Does the "Obesity Paradox" Have an Expiration Date? A Retrospective Cohort Study.

(1) Background: The "obesity paradox" refers to a protective effect of higher body mass index (BMI) on mortality in acute infectious disease patients. However, the long-term impact of this paradox remains uncertain. (2) Methods: A retrospective study of patients diagnosed with community-acquired acute infectious diseases at Shamir Medical Center, Israel (2010-2020) was conducted. Patients were grouped by BMI: underweight, normal weight, overweight, and obesity classes I-III. Short- and long-term mortality rates were compared across these groups. (3) Results: Of the 25,226 patients, diverse demographics and comorbidities were observed across BMI categories. Short-term (90-day) and long-term (one-year) mortality rates were notably higher in underweight and normal-weight groups compared to others. Specifically, 90-day mortality was 22% and 13.2% for underweight and normal weight respectively, versus 7-9% for others (p < 0.001). Multivariate time series analysis revealed underweight individuals had a significantly higher 5-year mortality risk (HR 1.41 (95% CI 1.27-1.58, p < 0.001)), while overweight and obese categories had a reduced risk (overweight-HR 0.76 (95% CI 0.72-0.80, p < 0.001), obesity class I-HR 0.71 (95% CI 0.66-0.76, p < 0.001), obesity class II-HR 0.77 (95% CI 0.70-0.85, p < 0.001), and obesity class III-HR 0.79 (95% CI 0.67-0.92, p = 0.003)). (4) Conclusions: In this comprehensive study, obesity was independently associated with decreased short- and long-term mortality. These unexpected results prompt further exploration of this counterintuitive phenomenon.

Marital status impact on the outcomes of patients admitted for acute decompensation of heart failure: A retrospective, single-center, analysis.

BACKGROUND: Conflicting evidence exists regarding the association between marital status and outcomes in patients with heart failure (HF). Further, it is not clear whether type of unmarried status (never married, divorced, or widowed) disparities exist in this context. HYPOTHESIS: We hypothesized that marital status will be associated with better outcomes in patients with HF. METHODS: This single-center retrospective study utilized a cohort of 7457 patients admitted with acute decompensated HF (ADHF) between 2007 and 2017. We compared baseline characteristics, clinical indices, and outcomes of these patients grouped by their marital status. Cox regression analysis was used to explore the independency of the association between marital status and long-term outcomes. RESULTS: Married patients accounted for 52% of the population while 37%, 9%, and 2% were widowed, divorced, and never married, respectively. Unmarried patients were older (79.8 ± 11.5 vs. 74.8 ± 11.1 years; p < 0.001), more frequently women (71.4% vs. 33.2%; p < 0.001), and less likely to have traditional cardiovascular comorbidities. Compared with married patients, all-cause mortality incidence was higher in unmarried patients at 30 days (14.7% vs. 11.1%, p < 0.001), 1 year, and 5 years (72.9% vs. 68.4%, p < 0.001). Nonadjusted Kaplan-Meier estimates for 5-year all-cause mortality by sex, demonstrated the best prognosis for married women, and by marital status in unmarried patients, the best prognosis was demonstrated in divorced patients while the worst was recorded in widowed patients. After adjustment for covariates, marital status was not found to be independently associated with ADHF outcomes. CONCLUSIONS: Marital status is not independently associated with outcomes of patients admitted for ADHF. Efforts for outcomes improvement should focus on other, more traditional risk factors.

Physicians and Machine-Learning Algorithm Performance in Predicting Left-Ventricular Systolic Dysfunction from a Standard 12-Lead-Electrocardiogram.

Early detection of left ventricular systolic dysfunction (LVSD) may prompt early care and improve outcomes for asymptomatic patients. Standard 12-lead ECG may be used to predict LVSD. We aimed to compare the performance of Machine Learning Algorithms (MLA) and physicians in predicting LVSD from a standard 12-lead ECG. By utilizing a dataset of 13,820 pairs of ECGs and echocardiography, a deep residual convolutional neural network was trained for predicting LVSD (ejection fraction (EF) < 50%) from ECG. The ECGs of the test set (n = 850) were assessed for LVSD by the MLA and six physicians. The performance was compared using sensitivity, specificity, and C-statistics. The interobserver agreement between the physicians for the prediction of LVSD was moderate (κ = 0.50), with average sensitivity and specificity of 70%. The C-statistic of the MLA was 0.85. Repeating this analysis with LVSD defined as EF < 35% resulted in an improvement in physicians' average sensitivity to 84% but their specificity decreased to 57%. The MLA C-statistic was 0.88 with this threshold. We conclude that although MLA outperformed physicians in predicting LVSD from standard ECG, prior to robust implementation of MLA in ECG machines, physicians should be encouraged to use this approach as a simple and readily available aid for LVSD screening.

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.

Acute myocardial infarction in the Covid-19 era: Incidence, clinical characteristics and in-hospital outcomes-A multicenter registry.

BACKGROUND: We aimed to describe the characteristics and in-hospital outcomes of ST-segment elevation myocardial infarction (STEMI) patients during the Covid-19 era. METHODS: We 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. RESULTS: The 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). CONCLUSIONS: STEMI 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.

The impact of lockdown enforcement during the SARSCoV-2 pandemic on the timing of presentation and early outcomes of patients with ST-elevation myocardial infarction.

INTRODUCTION: Early reports described decreased admissions for acute cardiovascular events during the SarsCoV-2 pandemic. We aimed to explore whether the lockdown enforced during the SARSCoV-2 pandemic in Israel impacted the characteristics of presentation, reperfusion times, and early outcomes of ST-elevation myocardial infarction (STEMI) patients. METHODS: A multicenter prospective cohort comprising all STEMI patients treated by primary percutaneous coronary intervention admitted to four high-volume cardiac centers in Israel during lockdown (20/3/2020-30/4/2020). STEMI patients treated during the same period in 2019 served as controls. RESULTS: The study comprised 243 patients, 107 during the lockdown period of 2020 and 136 during the same period in 2019, with no difference in demographics and clinical characteristics. Patients admitted in 2020 had higher admission and peak troponin levels, had a 2.4 fold greater likelihood of Door-to-balloon times> 90 min (95%CI: 1.2-4.9, p = 0.01) and 3.3 fold greater likelihood of pain-to-balloon times> 12 hours (OR 3.3, 95%CI: 1.3-8.1, p<0.01). They experienced higher rates hemodynamic instability (25.2% vs 14.7%, p = 0.04), longer hospital stay (median, IQR [4, 3-6 Vs 5, 4-6, p = 0.03]), and fewer early (<72 hours) discharge (12.4% Vs 32.4%, p<0.001). CONCLUSIONS: The lockdown imposed during the SARSCoV-2 pandemic was associated with a significant lag in the time to reperfusion of STEMI patients. Measures to improves this metric should be implemented during future lockdowns.

Automated external defibrillator use and outcomes after out-of-hospital cardiac arrest: an Israeli cohort study.

BACKGROUND: Out-of-hospital cardiac arrests (OHCA) are a serious healthcare situation with low survival rates. Application of an automated external defibrillator (AED) by bystanders shortens time to defibrillation and increases survival. In Israel, a regulation ensuring the presence of AED in public places was issued and implemented since 2014. We investigated whether this regulation had an impact on the outcomes of OHCA patients. METHODS: We performed a retrospective, single-center observational study. Included in the cohort were patients who were admitted to the department of intensive care cardiac unit with OHCA. Patients were stratified into two groups according to the year the regulation was introduced: group 1 (2009-2013) and group 2 (2014-2018). RESULTS: A total of 77 patients were included in group 1 and 61 in group 2. The utilization of AED was significantly higher in group 2 compared to group 1 (42% vs. 27%; P = 0.04). Compared to group 1 patients, group 2 had lower 48 h (0% vs. 8%; P = 0.02) and 30-day mortality (28% vs. 42%; P = 0.02). Cognitive damage following recovery was less frequent in group 2 (55% vs. 81%; P = 0.01). CONCLUSION: Deployment of AEDs in public places by mandatory regulations increased utilization for OHCA and may improve outcomes.

Long-term renal outcomes and mortality following renal injury among myocardial infarction patients treated by primary percutaneous intervention.

OBJECTIVES: Limited data are present on persistent renal impairment following acute kidney injury (AKI) among ST elevation myocardial infarction (STEMI) patients undergoing primary percutaneous coronary intervention (PCI). We evaluated the incidence and prognostic implications of acute kidney disease (AKD), defined as reduced kidney function for the duration of between 7 and 90 days after exposure to an AKI initiating event, as well as long-term renal outcomes among STEMI patients undergoing primary PCI who developed AKI. PATIENTS AND METHODS: We retrospectively studied 225 consecutive STEMI patients who developed AKI. Patients were assessed for the occurrence of AKD and long-term renal outcomes on the basis of serum creatinine levels measured at 7 days/hospital discharge and within 90-180 days of renal insult. Mortality was assessed at 90 days and over a period of 1271±903 days (range: 2-2130 days) following the renal insult. RESULTS: Progression to AKD occurred in 81/225 (36%) patients and was associated with higher 90-day (35 vs. 11%, P<0.001) and long-term mortality (35 vs. 17%, P<0.001). Normalization of serum creatinine to a level equal/lower than hospital admission level at more than 90 days from renal insult occurred in 41% of patients with AKD, whereas 59% of these patients showed new/progressed chronic kidney disease. In contrast, only 7% of patients without AKD showed the progression of pre-existing renal disease while, in the rest, the serum creatinine level remained stable. CONCLUSION: Progression to AKD following an acute renal insult in STEMI is frequent and associated with worse survival and adverse long-term renal outcomes.

Trends and predictors of prehospital delay in patients undergoing primary coronary intervention.

OBJECTIVE: Delay in seeking medical care following symptom onset in patients with acute ST-elevation myocardial infarction (STEMI) is related to increased morbidity and mortality. Actual trends of prehospital delays in patients hospitalized with STEMI have not been well characterized. We evaluated trends in the length of time that had elapsed from symptom onset to hospital presentation among STEMI patients admitted to our hospital. PATIENTS AND METHODS: We retrospectively studied 2203 consecutive patients hospitalized for acute STEMI who underwent primary percutaneous coronary intervention (PCI) between January 2008 and December 2016. Information on the delay in time from symptom onset to presentation at hospital was extracted from the patients' medical records. RESULTS: Over the 9-year study period, the median duration of prehospital delay for patients undergoing primary PCI showed significant variations, being maximal between the years 2013 and 2014 (150 vs. 90 min, respectively, P<0.001). A significant increase was found in the proportion of patients with prehospital delay less than 2 h, being maximal between the years 2011 and 2013 (64 vs. 47%, P=0.001). An opposite trend was found for decrease in patients with prehospital delay more than 6 h, being maximal between 2008 and 2015 (32 vs. 23%, P=0.001). Multivariate logistic regression model showed that older age, diabetes, female sex, and first STEMI were associated independently with prehospital delay more than 2 h. CONCLUSION: Prehospital delay periods for patients undergoing primary PCI showed variations over time. More efforts are needed to educate at-risk populations about seeking early medical assistance.

Relation of positive fluid balance to the severity of renal impairment and recovery among ST elevation myocardial infarction complicated by cardiogenic shock.

PURPOSE: We analyzed the relationship between a positive fluid balance and its persistence over time on acute kidney injury (AKI) development, severity and resolution among ST elevation myocardial infarction (STEMI) patients complicated by cardiogenic shock. METHODS: We retrospectively studied the cumulative fluid balance intake and output at 96h following hospital admission in 84 consecutive adult patients with STEMI complicated by cardiogenic shock. The cohort was stratified into two groups, based on the presence or absence of positive fluid balance on day 4. Patients' records were assessed for the development of AKI, AKI severity and recovery. RESULTS: Patients having positive fluid balance were more likely to develop a more severe AKI stage (52% vs. 13%; p<0.001), were less likely to have recovery of their renal function (29% vs. 75%, p=0.001), and demonstrated positive correlation between the amount of fluid accumulated and the rise in serum creatinine (R=0.42, p=0.004). For every 1l increase in positive fluid balance, the adjusted possibility for recovery of renal function decreased by 21% (OR=0.796, 95% CI 0.67-0.93; p=0.006). CONCLUSIONS: A positive fluid balance was strongly associated with higher stage AKI and lower rate of AKI recovery in STEMI complicated by cardiogenic shock.