Elevated Native T1 Values in the Remote Myocardium Supplied by Obstructive Non-Infarct Related Coronary Arteries in Post-STEMI Cardiac Magnetic Resonance.

INTRODUCTION: Native T1 mapping values are elevated in acutely injured myocardium. We sought to study whether native T1 values, in the non-infarct related myocardial territories, might differ when supplied by obstructive or nonobstructive coronary arteries. METHODS: Consecutive patients (N = 60, mean age 59 years) with the first STEMI following primary percutaneous coronary intervention, underwent cardiac magnetic resonance within 5 ± 2 days. A retrospective review of coronary angiography reports classified coronary arteries as infarct-related coronary artery (IRA) and non-IRA. Obstructive coronary artery disease (CAD) was defined as stenosis ≥50%. Native T1 values were presented using a 16-segment AHA model according to the three main coronary territories: left anterior descending (LAD), left circumflex (LCX), and right coronary artery (RCA). RESULTS: The cutoff native T1 value for predicting obstructive non-IRA LAD was 1,309 msec with a sensitivity and specificity of 67% and 82%, respectively (AUC 0.76, 95% CI: 0.57-0.95, p = 0.04). The cutoff native T1 value for predicting obstructive non-IRA RCA was 1,302 msec with a sensitivity and specificity of 83% and 55%, respectively (AUC 0.7, 95% CI: 0.52-0.87, p = 0.05). Logistic regression model adjusted for age and infarct size demonstrated that native T1 was an independent predictor for the obstructive non-IRA LAD (OR 4.65; 1.32-26.96, p = 0.05) and RCA (OR 3.70; 1.44-16.35, p = 0.03). CONCLUSION: Elevated native T1 values are independent predictors of obstructive non-IRA in STEMI patients. These results suggest the presence of concomitant remote myocardial impairment in the non-infarct territories with obstructive CAD.

No correlation between diffuse idiopathic skeletal hyperostosis and coronary artery disease on computed tomography using two different scoring systems.

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 < 0.005) but this association did not persist on multivariate analysis. There was a positive trend toward higher CAD-RADS scores in the DISH group (P = 0.03) but after adjustment for age, male sex, and family history, this tendency was not significant. 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.

PESI score for predicting clinical outcomes in PE patients with right ventricular involvement.

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 < 0.001). C-Statistic analysis for the PESI score yielded an AUC-0.746 (0.637-0.854), p = 0.001, compared to the BOVA score: AUC-0.679 (0.584-0.775), p = 0.011. PESI score was found to predict adverse outcomes among normotensive PE patients with RV involvement.

Outcomes among patients admitted for non-ST-segment myocardial infarction in the pre-pandemic and pandemic COVID-19 era: Israel Nationwide study.

BACKGROUND: Since 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). OBJECTIVE: We 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. METHOD: A 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). RESULTS: There 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 < 0.001]. Nevertheless, the time from hospital admission to reperfusion was similar in both groups. The rate of coronary angiography was also similar in both groups. The in-hospital mortality rate was similar in both the COVID-19 era and the control period groups (2.3% vs. 4.7%, respectively, P = 0.149) as was the 30-day mortality rate (3.7% vs. 5.1%, respectively, P = 0.238). CONCLUSION: In 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.

Peripheral Arterial Disease in Patients With Acute Coronary Syndrome: Results From a Large Real-World Registry.

BACKGROUND: Limited data exist regarding the significance of peripheral arterial disease (PAD) in patients with acute coronary syndrome (ACS). METHODS: 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. RESULTS: PAD patients were older (70±11 vs 63±13; p<0.01), 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%; p<0.001) and revascularisation (80% vs 86%; p<0.001). Patients with PAD were more likely to sustain 30-day MACE (22% vs 14%; p<0.001) and mortality (10% vs 4.4%; p<0.001), 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%; p<0.001). 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. CONCLUSIONS: Acute coronary syndrome with concomitant PAD represents a high-risk subgroup that warrants special attention and a more tailored approach.

The Aspirin Primary Prevention Conundrum.

BACKGROUND: In this review, the authors re-examine the role of aspirin in the primary prevention of cardiovascular disease. They discuss the history of the use of aspirin in primary prevention, the current guidelines, and the recent evidence surrounding aspirin use as primary prevention in special populations such as those with moderate cardiovascular risk, diabetes mellitus, and the elderly.

[PLATELETS FUNCTION IN A DROP OF BLOOD: FLOW CYTOMETRY ANALYSIS COMPARED TO PLATELET AGGREGATION].

INTRODUCTION: Light transmission aggregometry (LTA) is the most commonly used test for the diagnosis of platelet function disorders, but requires large amounts of blood samples and normal platelet count. OBJECTIVES: To compare flow cytometric (FC) platelet function testing to standard LTA in the general population, in patients treated with anti-platelets drugs and in term and preterm neonates. METHODS: Platelet function was assessed with LTA and FC using PAC1 binding and p-selectin expression, as platelet activation markers, in response to agonist activation. A comparison between LTA and FC was performed in a Clopidogrel treated patient, before and after (24 and 72 hours) loading the drug. The platelet activation markers PAC1 and p-selectin, were compared in umbilical cord blood samples of in-term and preterm neonates. RESULTS: ADP-induced platelet aggregation was comparable to p-selectin expression assayed by FC (r=0.79-0.86) as measured before and after Clopidogrel loading. Both tests showed good response to Clopidogrel in 72 hours but not in 24 hours after its loading. Preterm cord blood platelets showed decreased ADP-induced activation in both activation markers: PAC1 and p-selectin, but only p-selectin reached statistical significance. We identified possible platelet activation markers in response to commonly used agonists' stimulation for FC analysis. CONCLUSIONS: FC analysis of platelet function has added value in the diagnosis of impaired platelet function and anti-platelet drug response. Using FC enables us to test platelet function in minimal blood volume and regardless of platelet count. Identification of the unique activation marker for each agonist is prerequisite for FC analysis of platelet function.

Disease management in the treatment of patients with chronic heart failure who have universal access to health care: a randomized controlled trial.

BACKGROUND: The efficacy of disease management programs in improving the outcome of heart failure patients remains uncertain and may vary across health systems. This study explores whether a countrywide disease management program is superior to usual care in reducing adverse health outcomes and improving well-being among community-dwelling adult patients with moderate-to-severe chronic heart failure who have universal access to advanced health-care services and technologies. METHODS: In this multicenter open-label trial, 1,360 patients recruited after hospitalization for heart failure exacerbation (38%) or from the community (62%) were randomly assigned to either disease management or usual care. Disease management, delivered by multi-disciplinary teams, included coordination of care, patient education, monitoring disease symptoms and patient adherence to medication regimen, titration of drug therapy, and home tele-monitoring of body weight, blood pressure and heart rate. Patients assigned to usual care were treated by primary care practitioners and consultant cardiologists. The primary composite endpoint was the time elapsed till first hospital admission for heart failure exacerbation or death from any cause. Secondary endpoints included the number of all hospital admissions, health-related quality of life and depression during follow-up. Intention-to-treat comparisons between treatments were adjusted for baseline patient data and study center. RESULTS: During the follow-up, 388 (56.9%) patients assigned to disease management and 387 (57.1%) assigned to usual care had a primary endpoint event. The median (range) time elapsed until the primary endpoint event or end of study was 2.0 (0-5.0) years among patients assigned to disease management, and 1.8 (0-5.0) years among patients assigned to usual care (adjusted hazard ratio, 0.908; 95% confidence interval, 0.788 to 1.047). Hospital admissions were mostly (70%) unrelated to heart failure. Patients assigned to disease management had a better health-related quality of life and a lower depression score during follow-up. CONCLUSIONS: This comprehensive disease management intervention was not superior to usual care with respect to the primary composite endpoint, but it improved health-related quality of life and depression. A disease-centered approach may not suffice to make a significant impact on hospital admissions and mortality in patients with chronic heart failure who have universal access to health care. CLINICAL TRIAL REGISTRATION: Clinicaltrials.gov identifier: NCT00533013 . Trial registration date: 9 August 2007. Initial protocol release date: 20 September 2007.

The "Burden" of Malignancy in a Tertiary Hospital Intensive Cardiovascular Care Unit.

OBJECTIVES: During the past decade, the most common causes of mortality and morbidity were cardiovascular diseases and malignancies. The aim of the current study was to describe the incidence, course of admission, and short-term (30-day) prognosis of patients with and without malignancy, admitted to a tertiary center intensive cardiovascular care unit (ICCU). METHODS: A prospective observational study of 2,259 patients admitted to the ICCU was conducted between January 2014 and December 2015. Patients with malignancies (n = 256) were divided into 2 groups: those with solid and those with homogenous tumors. RESULTS: The time of diagnosis was categorized into 3 patient groups: recent (<6 months), 59 patients (23%); late (6-24 months), 49 patients (19%), and very late (>24 months), 148 patients (58%). Those with a history of malignancy were older (73 ± 12 vs. 64 ± 15, p < 0.001) and were more likely to be female (p = 0.002). After using a multivariate logistic regression model analysis, no differences were found in therapeutic interventions and clinical outcomes, including major bleeding and acute renal failure, between patients with and without malignancies. CONCLUSIONS: Patients with a malignancy comprised about 10% of the entire ICCU population. While mortality was independently associated with advanced age, renal failure, and a diagnosis of ST-elevation myocardial infarction, malignancy alone was not found to be independently associated with a higher mortality rate at 30 days of follow-up.

Real-World Use of Novel P2Y12 Inhibitors in Patients with Acute Myocardial Infarction: A Treatment Paradox.

OBJECTIVE: To assess the real-world use, clinical outcomes, and adherence to novel P2Y12 inhibitors. METHODS: We evaluated 1,093 consecutive acute myocardial infarction patients undergoing a percutaneous intervention. Patients were derived from a prospective, multicenter, nationwide registry and were followed for 30 days; 381 patients (35%) received clopidogrel, 468 (43%) received prasugrel, and 244 (22%) received ticagrelor. Patients treated with clopidogrel were older and more likely to suffer from chronic renal failure and stroke and/or present with non-ST-elevation myocardial infarction (NSTEMI) (p < 0.01 for all). Independent predictors of undertreatment with novel P2Y12 inhibitors included: older age (OR 0.17; 95% CI 0.1-0.27, p < 0.0001), a prior stroke (OR 0.41; 95% CI 0.2-0.68, p = 0.008), and NSTEMI (OR 0.37; 95% CI 0.26-0.54, p < 0.0001). RESULTS: Novel P2Y12 inhibitors were associated with a lower incidence of cardiovascular events, major bleeding, and/or death (7.6 vs.11%, HR 0.67; 95% CI 0.43-1, p = 0.05). However, after a multivariate analysis this trend was not statistically significant. Patients discharged with ticagrelor versus thienopyridines demonstrated a higher rate of crossover to other P2Y12 inhibitors (11 vs. 5%, p = 0.03). CONCLUSIONS: In a real-world cohort, there was an underutilization of novel P2Y12 inhibitors which was more pronounced in higher-risk subsets that might benefit from novel P2Y12 inhibitors at least as much as other patients.

Evaluation of Patients with Acute Chest Pain Using SPECT Myocardial Perfusion Imaging: Prognostic Implications of Mildly Abnormal Scans.

BACKGROUND: While patients presenting to emergency departments (ER) with chest pain are increasingly managed in chest pain units (CPU) that utilize accelerated diagnostic protocols for risk stratification, such as single-photon emission computed tomography (SPECT) myocardial perfusion imaging (MPI), data are lacking regarding the prognostic implications of mildly abnormal scans in this population. OBJECTIVES: To evaluate the prognostic implications of mildly abnormal SPECT MPI results in patients with acute chest pain. METHODS: Of the 3753 chest pain patients admitted to the CPU at the Leviev Heart Center, Sheba Medical Center 1593 were further evaluated by SPECT MPI. Scans were scored by extent and severity of stress-induced perfusion defects, with 1221 patients classified as normal, 82 with myocardial infarction without ischemia, 236 with mild ischemia, and 54 with more than mild ischemia. Mild ischemia patients were further classified to those who did and did not undergo coronary angiography within 7 days. RESULTS: Mild ischemia patients who underwent coronary angiography were more likely to be male (92% vs. 81%, P = 0.01) and to have left anterior descending ischemia (67% vs. 42%, P = 0.004). After 50 months, these patients returned less often to the ER with chest pain (53% vs. 87%, P < 0.001) and had a lower combined endpoint of acute coronary syndrome and death (8% vs. 16%, P < 0.001). CONCLUSIONS: Compared to patients with chronic stable angina, patients presenting with acute chest pain exhibiting mildly abnormal SPECT MPI findings should perhaps undergo a more aggressive diagnostic and therapeutic approach.

Outcome of contemporary acute coronary syndrome complicated by ventricular tachyarrhythmias.

AIM: To evaluate the incidence and prognostic implications of ventricular tachyarrhythmias (VTAs) complicating acute myocardial infarction (MI). METHODS AND RESULTS: We evaluated 7669 MI patients [ST elevation (n = 3573) and non-ST-elevation acute coronary syndrome (ACS) (n = 4096)] from the Acute Coronary Syndrome Israeli Survey for the incidence of VTA. Ventricular tachyarrhythmia occurred in 3.8% of patients [2.1% early (≤ 48 h) and 1.7% late (>48 h) VTA]. In-hospital mortality rates were higher for patients with VTA when compared with patients with no VTA (P < 0.001). Consistent with these findings, multivariable analysis demonstrated that early and late VTAs were associated with increased risk of in-hospital death [hazard ratio (HR) = 3.84; 95% confidence interval (CI) 1.77-6.78, P < 0.001, and HR = 8.23; 95% CI 4.84-13.98, P < 0.001, respectively]. In contrast, post-discharge outcomes demonstrated that only late VTA was independently associated with a significant increased risk of 30-day mortality (HR = 5.17; 95% CI 1.54-17.27, P = 0.007) with a trend towards an increased 1-year mortality risk (HR = 1.69; 95% CI 0.79-3.62, P = 0.17). The long-term risk associated with in-hospital VTA was driven by sustained ventricular tachycardia (VT) (HR = 3.28; 95% CI 1.92-5.60, P < 0.001) but not ventricular fibrillation (HR = 1.27; 95% CI 0.65-2.49, P = 0.47). CONCLUSIONS: Our findings suggest that in patients with ACS, both early and late VTAs are associated with an increased risk of in-hospital mortality. However, only late VTA, mostly sustained VT, is associated with long-term adverse outcome.

Bypassing the emergency room to reduce door-to-balloon time and improve outcomes of ST elevation myocardial infarction patients: analysis of data from 2004-2010 ACSIS registry.

OBJECTIVES: Our objective was to assess whether bypassing the emergency room (ER) is associated with meaningful reduction in Major Adverse Cardiac and Cerebrovascular Event (MACCE) or mortality in a large cohort of ST Elevation Myocardial Infarction (STEMI) patients. BACKGROUND: Prior studies suggest that bypassing the emergency room reduces door-to-balloon time (DBT). However, it is not clear whether this translates into reduced mortality. METHODS: We analyzed data of 1,552 consecutive patients with STEMI treated by primary percutaneous coronary intervention (PCI) and enrolled in the Acute Coronary Syndrome Israeli Survey (ACSIS) registry. Thirty percent of patients (n = 459) arrived directly to the Intensive Cardiac Care Unit or catheterization laboratory and 70% (n = 1093) were assessed first in the ER. Our primary end points were DBT, 30-day MACCE, and 30-day and 1-year mortality. Our secondary end points were pre-discharge ejection fraction less than 40%, in-hospital pulmonary edema, in-hospital cardiogenic shock, ST resolution, and duration of hospitalization. RESULTS: Bypassing the ER was associated with signficantly shorter DBT (59 vs. 97 minutes, P = 0.001). There was no difference in 30-day MACCE and 30-day or 1-year mortality between the 2 study groups. The findings were consistent in multiple subgroups, including women, anterior STEMI, off hours PCI, and patients with pain-to-door (PDT) time of less than 120 minutes. CONCLUSION: Bypassing the ER is associated with significant shortening of DBT. This reduction, however, is not associated with any change in 30-day MACCE and 30-day or 1-year mortality.

Temporal Trends and Outcomes Associated with Major Bleeding in Acute Coronary Syndromes: A Decade-Long Perspective from the Acute Coronary Syndrome Israeli Surveys 2000-2010.

OBJECTIVES: The implementation of an early invasive approach and the increased use of potent anti-thrombotic drugs have resulted in higher rates of major bleeding events (MBE) in patients with acute coronary syndrome (ACS). There are limited data on the temporal trends for the rates of MBE over the last decade and associated outcomes. METHODS: Rates, characteristics, risk factors and clinical outcomes associated with MBE were assessed among 11,538 patients enrolled in the biennial Acute Coronary Syndrome Israeli Surveys (ACSIS) 2000-2010. RESULTS: A total of 143 patients (1.2%) experienced MBE during the index hospitalization for ACS. There was a significant increase in the risk of MBE in the late (2006-2010) versus the early (2000-2004) surveys (0.9 and 1.6% respectively, adjusted OR 1.86, p < 0.001). In the multivariate analysis, factors independently associated with a significant increase in the risk of MBE included undergoing primary percutaneous coronary intervention (OR 2.21, p < 0.005), experiencing renal failure (OR 4.19, p < 0.001) and systolic blood pressure level at admission (OR 1.12, per 10- mm Hg decrement, p = 0.011). Patients who experienced MBE had a >3.5-fold increased risk for 1-year mortality (adjusted HR = 3.52, p < 0.001). Interestingly, the mortality risk associated with MBE was evident only among those who experienced non-access-site bleeding (HR = 1.9; p = 0.001). CONCLUSIONS: In the past decade, there has been a significant increase in the rate of MBE. However, we found that only major bleeding that was not related to the vascular access site affected subsequent mortality.

Thrombophilic state in young patients with acute myocardial infarction.

The prevalence of thrombophilia and dyslipidemia among young survivors of acute coronary syndrome has not been clearly defined. The purpose of the current study was to investigate the prevalence of multiple markers of thrombophilia and dyslipidemia in a cohort of consecutive young survivors of acute coronary syndrome. The study cohort included 156 consecutive young patients (men <45 and women <50 years), admitted to the intensive cardiac care unit with newly diagnosed acute coronary syndrome. Analysis included baseline, clinical and epidemiological characteristics, angiographic coronary anatomy, echocardiographic evaluation, extensive lipid and thrombophilia laboratory profiles, and in-hospital and 1-year clinical outcomes for all patients. Acute myocardial infarction was diagnosed in 142 (92 %) patients, of whom 108 (72 %) had ST-segment elevation. Eighteen (12 %) patients had no traditional risk factors. Low levels of high-density lipoprotein (<40 mg/dL) were found in 101 (65 %) patients, and 49 (34 %) patients had elevated levels of lipoprotein(a) (Lp(a)) (>30 mg/dL). Eighteen (12 %) patients were diagnosed with antiphospholipid antibody syndrome (APS), and 73 (47 %) had at least one laboratory finding consistent with thrombophilia. Patients with APS had significantly higher levels of Lp(a) (46 ± 32 vs. 29 ± 31 mg/dL, p = 0.005). APS is a common prothrombotic state found in young survivors of acute coronary syndrome. Lp(a) levels are elevated among APS patients who present with premature acute coronary syndrome.

Evaluation of platelet response to different clopidogrel dosing regimens in patients with acute coronary syndrome in clinical practice.

High-post clopidogrel platelet reactivity in acute coronary syndrome (ACS) patients is associated with adverse outcomes and may be related to clopidogrel dosing. Clinical studies evaluating different clopidogrel doses have resulted in conflicting conclusions. Clopidogrel dosing regimens have evolved over time, enabling us to evaluate platelet reactivity in real-life ACS patients undergoing percutaneous coronary intervention and treated with three different clopidogrel doses. Platelet reactivity was assessed with light transmitted aggregometry on the third day post clopidogrel loading in 404 consecutive ACS patients. Of them, 198 were treated with a standard regimen (300 mg loading, 75 mg/day maintenance dose), 95 with a high loading regimen (600 mg loading, 75 mg/day maintenance dose) and 111 with a high loading/high maintenance regimen (600 mg loading, 150 mg/day maintenance). Compared with the standard regimen, the high loading regimen resulted in significantly lower mean platelet reactivity to adenosine diphosphate (ADP) with a lower proportion of patients exhibiting clopidogrel non-responsiveness (11% vs. 28%, p = 0.004). Compared with the high loading regimen, the high loading/high maintenance regimen resulted in significantly lower mean platelet reactivity to ADP, but without a further drop in the number of non-responders (8.1% vs. 11%, p = 0.16). In conclusion, greater overall inhibition can be achieved with higher loading and maintenance doses in ACS patients. However, despite high clopidogrel doses, a sizable proportion of patients remained "resistant" to the effects of clopidogrel.

[A snapshot: the causes of admission and complications to an acute coronary care unit in a tertiary center in Israel].

BACKGROUND: The reasons for admission to the Acute Coronary Care Unit (ACCU) have changed in the past few years. The classical cause of acute coronary syndrome sets aside the causes of acute heart failure and post-procedural complications. There is also a change in the demographic characteristics and co-morbidities of the admitted patients. OBJECTIVES: The aim of this study is to illustrate the current causes of admission and complications during hospitalization in a tertiary center. METHOD: We compiled a computerized prospective registry during the months of January to March 2014. The registry includes the cause of admission, demographic characteristics, co-morbidities, interventions and clinical outcomes. RESULTS: A total of 257 patients were admitted to the ACCU with a calculated sum of 937 hospitalization days. The average age was 67 ± 15; a third of the patients were above the age of 75 and a third were female; 100 patients have presented with other co-morbidities such as COPD, chronic renal failure, CVA or malignancy; and 46% of the patients were admitted due to acute coronary syndrome (ACS). Other causes were acute heart failure, shock and post-procedural complications. The average length of hospitalization was 2.9 ± 1.7 days for ACS patients compared to 4.3 ± 5 days due to other causes. Approximately 25% had developed acute heart failure during their hospital stay; most of them were older with higher rates of co-morbidities. The duration of hospitalization was longer in those patients, 5.5 ± 5 days, compared to 3.2 ± 4 (p < 0.005); 20% of the patients needed mechanical ventilation; 8.3% had acute renal failure; 4.7% acquired infection while hospitalized; 3.1% had major bleeding and 1.9% had arrhythmias. The total mortality rate was 2.3%. Patients who presented with ACS had a mortality rate of 1% compared to patients who were admitted due to heart failure or shock who had a mortality rate of 10.4% in this period. CONCLUSION: We have presented the current trend of admission to the ACCU with a shift from ACS to other cardiac causes such as acute heart failure, shock or peri-procedural complications. The rate of co-morbidities and hospital complications is increasing as the patients' age increases. This shift of patients' characteristics requires a re-examination of the role of the medical staff in this new era. There is a need to increase funding for acquiring new technology, staff education and reinforcing current staff.

Predictors of high-risk angiographic findings in patients with non-ST-segment elevation acute coronary syndrome.

BACKGROUND: Current risk assessment of patients with non-ST-elevation acute coronary syndrome (NSTE-ACS) may fail to identify some patients with severe coronary artery disease (CAD). We aimed to identify predictors of the angiographic extent and severity of CAD in patients with NSTE-ACS undergoing early angiography and to evaluate its impact on prognosis. METHODS: We evaluated 923 patients with NSTE-ACS who underwent coronary angiography. High-risk coronary anatomy (HRCA) was defined as left main disease > 50%, proximal LAD lesion > 70%, or 2- to 3-vessel disease involving the LAD. Clinical characteristics, in-hospital, and 30-day outcome and 1-year mortality were compared between the high-risk (N = 370) and the low-risk groups (N = 553). RESULTS: Proportion of patients with elevated cardiac biomarkers was similar in both groups. The presence of peripheral vascular disease (OR = 1.88, 95% confidence interval [CI] = 1.62-5.80, P < 0.001) and a GRACE score of >140 (OR = 1.88, 95% CI = 1.29-2.75, P < 0.001) were the strongest predictors of HRCA. Patients with HRCA were prone to more complications during hospitalization and at 30 days (11.9% vs. 6%, P < 0.01) and increased 1-year mortality (6.7% vs. 0.9%, P < 0.001). HRCA was the strongest predictor for 30-day MACCE (OR = 2.32, 95% CI = 1.42-3.79, P < 0.001). HRCA (OR = 8.36, 95% CI = 1.01-69.4, P = 0.049; OR = 3.64, 95% CI = 1.2-11.07, P = 0.02) and GRACE score of >140 (OR = 6.86, 95% CI = 1.68-27.9, P = 0.007; OR = 4.84, 95% CI = 1.74-13.5, P = 0.002) were significant predictors of 30-day and 1-year mortality, respectively. CONCLUSIONS: HRCA is predicted by clinical parameters and was not associated with elevated cardiac biomarkers. These patients fared worse when compared with those with low-risk anatomy. We suggest that HRCA predictors should be included in the risk stratification of patients with NSTE-ACS.

Temporal trends in the use of high-dose potent statins following acute coronary syndrome in Israel.

OBJECTIVES: This study aimed to evaluate factors associated with the prescription of high-dose potent statin (HDPS) therapy following hospitalization for acute coronary events. STUDY DESIGN: Sub-analysis was made using the data of 3,525 patients enrolled in the 2008 and 2010 Acute Coronary Syndrome Israeli Surveys (ACSIS). METHODS: Analyses were carried out to identify demographic and clinical factors associated with the prescription of HDPS therapy (atorvastatin 40-80 mg/day or rosuvastatin 20-40 mg/day) at discharge compared with the prescription of lower-dose statins. RESULTS: Among the study patients, 1,387 (39%) were discharged on HDPS, 1,860 (53%) with lower-dose statin regimens and 278 (8%) with no recommendation for statin therapy. Multivariate logistic regression analysis showed that pre-admission usage of HDPS and participation in the more recent (2010) ACSIS survey were independently associated with a higher likelihood of HDPS prescription at discharge from the index event (odds ratio, OR, 21.07, p < 0.001, and 5.61, p < 0.001, respectively), whereas factors independently associated with a lack of HDPS prescription included age >75 years (OR 0.76, p = 0.03), low-density lipoprotein-cholesterol levels <100 mg/dl on admission (OR 0.67, p < 0.001) and a history of heart failure prior to the index hospitalization (OR 0.54, p = 0.0018). The 30-day compliance with the HDPS regimen was 98%. CONCLUSIONS: The findings show increased use of HDPS therapy in acute coronary syndrome (ACS) patients, although this mode of medical therapy is still underutilized in the important subset of high-risk ACS patients.

Prevalence of Cardiac Sarcoidosis in Middle-Aged Adults Diagnosed with High-Grade Atrioventricular Block.

INTRODUCTION: Atrioventricular block may be idiopathic or a secondary manifestation of an underlying systemic disease. Cardiac sarcoidosis is a significant underlying cause of high-grade atrioventricular block, posing diagnostic challenges and significant clinical implications. This study aimed to assess the prevalence and clinical characteristics of cardiac sarcoidosis among younger patients presenting with unexplained high-grade atrioventricular block. METHODS: We evaluated patients aged between 18 and 65 years presenting with unexplained high-grade atrioventricular block, who were systematically referred for cardiac magnetic resonance imaging, positron emission tomography-computed tomography, or both, prior to pacemaker implantation. Subjects with suspected cardiac sarcoidosis based on imaging findings were further referred for tissue biopsy. Cardiac sarcoidosis diagnosis was confirmed based on biopsy results. RESULTS: Overall, 30 patients with high-grade atrioventricular block were included in the analysis. The median age was 56.5 years (interquartile range 53-61.75, years). In 37%, cardiac magnetic resonance imaging, positron emission tomography-computed tomography, or both, were suggestive of cardiac sarcoidosis, and in 33% cardiac sarcoidosis was confirmed by tissue biopsy. Compared with idiopathic high-grade atrioventricular block patients, all cardiac sarcoidosis patients were males (100% vs 60%, P = .029), were more likely to present with heart failure symptoms (50% vs 10%, P = .047), had thicker inter-ventricular septum on echocardiography (12.2 ± 2.7 mm vs 9.45 ± 1.6 mm, P = .002), and were more likely to present with right ventricular dysfunction (33% vs 10%, P = .047). CONCLUSIONS: Cardiac sarcoidosis was confirmed in one-third of patients ≤ 65 years, who presented with unexplained high-grade atrioventricular block. Cardiac sarcoidosis should be highly suspected in such patients, particularly in males who present with heart failure symptoms or exhibit thicker inter-ventricular septum and right ventricular dysfunction on echocardiography.