 19% of the left ventricular mass. Discussion This is the first report of myocarditis cases as a possible complication associated with Omicron variant. Despite preliminary reports of less severe disease clinicians should be vigilant for potential deleterious cardiac complications of Omicron.

Intermediate zone troponin elevation is defined as one to five times the upper limit of normal. Approximately half the patients presenting with chest pain to the emergency department have initial intermediate zone troponin. We aimed to investigate the long-term outcome of patients hospitalized with chest pain and intermediate zone troponin elevation. We investigated 8269 patients hospitalized in a tertiary center with chest pain. All patients had serial measurements of troponin during hospitalization. Patients were divided into three groups based on their initial troponin levels: negative troponin (N = 6112), intermediate zone troponin (N = 1329) and positive troponin (N = 828). All patients underwent myocardial perfusion imaging (MPI) as part of the initial evaluation. Mean age of the study population was 68 ± 11, of whom 36% were women. Patients with an intermediate zone troponin were older, more likely to be males, and with significantly more cardiovascular co-morbidities. Multivariate analysis adjusted for age, gender, cardiovascular risk factors, and abnormal MPI result found that patients with intermediate zone troponin had a 70% increased risk of re-hospitalization at 1 year (HR 1.70, 95%CI 1.48–1.96, p-value

Mesenteric ischemia is a rare but lethal complication of transcatheter aortic valve replacement (TAVR). We present a challenging case of an 80-year-old man who had abdominal pain few hours following TAVR. Repeated abdominal and pelvic imaging showed no vascular obstruction, but exploratory laparoscopy revealed a necrotic bowel. (Level of Difficulty: Intermediate.), Graphical abstract

There are controversial data regarding the outcome and management of patients hospitalized with clinically diagnosed acute myocarditis.We retrospectively evaluated data of 322 consecutive patients admitted to the Sheba Medical Center with clinically suspected acute myocarditis from January 2005 to December 2017. Patients were subdivided into 2 groups based on their left ventricular ejection fraction (LVEF) at presentation: 1) patients with an LVEF50% (n = 60) and 2) patients with an LVEF ≥50% (n = 260). We aimed to evaluate the clinical characteristics, management, and in-hospital outcome as well as short-term and 1-year outcome of patients admitted with acute myocarditis.The mean age of the study population was 37 ± 14 years, most of them (84%) males. Although chest pain was the main complaint in 89% of the patients at presentation, only 35% had typical pericardial pain. Patients with a LVEF50% were more likely to demonstrate ST depression or T wave inversion on their electrocardiogram (ECG) at presentation (33% vs 18%, P = 0.007), and have higher levels of admission and peak troponin compared to those with LVEF ≥50%,(12.7 μ/L ± 15 µ/L vs 5.5 μ/L ± 9.2 μ/L, P = 0.001 for admission troponin, 18.8 μ/L ± 19.9 μ/L vs 8.4 μ/L ± 11.6 μ/L, P0.001, for peak troponin). Univariate analysis showed that patients with an LVEF50% were more likely to suffer from adverse cardiovascular events, defined as a composite of the following: 1) acute decompensated congestive heart failure; 2) ventricular arrhythmias; and 3) in-hospital mortality, compared to those with an LVEF ≥50% (15 [25%] vs10 [4%], P0.001). Consistently, multivariable analysis showed that patients with an LVEF50% had a 4-fold increased risk of adverse cardiovascular events compared to those patients with an LVEF ≥50% (heart rate [HR] = 4.30; 95% confidence interval [CI] 1.59-11.49; P0.001).Patients with clinical acute myocarditis seem to have an overall good prognosis. Although patients with an LVEF50% are at a higher risk of in-hospital adverse events compared to those with an LVEF ≥50%, this propensity is not reflected during 1-year of follow-up.

Aims To evaluate the effect of an intercurrent non-coronary illness on the management and outcome of patients with non-ST-segment elevation myocardial infarction (NSTEMI). Methods and results Consecutive hospitalized patients with a primary diagnosis of NSTEMI between August 2008 and December 2019 at Sheba Medical Center. All patients’ records were reviewed for the presence of a non-coronary precipitating event (NCPE): a major intercurrent acute non-coronary illness or condition, either cardiac or non-cardiac. The primary outcome was all-cause mortality. Cox regression with interaction analysis was applied. Final study population comprised 6491 patients, of whom 2621 (40%) had NCPEs. Patients with NCPEs were older (77 vs. 69 years) and more likely to have comorbidities. The most prevalent event was infection (35%, n = 922). During a median follow-up of 30 months, 2529 patients died. Patients with NCPEs were 43% more likely to die during follow-up in a multivariable model (95% CI: 1.31–1.55). Invasive strategy was associated with a 55% lower mortality among patients without NCPE and only 44% among patients with NCPE (P for interaction < 0.001). Dual antiplatelet therapy (DAPT) was associated with a 20% lower mortality in patients without NCEP and a non-significant mortality difference among patients with NCPE (P for interaction = 0.014). Sub-analysis by the specific NCPE showed the highest mortality risk among patients with infectious precipitant. The lower mortality associated with invasive strategy was not observed in this subgroup. Conclusion Among NSTEMI patients, the presence of an NCPE is associated with poor survival and modifies the effect of management strategies.

BackgroundSince the beginning of the coronavirus disease 2019 (COVID-19) pandemic in 2019, several countries have reported a substantial drop in the number of patients admitted with non-ST-segment myocardial infarction (NSTEMI).ObjectiveWe aimed to evaluate the changes in admissions, in-hospital management and outcomes of patients with NSTEMI in the COVID-19 era in a nationwide survey.MethodA prospective, multicenter, observational, nationwide study involving 13 medical centers across Israel aimed to evaluate consecutive patients with NSTEMI admitted to intensive cardiac care units over an 8-week period during the COVID-19 outbreak and to compare them with NSTEMI patients admitted at the same period 2 years earlier (control period).ResultsThere were 624 (43%) NSTEMI patients, of whom 349 (56%) were hospitalized during the COVID-19 era and 275 (44%) during the control period. There were no significant differences in age, gender and other baseline characteristics between the two study periods. During the COVID-19 era, more patients arrived at the hospital via an emergency medical system compared with the control period (P = 0.05). Time from symptom onset to hospital admission was longer in the COVID-19 era as compared with the control period [11.5 h (interquartile range, IQR, 2.5–46.7) vs. 2.9 h (IQR 1.7–6.8), respectively, P ConclusionIn contrast to previous reports, admission rates of NSTEMI were similar in this nationwide survey during the COVID-19 era. With longer time from symptoms to admission, but with the same time from hospital admission to reperfusion therapy and with similar in-hospital and 30-day mortality rates. Even in times of crisis, adherence of medical systems to clinical practice guidelines ensures the preservation of good clinical outcomes.

Background: In the face of the global pandemic that the coronavirus disease 2019 (COVID-19) has created, readily available prognostic markers may be of great use. Objective: To evaluate the association between serum magnesium (sMg) levels on admission and clinical outcomes in hospitalized COVID-19 patients. Methods: We retrospectively analyzed all patients admitted to a single tertiary center with a primary de novo diagnosis of COVID-19. Patients were followed for a mean of 10 ± 7 months. Demographic, clinical and laboratory data were collected and compared between five groups of patients according to sMg quintiles on hospital admission. Results: The cohort included 1522 patients (58% male, 69 ± 17 years old). A low sMg level (1st quintile) was associated with higher rates of diabetes and steroid use, whereas a high sMg level (5th quintile) was associated with dyslipidemia, renal dysfunction, higher levels of inflammatory markers and stay in the intensive care unit. All-cause in-hospital and long-term mortality was higher in patients with both low and high sMg levels, compared with mid-range sMg levels (2nd, 3rd and 4th quintiles; 19% and 30% vs. 9.5%, 10.7% and 17.8% and 35% and 45.3% vs. 23%, 26.8% and 27.3% respectively; p < 0.001 for all). After adjusting for significant clinical parameters indicating severe disease and renal dysfunction, only low sMg state was independently associated with increased mortality (HR = 1.57, p < 0.001). Conclusions: Both low and high sMg levels were associated with increased mortality in a large cohort of hospitalized COVID-19 patients. However, after correction for renal dysfunction and disease severity, only low sMg maintained its prognostic ability.

It is estimated that in the past two decades the number of patients diagnosed with diabetes mellites (DM) has doubled. Despite significant progress in the treatment of cardiovascular disease (CVD), including novel anti-platelet agents, effective lipid-lowering medications, and advanced revascularization techniques, patients with DM still are least twice as likely to die of cardiovascular causes compared with their non-diabetic counterparts, and current guidelines define patients with DM at the highest risk for atherosclerotic cardiovascular disease and major adverse cardiovascular events (MACE). Over the last few years, there has been a breakthrough in anti-diabetic therapeutics, as two novel anti-diabetic classes have demonstrated cardiovascular benefit with consistently reduced MACE, and for some agents, also improvement in heart failure status as well as reduced cardiovascular and all-cause mortality. These include the sodium-glucose cotransporter-2 inhibitors and the glucagon-like peptide-1 receptor agonists. The benefits of these medications are thought to be derived not only from their anti-diabetic effect but also from additional mechanisms. The purpose of this review is to provide the everyday clinician a detailed review of the various agents within each class with regard to their specific characteristics and the effects on MACE and cardiovascular outcomes.

Current guidelines suggest that an early invasive strategy should be considered for the treatment of non-ST-segment elevation myocardial infarction (NSTEMI). Although chronic kidney disease (CKD) is common among NSTEMI patients, these patients are under-represented in clinical trials, and data regarding their management are limited.The authors sought to evaluate the association between early invasive strategy and long-term survival among patients with NSTEMI and CKD.This was a retrospective analysis of 7,107 consecutive NSTEMI patients between 2008 and 2021. Patients were dichotomized into early (≤24 hours) and delayed invasive groups and stratified by kidney function. Inverse probability treatment weighting was used to adjust for differences in baseline characteristics. The primary outcome was all-cause mortality.The final study population comprised 3,529 invasively treated patients with a median age of 66 years (IQR: 58-74 years), 1,837 (52%) of whom were treated early. There were 483 (14%) patients with at least moderate CKD (estimated glomerular filtration rate [eGFR] 45 mL/min/1.73 mAmong NSTEMI patients, the association of early invasive strategy with long-term survival is modified by CKD and was not observed in patients with eGFR 45 mL/min/1.73 m

The European Society of Cardiology (ESC) guidelines for the management of acute coronary syndromes in patients presenting without persistent ST-segment elevation (non-ST-segment elevation myocardial infarction [NSTEMI]) has recommended immediate (2 h) percutaneous coronary intervention (PCI) in very-high risk patients and early (24 h) PCI in high-risk patients.To examine the ESC NSTEMI guidelines adherence in a nationwide survey in Israel using the Acute Coronary Syndrome Israeli Survey (ACSIS). We hypothesized that adherence to the guidlines' recommnded PCI timing in NSTEMI pateints will be inadequate, partly due to the inconsistent evidence regarding its effect on clinical outcomes.All NSTEMI patients who underwent PCI during the ACSIS surveys in 2016 and 2018 were included in the analysis.Out of 1793 NSTEMI patients, 1643 (92%) patients underwent PCI, and door to balloon time was documented in 1078 of them. One hundred and fifty-six (14.5%) patients and 922 (85.5%) patients were defined as very high-risk and high-risk NSTEMI patients, respectively. Of the very high-risk NSTEMI patients, only 10 (6.4%) underwent immediate coronary angiography, and 50 (32.1%) underwent early coronary angiography. Acute heart failure 139 (89.1%) was the main reason for including NSTEMI patients in the very high-risk category. Of the high-risk patients, early coronary angiography was performed in only 405 (43.9%) patients. Patients in whom coronary angiography was postponed were older and had more comorbidities.Despite guidelines recommendations for immediate and early PCI in very high-risk and high-risk NSTEMI patients, respectively, most patients do not undergo immediate or early PCI according to contemporary guidelines. Further studies are needed to better understand the reasons for guidelines' nonadherence in those high-risk patients.

Elderly patients are often excluded from a chest pain unit (CPU)-based evaluation of chest pain due to concern about adverse events and poorer outcomes. The aim of this study was to assess the feasibility and safety of thoroughly evaluating elderly patients ≥ 65 years of age presented with acute chest pain via a CPU. We evaluated 1220 consecutive patients admitted to our CPU, and stratified them according to age: those over and those under 65 years. Patients were evaluated for outcomes during hospitalization and for a composite endpoint at 60 days post discharge which included: recurrent hospitalization due to chest pain, need for coronary revascularization, acute coronary syndrome, and death. Overall, 241 (20%) patients were in the ≥ 65-year-old group and 979 (80%) patients in the group

Background and aims The beneficial effect of statin therapy has been well established for both primary and secondary prevention of cardiovascular disease. Nevertheless, it remains under-used among patients with chronic kidney disease (CKD). We aimed to investigate the impact of statin therapy across a wide spectrum of CKD patients presenting with acute coronary syndrome (ACS). Methods We included all patients with ACS enrolled in the Acute Coronary Syndrome Israel Survey (ACSIS) between the years 2006 and 2016, and allocated them to 3 groups according to their renal function based on an estimated glomerular filtration rate (eGFR) calculation on admission (MDRD formula): eGFR 60 ml/min/1.73 m2 (n = 6501, 73%). Primary outcome included in-hospital, 30-day, and 1-year major adverse cardiovascular events (MACE), and the independent prognostic effect of statins among CKD patients with ACS, by Cox regression analysis. Results All 8945 consecutive ACS patients were included in our analysis. On hospital discharge, statin prescriptions were negatively associated with eGFR ]eGFR>60 ml/min/1.73 m2 -95%, eGFR 30–59 ml/min/1.73 m2 -90%, eGFR Conclusions In our study, the beneficial effect of statins was maintained among CKD patients presenting with ACS. Therefore, these patients should be treated with statins regardless of their eGFR.

The GRACE risk score is currently recommended as the major score for risk prediction on admission in patients with acute coronary syndrome (ACS). Anemia in patients with ACS adversely affects their clinical outcomes, yet hemoglobin level on admission is not included as a parameter in the GRACE score. We hypothesized that hemoglobin level on admission would improve the predictive value of the GRACE score.We retrospectively studied one-year mortality in consecutive ACS patients included in the ACSIS (acute coronary syndrome Israeli Survey) registry between the years 2008 and 2013. Patients were classified into groups according to the GRACE score - ≥140 or140, and according to the hemoglobin level: severe anemia -8g/dl; mild anemia - 8-12g/dl; no anemia -12g/dl. We analyzed the incremental predictive value of admission hemoglobin levels over the GRACE score.We studied 11,505 patients. The GRACE score predicted 1-year mortality with an area under the curve (ROC) of 0.68 (95% CI 0.66-0.7). When hemoglobin level on admission was incorporated into the model, the ROC increased to 0.73 (95% CI 0.71-0.75, p0.001). The incremental value of hemoglobin levels on admission was significant only in the low (140) GRACE score group.In patients a with low GRACE score (140), anemia on admission has additional predictive value for one-year mortality. In contrast, in patients with a high GRACE risk score, hemoglobin level on admission did not improve prediction accuracy.

BACKGROUND Frailty is an underrecognized and important entity that bears worse prognosis. Although low serum alanine aminotransferase (ALT) can serve as a novel marker of frailty, its use was never assessed in acute coronary syndrome (ACS) patients. METHODS A retrospective analysis of hospitalized ACS patients in the intensive cardiac care unit (ICCU)between 1/5/2011 and 1/12/2020 at a single tertiary medical center. RESULTS The study included 3956 patients after excluding patients with ALT >40 IU/L, cirrhosis, and missing data, followed for a medianduration of 47 months (IQR 20-77).Patients were stratified into two groups based on their first ALT measurement within the index hospitalization: low-normal ALT group (ALT ≤10 IU/L) vs. high-normal ALT group (ALT >10 IU/L). Patients with ALT≤10 IU/L were older (mean age 71 years vs. 65 years, p

To evaluate the association of invasive management (coronary angiogram) with all-cause mortality among older adult (≥80 years of age) patients presenting with non-ST elevation myocardial infarction (NSTEMI) by frailty status.This study used a retrospective cohort of consecutive older adult patients who were hospitalized with NSTEMI as their primary clinical diagnosis between August 1, 2008, and December 31, 2019. Cox regression models were applied with stratification by frailty status (low, medium, and high). Extensive sensitivity analyses were conducted including propensity score matching and inverse probability treatment weighting models.The study population included 2317 patients with median age of 86 years (IQR, 83-90 years) of whom 1243 (53.6%) were men. Patients who were managed invasively (n=581 [25%]) were less likely to be frail (7% vs 44%, P.001). During the follow-up (median, 19 months, IQR, 4-41 months), 1599 (69%) patients died. In a multivariable Cox model, invasive approach was associated with adjusted hazard ratio (HR) of 0.61 (95% CI, 0.53 to 0.71) for the risk of death. The benefit of invasive approach was consistent among low, medium, and high frailty subgroups with adjusted HRs of 0.74 (95% CI, 0.58 to 0.93), 0.65 (95% CI, 0.50 to 0.85), and 0.52 (95% CI, 0.34 to 0.78), respectively (P for interaction = 0.48). Results were consistent with propensity score matching and inverse probability treatment weighting analyses (HR, 0.6; 95% CI, 0.50 to 0.71 and HR, 0.67; 95% CI, 0.55 to 0.82, respectively). Sensitivity analysis addressing potential immortal time bias and residual confounding yielded similar results.Invasive approach is associated with improved survival among older adults with NSTEMI irrespective of frailty status.

BACKGROUND Clinical risk assessment with quantitative formal risk scores may add to intuitive physician risk assessment and are advised by the international guidelines for the management of acute coronary syndrome (ACS) patients. Most previous studies have used the binary regression/classification approach (dead/alive) for long-term mortality post-ACS, without considering the time-to-event as in survival analysis. The use of machine learning (ML)-based survival models has yet to be validated. The primary objective was to compare survival prediction performance of 1-year mortality following ACS of two newly developed ML-based models [random survival forest (RSF) and deep learning (DeepSurv)] with the traditional Cox-proportional hazard (CPH) model. The secondary objective was external validation of the findings. METHODS This was a retrospective, supervised learning data mining study based on the Acute Coronary Syndrome Israeli Survey (ACSIS) and the Myocardial Ischemia National Audit Project (MINAP). The ACSIS data were divided to train/test in a 70/30 fashion. Next, the models were externally validated on the MINAP data. Harrell's C-index, inverse probability of censoring weighting (IPCW), and the Brier-score were used for models' performance comparison. RESULTS RSF performed best among the three models, with Harrell's C-index on training and testing sets reaching 0.953 and 0.924 respectively, followed by CPH multivariate selected model (0.805/0.849), CPH Univariate selected model (0.828/0.806), DeepSurv model (0.801/0.804), and the traditional CPH model (0.826/0.738). The RSF model also had the highest performance on the validation data set with 0.811 for Harrell's C-index, 0.844 for IPCW, and 0.093 for Brier score. The CPH model performance on the validation set had C-index range between 0.689 to 0.790, 0.713 to 0.826 for IPCW, and 0.094 to 0.103 Brier score. CONCLUSIONS RSF survival predictions for long-term mortality post-ACS show improved model performance compared with the classic statistical method. This may benefit patients by allowing better risk stratification and tailored therapy, however further prospective evaluations are required.

Pulmonary embolism (PE) patients with right ventricular (RV) involvement are a heterogenous group who mandate further risk stratification. Our objective was to evaluate the efficacy of the PE severity index (PESI) for predicting adverse clinical outcomes among PE patients with RV involvement. Consecutive normotensive PE patients with RV involvement were allocated according to admission PESI score (PESI ≤ III vs. PESI ≥ IV). The primary outcome included hemodynamic instability and in-hospital mortality. Secondary outcomes included each component of the primary outcome as well as mechanical ventilation, thrombolytic therapy, acute kidney injury, and major bleeding. Multivariable logistic regression model was performed to assess the independent association between the PESI score and primary outcome. C-Statistic was used to compare the PESI with the BOVA score. A total of 253 patients were evaluated: 95 (38%) with a PESI ≥ IV. Of them, 82 (32%) patients were classified as intermediate–low risk and 171 (68%) as intermediate–high risk. Fifty (20%) patients had at least 1 adverse event. Multivariate analysis demonstrated the PESI to be an independent predictor for the primary outcome (HR 4.81, CI 95%, 1.15–20.09, p = 0.031), which was increased with a concomitant increase of the PESI score (PESI I 4.2%, PESI II 3.4%, PESI III 12%, PESI IV 16.3%, PESI V 23.1%, p for trend

BackgroundWe aimed to describe the characteristics and in-hospital outcomes of ST-segment elevation myocardial infarction (STEMI) patients during the Covid-19 era.MethodsWe conducted a prospective, multicenter study involving 13 intensive cardiac care units, to evaluate consecutive STEMI patients admitted throughout an 8-week period during the Covid-19 outbreak. These patients were compared with consecutive STEMI patients admitted during the corresponding period in 2018 who had been prospectively documented in the Israeli bi-annual National Acute Coronary Syndrome Survey. The primary end-point was defined as a composite of malignant arrhythmia, congestive heart failure, and/or in-hospital mortality. Secondary outcomes included individual components of primary outcome, cardiogenic shock, mechanical complications, electrical complications, re-infarction, stroke, and pericarditis.ResultsThe study cohort comprised 1466 consecutive acute MI patients, of whom 774 (53%) were hospitalized during the Covid-19 outbreak. Overall, 841 patients were diagnosed with STEMI: 424 (50.4%) during the Covid-19 era and 417 (49.6%) during the parallel period in 2018. Although STEMI patients admitted during the Covid-19 period had fewer co-morbidities, they presented with a higher Killip class (p value = .03). The median time from symptom onset to reperfusion was extended from 180 minutes (IQR 122–292) in 2018 to 290 minutes (IQR 161–1080, p < .001) in 2020. Hospitalization during the Covid-19 era was independently associated with an increased risk of the combined endpoint in the multivariable regression model (OR 1.65, 95% CI 1.03–2.68, p value = .04). Furthermore, the rate of mechanical complications was four times higher during the Covid-19 era (95% CI 1.42–14.8, p-value = .02). However, in-hospital mortality remained unchanged (OR 1.73, 95% CI 0.81–3.78, p-value = .16).ConclusionsSTEMI patients admitted during the first wave of Covid-19 outbreak, experienced longer total ischemic time, which was translated into a more severe disease status upon hospital admission, and a higher rate of in-hospital adverse events, compared with parallel period.

Background: Pulmonary embolism (PE) patients with right ventricular (RV) involvement are a heterogenous group who mandate further risk stratification. Our objective was to evaluate the efficacy of the PE severity index (PESI) for predicting adverse clinical outcomes among PE patients with RV involvement. Methods and Results: Consecutive normotensive PE patients with RV involvement were allocated according to admission PESI score (PESI

Background The clinical diagnosis of peri-myocardial infarction pericarditis declined dramatically in the era of primary PCI and novel antiplatelet agents. However, recent data documents the presence of pericardial effusion in substantial proportion of acute MI patients, while recent randomized trial showed that anti-inflammatory drugs seem to improve cardiovascular outcomes, although the mechanism of the benefit remains uncertain. Methods We prospectively evaluated 187 consecutive patients, without known prior coronary disease, who underwent primary PCI for STEMI. All patients underwent cardiac MRI (CMR) on day 5±1 post admission. CMR was performed using a 1.5 T (n=101) and 3 T (n=86) scanners. Delayed enhancement (DE) and microvascular obstruction (MVO) were quantified as % of the left ventricular mass (LV). The presence of DE and MVO was recorded according to the AHA segments model. DE was also qualitatively assessed for the degree of transmurality in each segment. CMR pericarditis was defined as evidence of pericardial enhancement on DE images. The presence of pericardial effusion was also documented. Pericarditis extent was expressed as the number of pericardial segments with increased DE. Major adverse cardiac events were defined as the composite of death, recurrent myocardial infarction, stroke, urgent revascularization and hospitalization due to either heart failure or bleeding during the first year following STEMI. Results Pericardial effusion was found in 94 patients (50%) and enhancement of the pericardium on DE images in 120 patients (65%). In contrary, a clinical diagnosis of peri-myocardial infarction pericarditis was documented and anti-inflammatory therapy was initiated only in three patients (1%). A significant positive correlation was demonstrated between pericardial involvement and either quantitative or qualitative assessment of DE (p Conclusions In contrast to the low rate of clinically diagnosed pericarditis, CMR documented pericardial involvement in more than 65% of STEMI patients. This finding is independently associated with the extent and degree and location of myocardial damage. Funding Acknowledgement Type of funding source: None

The contemporary benefit of routine beta-blocker therapy following myocardial infraction in the absence of heart failure or left ventricular systolic dysfunction is unclear. We investigated the impact of beta-blockers on post myocardial infarction outcome in patients without heart failure or left ventricular systolic dysfunction among patients enrolled in the biennial Acute Coronary Syndrome Israeli Surveys. MACE rates at 30 days and overall mortality at one year were compared among patients discharged on beta-blockers versus not, after multivariate analysis to adjust for baseline differences. Between the years 2000 to 2016, data from 15.211consecutive ACS patients were collected. Of 7,392 patients who met the inclusion criteria, 6007 (79.9%) were discharged on beta-blocker therapy. Prescription of beta-blockers at discharge increased modestly from 32% to 38% over the 16-year period. The 30-day MACE rates were similar in patients on vs. not on beta-blockers at discharge (9.0% and 9.5%, respectively). One year survival did not differ significantly between those on vs. not on beta-blockers (HR 0.8, 95% CI 0.58 to 1.11, p = 0.18).In conclusion, beta-blocker therapy did not affect 30 days MACE or 1-year survival after myocardial infarction in patients without heart failure or reduced ejection fraction.

Intermediate zone troponin elevation is defined as one to five times the upper limit of normal. Approximately half the patients presenting with chest pain to the emergency department have initial intermediate zone troponin.We aimed to investigate the long-term outcome of patients hospitalized with chest pain and intermediate zone troponin elevation.We investigated 8269 patients hospitalized in a tertiary center with chest pain. All patients had serial measurements of troponin during hospitalization. Patients were divided into three groups based on their initial troponin levels: negative troponin (N = 6112), intermediate zone troponin (N = 1329) and positive troponin (N = 828). All patients underwent myocardial perfusion imaging (MPI) as part of the initial evaluation.Mean age of the study population was 68 ± 11, of whom 36% were women. Patients with an intermediate zone troponin were older, more likely to be males, and with significantly more cardiovascular co-morbidities. Multivariate analysis adjusted for age, gender, cardiovascular risk factors, and abnormal MPI result found that patients with intermediate zone troponin had a 70% increased risk of re-hospitalization at 1 year (HR 1.70, 95%CI 1.48-1.96, p-value 0.001) and 5.3 times higher risk of total mortality at 1-year (HR 5.33, 95%CI 3.65-7.78, p-value 0.001). sub-group analysis found that among the intermediate zone troponin group, patients with double intermediate zone troponin had the poorest outcome.Intermediate zone troponin elevation is an independent risk factor associated with adverse outcomes and therefore patients with an initial value in this range should be closely monitored and aggressively managed.

Background: Takotsubo cardiomyopathy affects between 1.7% and 2.2% of patients hospitalized with suspected acute coronary syndromes. Characterized by chest pain, electrocardiogram changes, and transient left ventricular apical wall motion abnormality, it is under-recognized and often misdiagnosed. Objectives: In order to better differentiate between St-segment myocardial infarction and Takotsubo cardiomyopathy, we developed a scoring system. Methods: Of the 82 patients enrolled with Takotsubo cardiomyopathy, 67 had ST-segment elevation on electrocardiogram and were compared with 79 ST-elevation myocardial infarction patients. A multi-variant logistic regression model was used to find factors independently associated with Takotsubo cardiomyopathy. The Platelets and Thrombosis in Sheba (PLATIS)-Takotsubo cardiomyopathy is based on a 10-point scoring system: stressful events (3), females (2), no history of diabetes mellitus (2), estimated left ventricular ejection fraction ≤ 40% on admission echo (1), positive troponin on admission (1), and no smoking (1). Patients with Takotsubo cardiomyopathy were older (66 ± 11 vs 60 ± 11 years, p Results: In a multivariate logistic regression analysis, the average Platelets and Thrombosis in Sheba-Takotsubo cardiomyopathy scoring was significantly higher in Takotsubo cardiomyopathy compared with ST-elevation myocardial infarction patients (8.35 ± 1.7 vs 3.42 ± 1.6, p Conclusion: The Takotsubo cardiomyopathy scoring system is a simple, reliable tool that can assist in diagnosing and differentiating between patients with Takotsubo cardiomyopathy and those with ST-elevation myocardial infarction.