Modifiers of the Association between E/e' Ratio and Survival among Patients with No Apparent Structural or Functional Cardiac Abnormality.

BACKGROUND: The ratio between early mitral flow wave to early diastolic mitral annulus velocity (E/e' ratio) varies according to age and sex and is associated with mortality in heart failure. We sought to describe the association between E/e' and mortality in patients with no apparent structural or functional cardiac abnormality and explore possible modifiers of this association. METHODS: A retrospective study of 104,315 patients who underwent echocardiographic evaluation during 2009-2021 in the largest tertiary center in Israel. Patients with cancer, ventricular dysfunction, significant valvular or structural heart disease, or evidence of pulmonary hypertension were excluded. RESULTS: The final analysis included 32,836 patients with a median age of 56 (43-66) years, and 13,547 (41%) were female. The median E/e' was 8.3 (6.8-10.3), and 9,306 (28%) had an E/e' >10. During a median follow-up of 5.7 (3.3-8.5) years, 2,396 (7.3%) individuals died. E/e' >10 was associated with mortality (adjusted hazard ratio [HR] 1.16, 95% confidence interval [CI] 1.07-1.27, p<0.001). The mortality risk associated with E/e' >10 was significantly higher in those aged ≤70 (HR 1.26, 95% CI 1.12-1.42, p<0.001), males (HR 1.34, 95% CI 1.19-1.49, p<0.001), a normal left ventricular mass (HR 1.13, 95% CI 1.02-1.24, p = 0.017), and pulmonary artery pressure <30 mmHg (HR 1.18, 95% CI 1.06-1.30, p = 0.003). CONCLUSION: An elevated E/e' is associated with mortality, specifically in younger individuals, males, and those with a normal left ventricular mass and lower pulmonary artery pressure. This suggests that an elevated E/e' might be a marker of subclinical risk in these subgroups. Further studies are needed to identify whether an elevated E/e' is useful in shared decision-making regarding the management of cardiovascular risk factors.

Association of Shock Index with Echocardiographic Parameters in Cardiac Intensive Care Unit.

BACKGROUND: A high shock index (SI), the ratio of heart rate (HR) to systolic blood pressure (SBP), has been associated with unfavorable outcomes. We sought to determine the hemodynamic underpinnings of an elevated SI using 2-D and doppler Transthoracic Echocardiography (TTE) in unselected cardiac intensive care unit (CICU) patients. METHODS: We included Mayo Clinic CICU admissions from 2007 to 2018 who were in sinus rhythm at the time of TTE. The SI was calculated using HR and SBP at the time of TTE. Patients were grouped according to SI: <0.7, 4012 (64%); 0.7-0.99, 1764 (28%); and ≥ 1.0, 513 (8%). Pearson's correlation coefficient was used to assess associations between continuous variables. RESULTS: We included 6289 unique CICU patients, 58% of whom had acute coronary syndrome. The median age was 67.9 years old and 37.8% were females. The mean SI was 0.67 BPM/mmHg. As the SI increased, markers of left ventricular (LV) systolic function and forward flow decreased, including left ventricular ejection fraction (LVEF), fractional shortening, left ventricular outflow tract (LVOT) velocity time integral (VTI), stroke volume, LV stroke work index, and cardiac power output. Biventricular filling pressures increased, and markers of right ventricular function worsened with rising SI. Most TTE measurements reflecting LV function and forward flow were inversely correlated with SI, including LV stroke work index (r = -0.59) and LVOT VTI (r = -0.41), as were both systemic vascular resistance index (r = -0.43) and LVEF (r = -0.23). CONCLUSION: CICU patients with elevated SI have worse biventricular function and systemic hemodynamics, particularly decreased stroke volume and related calculated TTE parameters. The SI is an easily available marker that can be used to identify CICU patients with unfavorable hemodynamics who may require further assessment.

Significance of Anteroseptal Late Gadolinium Enhancement Among Patients With Acute Myocarditis.

Anteroseptal location of late gadolinium enhancement (LGE) in patients with acute myocarditis (AM) detected by cardiovascular magnetic resonance may indicate an independent marker of unfavorable outcomes according to recent data. We aimed to evaluate the clinical characteristics, management, and inhospital outcomes in patients with AM with positive LGE based on its presence in the anteroseptal location. We analyzed data from 262 consecutive patients hospitalized with a diagnosis of AM with positive LGE within 5 days of hospitalization (n = 425). Patients were divided into 2 groups: those with anteroseptal LGE (n = 25, 9.5%) and those with non-anteroseptal LGE (n = 237, 90.5%). Except for age that was higher in patients with anteroseptal LGE, the demographic and clinical characteristics did not differ significantly between both groups including past medical history, clinical presentation, electrocardiogram parameters, and lab values. Moreover, patients with anteroseptal LGE were more likely to present with reduced left ventricular ejection fraction and to receive congestive heart failure treatments. Although univariate analysis showed that patients with anteroseptal LGE were more likely to have inhospital major adverse cardiac events (28% vs 9%, p = 0.003), there was no difference inhospital outcomes on multivariable analysis between both groups (hazard ratio, 1.17 [95% confidence interval, 0.32 to 4.22], p = 0.81). A higher left ventricular ejection fraction in either echocardiography or cardiovascular magnetic resonance corresponded to better inhospital outcomes regardless of the presence or absence of anteroseptal LGE. In conclusion, the presence of anteroseptal LGE did not confer additional prognostic value for inhospital outcomes.

The Association between Marital Status and Outcomes of Patients Hospitalized with Heart Failure.

BACKGROUND: Little is known about the association between marital status and long-term outcomes of patients hospitalized with heart failure (HF). We aimed to examine the association between marital status and early as well as long-term outcomes of patients hospitalized with HF. METHOD: We analyzed data of 4089 patients hospitalized with HF and were enrolled in the multicenter national survey in Israel between March and April 2003 and were followed until December 2014. Patients were classified into married (N = 2462, 60%) and unmarried (N = 1627, 40%). RESULTS: Married patients were more likely to be males, younger, and more likely to have past myocardial infarction and previous revascularization. Also, they tended to have higher rates of diabetes mellitus (DM) and dyslipidemia, as well as smokers. Survival analysis showed that unmarried patients had higher mortality rates at 1 and 10 years (33% vs. 25%, at 1 year, 89% vs. 80% at 10 years, all p < 0.001). Consistently, multivariable analysis showed that unmarried patients had independently 44% and 35% higher risk of mortality at 1- and 10-year follow-up respectively (1-year HR = 1.44; 95%CI 1.14-1.81; p = 0.002, 10-year HR = 1.35; 95%CI 1.19-1.53; p ≤ 0.001). Other consistent predictors of mortality at both 1- and 10-year follow-up include age, renal failure, and advanced HF. CONCLUSIONS: Being unmarried is independently associated with worse short- and long-term outcomes, particularly among women. Thus, attempts to intensify secondary preventive measures should focus mainly on unmarried patients and mainly women.

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.

Characterization of heart failure patients with reverse left ventricular remodelling post-angiotensin receptor blockers/neprilysin inhibitors therapy.

AIMS: To assess the effect of angiotensin receptor blockers/neprilysin inhibitors (ARNI) on left ventricular (LV) ejection fraction (LVEF) and LV dimensions in a real-life cohort of heart failure and reduced ejection fraction (HFrEF) patients, while analysing patient characteristics that may predict reverse LV remodelling. METHODS AND RESULTS: The ARNI-treated HFrEF patients followed at a single tertiary medical centre HF-outpatient clinic were included in the study. Clinical and echocardiographic parameters were evaluated prior to ARNI initiation, and while on ARNI therapy, assessing patient characteristics associated with reverse LV remodelling. The cohort included 91 patients (mean age 60.5 years, 90% male) and 47 (52%) patients exhibited ARNI responsiveness, defined as an increase in LVEF during therapy. Overall, LVEF increased by 19% post-ARNI (23.8 to 28.4%, P < 0.001). Subgroup analysis revealed several parameters associated with significant LVEF improvement, including baseline LVEF <30%, non-ischaemic HF aetiology, lack of cardiac resynchronization therapy (CRT), better initial functional class and ARNI initiation within 3 years from HF diagnosis (P ≤ 0.001 for all). Significant reduction in LV dimensions was noted in patients with lower initial LVEF, non-ischaemic HF and no CRT. Further combined subgrouping of the study population demonstrated that patients with both LVEF <30% and a non-ischaemic HF gained most benefit from ARNI with an average of 51% improvement in LVEF (19.9 to 30%, P < 0.001). CONCLUSIONS: The ARNI treatment response is not uniform among HFrEF patient subgroups. More pronounce reverse LV remodelling is associated with early ARNI treatment initiation in the course of HFrEF, and in those with LVEF <30%, non-ischaemic HF and no CRT.

Post-ST-Segment-Elevation Myocardial Infarction Platelet Reactivity Is Associated With the Extent of Microvascular Obstruction and Infarct Size as Determined by Cardiac Magnetic Resonance Imaging.

Background Despite optimized medical management and techniques of primary percutaneous coronary intervention, a substantial proportion of patients with ST-segment-elevation myocardial infarction (STEMI) display significant microvascular damage. Thrombotic microvascular obstruction (MVO) has been implicated in the pathogenesis of microvascular and subsequent myocardial damage attributed to distal embolization and microvascular platelet plugging. However, there are only scarce data regarding the effect of platelet reactivity on MVO. Methods and Results We prospectively evaluated 105 patients in 2 distinct periods (2012-2013 and 2016-2018) who presented with first ST-segment-elevation myocardial infarction and underwent primary percutaneous coronary intervention. All patients were treated with dual antiplatelet therapy (DAPT). Blood samples were analyzed for platelet reactivity, and cardiac magnetic resonance imaging scans were evaluated for late gadolinium enhancement and MVO. DAPT suboptimal response was defined as hyporesponsiveness to either aspirin or P2Y12 receptor inhibitor agents and demonstrated in 31 patients (29.5%) of the current cohort. Suboptimal platelet response to DAPT was associated with a significantly greater extent of MVO when expressed as a percentage of the left ventricular mass, left ventricular scar, and the number of myocardial left ventricular segments showing MVO (P<0.01 for each). Adjusted multivariable logistic regression model revealed that suboptimal response to DAPT is significantly associated with both greater late gadolinium enhancement (P<0.01) and MVO extent (odds ratio, 3.7 [95% CI, 1.3-10.5]; P=0.01). Patients with a greater extent of MVO were more likely to sustain major adverse cardiovascular events at a 1-year follow-up (37% versus 11%; P<0.01). Conclusions In patients undergoing primary percutaneous coronary intervention for ST-segment-elevation myocardial infarction, platelet reactivity in response to DAPT is a key predictor of the extent of both myocardial and microvascular damage.

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.

Ethnic Disparity in Mortality Among Ischemic Heart Disease Patients. A-20 Years Outcome Study From Israel.

Background: Long-term morbidity and mortality data among ischemic heart disease (IHD) patients of different ethnicities are conflicting. We sought to determine the independent association of ethnicity and all-cause mortality over two decades of follow-up of Israeli patients. Methods: Our study comprised 15,524 patients including 958 (6%) Arab patients who had been previously enrolled in the Bezafibrate Infarction Prevention (BIP) registry between February 1, 1990, and October 31, 1992, and subsequently followed-up for long-term mortality. We compared clinical characteristics and outcomes of Israeli Arabs and Jews. Propensity score matching (PSM) (1:2 ratios) was used for validation. Results: Arab patients were significantly younger (56 ± 7 years vs. 60 ± 7 years; p < 0.001; respectively), and had more cardiovascular disease (CVD) risk factors. Kaplan-Meier survival analysis showed that all-cause mortality was significantly higher among Arab patients (67 vs. 61%; log-rank p < 0.001). Multivariate adjusted analysis showed that mortality risk was 49% greater (HR 1.49; 95% CI: 1.37-1.62; p < 0.001) among Arabs. Conclusions: Arab ethnicity is independently associated with an increased 20-year all-cause mortality among patients with established IHD.

CHADS2 and CHA2DS2-VASc scores as predictors of platelet reactivity in acute coronary syndrome.

BACKGROUND: Platelet function testing (PFT) in patients treated with P2Y12 inhibitors has been widely evaluated for the prediction of stent thrombosis, myocardial infarction, and bleeding events following percutaneous coronary intervention (PCI) in acute coronary syndrome (ACS). Thus, PFT-guided treatment could positively affect patient outcomes. Data regarding clinical parameters for predicting platelet reactivity in ACS patients are limited. Therefore, our study aims to evaluate CHADS2 and CHA2DS2-VASc scores as predictors for platelet reactivity in ACS patients. METHODS: Two hundred and ninety-one consecutive patients who underwent PCI and were treated with aspirin and clopidogrel due to ACS were tested for their CHADS2, CHA2DS2-VASc scores and platelet reactivity using adenosine diphosphate (ADP)-induced aggregation (conventional aggregometry). Patients were classified into groups according to their CHADS2 and CHA2DS2-VASc scores. Low-risk group (0-1 score) for CHADS2 and CHA2DS2-VASc scores and high-risk group (2-6, 2-9) for CHADS2 and CHA2DS2-VASc scores, respectively. Furthermore, platelet reactivity in each group were compared (low CHADS2 group vs high CHADS2 group, and low CHA2DS2-VASc vs high CHA2DS2-VASc). Platelet reactivity was defined as low platelet reactivity (<19 U), optimal platelet reactivity [(OPR); 19-46 U], and high on-treatment platelet reactivity [(HPR); >46 U]. Thereafter receiver operating characteristic curve analysis was conducted to verify whether CHADS2 and CHA2DS2-VASc scores could predict platelet reactivity. RESULTS: Low CHADS2 and CHA2DS2-VASc scores were significantly correlated with lower mean platelet ADP-induced aggregation as compared with high CHADS2 and CHA2DS2-VASc scores [45.5 U (± 16) vs. 54.8 U (±15) and 44.2 U (±16) vs. 51.0 U (±17), respectively, p = 0.01 for both]. CONCLUSION: In ACS patients treated with clopidogrel following PCI, high CHADS2 and CHA2DS2-VASc scores correlated with HPR and lower scores correlated with OPR. Further studies are needed to evaluate our findings' clinical implications.

Female gender is associated with a worse prognosis amongst patients hospitalised for de-novo acute heart failure.

BACKGROUND: Recent evidence showed that new-onset (de-novo) acute heart failure (AHF) is a distinct type of AHF. However, the prognostic implication of gender on these patients remains unclear. AIMS: We aimed to investigate the impact of gender on both short and long-term mortality outcomes after hospitalisation for de-novo AHF. METHODS: We analysed the data of 721 patients with de-novo AHF, who were enrolled in the HF survey in Israel between March and April 2003 and were followed until December 2014. RESULTS: Fifty-four percent (N = 387) of the patients were men. In comparison to women, men patients were more likely to be younger, smokers, and with ischemic HF aetiology. At 30 days, mortality rates were higher in women (12% vs 7%, P = .013). Survival analysis showed that at 1 and 10 years the all-cause mortality rates were significantly higher in women (28% vs 17%, and 78% vs 67%, 1 and 10 years, P < .001, respectively). Consistently, multivariable analysis showed that women had an independently 82% and 24% higher mortality risk at 1 and 10 years, respectively, (1-year hazard ratio = 1.82; 95% confidence interval = 1.07 to 3.11, P = .03; 10-year hazard ratio = 1.24; 95% confidence interval = 1.03 to 1.48, P = .02). CONCLUSIONS: Amongst patients with de-novo AHF, women had higher mortality rates compared with men. The observed gender-related differences in de-novo AHF patients highlight the need for further and deeper research in this field.

Sex Differences in Clinical Characteristics and 1- and 10-Year Mortality Among Patients Hospitalized With Acute Heart Failure.

BACKGROUND: The impact of sex on mortality in patients with acute heart failure (AHF) is unresolved. We aimed to investigate the impact of sex on both short- and long-term mortality outcomes after hospitalization for AHF. METHODS: We analyzed data of 2,328 patients with AHF who were enrolled in the multicenter national survey in Israel between March and April 2003 and followed up until December 2014. RESULTS: Women comprised 45% of the study population. In comparison with men, women were older, had higher rates of heart failure with preserved ejection fraction as well as hypertensive heart disease and had a lower rate of coronary artery disease (all P < 0.001). Survival analysis showed that at 1 year the rate of all-cause mortality was 31% among women compared to 28% among men (P = 0.19). At 10-year follow-up mortality rates were significantly higher among women compared to men (87% vs. 83%, P = 0.048). However, this sex association disappeared once multivariable analysis was carried out, (hazard ratio [HR] = 0.93; CI = 0.79-1.09, P = 0.36). Renal dysfunction, older age and severe heart failure were consistent independent predictors of mortality among men and women. Hyponatremia was a prognostic predictor only among men, whereas digoxin use predicted mortality only among women. CONCLUSIONS: There are important differences in the clinical characteristics between women and men hospitalized with AHF. There were no significant differences in both short- and long-term mortality following multivariable analysis. Although, most independent predictors of mortality were consistent among both sexes, few sex-based differences in prognostic predictors were identified.

Sex-Based Differences in Characteristics and In-Hospital Outcomes among Patients With Diagnosed Acute Myocarditis.

Data are scarce regarding sex differences among patients with acute myocarditis (AM). Our aim was to define the sex differences in clinical characteristics as well as in-hospital outcomes in a cohort of consecutive patients hospitalized due to AM. We analyzed data of 322 consecutive patients from January 2005 to December 2017 who were hospitalized with the diagnosis of AM. Eighty-four percent (N = 272) of the patients were males. When compared to females, male patients were younger (36 ± 14 vs 45 ± 17 years, p <0.001), more likely to present with ST segment elevation (75% vs 44%. p <0.001) as well as PR depression upon ECG, and have higher admission troponin levels (7.6 ± 11 vs 2.3 ± 4 µg/L, p <0.001). Moreover, males were more likely to have late gadolinium enhancement upon cardiac magnetic resonance. While male patients were more likely to have ventricular arrhythmias during hospitalization (7% vs 0%, p = 0.05), there were no differences in the incidence of in-hospital mortality or the need for escalation therapy during hospitalization between both groups. There were no episodes of mortality upon all patients among a follow-up of 1 year. In conclusion, male patients, which constitute the majority of patients admitted with AM were younger, more likely to present with ST elevation, had higher troponin levels at admission, and had a higher rate of ventricular arrhythmias compared to females. There were no differences in post-discharge mortality rates between males and females.

Epidemiology Characteristics and Outcome of Patients With Clinically Diagnosed Acute Myocarditis.

BACKGROUND: There are controversial data regarding the outcome and management of patients hospitalized with clinically diagnosed acute myocarditis. METHODS: 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 LVEF <50% (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. RESULTS: 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 LVEF <50% 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, P <0.001, for peak troponin). Univariate analysis showed that patients with an LVEF <50% 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%], P <0.001). Consistently, multivariable analysis showed that patients with an LVEF <50% 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; P <0.001). CONCLUSIONS: Patients with clinical acute myocarditis seem to have an overall good prognosis. Although patients with an LVEF <50% 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.

Differences in Mortality of New-Onset (De-Novo) Acute Heart Failure Versus Acute Decompensated Chronic Heart Failure.

Minimal attention has been paid to understanding the implications of the chronicity of heart failure (HF) diagnosis on prognosis of hospitalized patients with acute HF (AHF). We aimed to assess the differences in outcomes between hospitalized patients with AHF that are new-onset (de-novo) AHF and acutely decompensated chronic HF (ADCHF). We analyzed data of 2,328 patients with AHF, who were enrolled in the HF survey in Israel. Patients were classified into de-novo AHF and ADCHF. A total of 721 (31%) patients were classified as de-novo AHF and 1,607 (69%) patients were classified as ADCHF. Patients with de-novo AHF were more likely to be younger, with fewer co-morbidities represented by lower Charlson index, and less likely to have past myocardial infarction as well as coronary revascularization. At 30 days mortality rates were similar in both groups (9% vs 8% in de-novo AHF and ADCHF, respectively). Survival analysis showed that at 1 and 10 years the all-cause mortality rates were significantly higher in patients with ADCHF (33% vs 22% and 90% vs 72%, 1 and 10 years, log-rank p < 0.001, respectively). Consistently, multivariable analysis showed that patients with ADCHF had an independently 58% and 48%, higher mortality risk at 1 and 10 years, respectively, (1-year hazard ratio = 1.58; 95% confidence interval 1.05 to 2.38, p = 0.03; 10-year hazard ratio = 1.48; 95% confidence interval = 1.23 to 2.77; p < 0.001). In conclusion, previous history of HF is an independent predictor of 1-year and 10-year mortality after hospitalization for AHF. Distinction between de-novo AHF and ADCHF may improve our understanding and risk stratification of patients with AHF.

Ethnic disparity in Israel impacts long-term results after heart transplantation.

BACKGROUND: Ethnicity may affect graft longevity and recipient mortality after heart transplantation (HTx). We hypothesized that differences in ethnic origin between Arabs and Jews undergoing HTx in Israel may contribute to differences in long-term outcomes. METHODS: The study population comprised all 254 patients who underwent HTx between 1991 and 2017 in a tertiary medical center located in the center of Israel. Patients were categorized as either Jews (226 patients, 89%) or Arabs (28 patients, 11%). The primary end point was cardiac allograft vasculopathy (CAV), secondary end points were cardiovascular (CV) mortality and the combined end point of CAV/CV mortality. RESULTS: In comparison with Jews, Arab patients were significantly younger (ave. age 42 vs. 50) and had shorter in-hospital stay (45 vs. 80 days). However, Kaplan-Meier survival analysis showed that at 10 years of follow-up CAV rates were significantly higher among Arabs (58%) compared with Jews (23%; log-rank P = 0.01) for the overall difference during follow-up. Similar results were shown for the separate end point of CV mortality and the combined end point of CAV/CV mortality. Multivariate analysis, which controlled for age, gender, statin treatment, and other potential confounders, showed that Arab recipient ethnic origin was associated with a significant > 2.5-fold (p = 0.01) increase in the risk for CAV; a > 4-fold increase in the risk for CV mortality (p = 0.001); and approximately 4-fold increase in the risk for the combined end point (p = 0.001). These findings were validated by propensity score analysis. CONCLUSIONS: Our data suggest that Arab ethnic origin is associated with a significantly increased risk for CAV and mortality following HTx. Suggested explanations contributing to ethnic disparities in Israel include socioeconomic, environmental and genetic factors. Further studies are required to evaluate whether more aggressive risk factor management in the Israeli Arab population following HTx would reduce CAV and CV mortality in this high-risk population. Increased awareness and early intervention of the Israeli healthcare system and cooperation with the Arab community is of paramount importance.

The Association of Body Mass Index and 20-Year All-Cause Mortality Among Patients With Stable Coronary Artery Disease.

BACKGROUND: Limited data exist regarding the long-term association of body mass index (BMI) and all-cause mortality among patients with stable coronary artery disease (CAD). Accordingly, the aim of this study is to explore the association between BMI and long-term all-cause mortality among patients with stable CAD. METHODS: Our study included 15,357 patients with stable CAD who were enrolled in the Bezafibrate Infarction Prevention (BIP) registry between February, 1990 and October1992, and subsequently followed-up through December 2014. RESULTS: 5,051 (33%) patients were classified as normal weight (BMI 18.5-24.99kg/m2), while 7,841 (51%) patients were classified as overweight (BMI 25-29.99kg/m2), and 2,465 (16%) as obese (BMI≥30). Kaplan-Meier survival analysis showed that at 20 years of follow-up the rate of all-cause mortality was significantly higher among obese patients (67%) compared to overweight (61%) and normal weight (61%); log rank p-value for the overall difference <0.001. Multivariable analysis showed that obese patients had an independently 12% greater mortality risk compared to normal weight patients (HR=1.12; 95% CI 1.02-1.23; p=0.02), whereas, overweight patients experienced a similar mortality risk as normal weight patients (HR=0.99; 95% CI 0.92-1.06; p=0.76). The mortality risk associated with obesity was pronounced among patients younger than 65 years (p-value for interaction<0.05). CONCLUSIONS: Our findings indicate that obesity is independently associated with increased risk for long-term mortality among patients with stable coronary artery disease, whereas overweight does not appear to confer an additional risk in this population.

Sub-acute vs. Late-onset Presentation of Oncotherapy Related Cardiotoxicity: Predictors of Cardiac Function Recovery and Long-Term Outcome.

BACKGROUND: Cardiac damage caused by oncological therapy may manifest early or many years after the exposure. OBJECTIVES: To determine the differences between sub-acute and late-onset cardiotoxicity in left ventricular ejection fraction (LVEF) recovery as well as long-term prognosis. METHODS: We studied 91 patients diagnosed with impaired systolic function and previous exposure to oncological therapy. The study population was divided according to sub-acute (from 2 weeks to ≤ 1 year) and late-onset (> 1 year) presentation cardiotoxicity. Recovery of LVEF of at least 50% was defined as the primary end point and total mortality was the secondary end point. RESULTS: Fifty-three (58%) patients were classified as sub-acute, while 38 (42%) were defined as late-onset cardiotoxicity. Baseline clinical characteristics were similar in the two groups. The mean LVEF at presentation was significantly lower among patients in the late-onset vs. sub-acute group (28% vs. 37%, respectively, P < 0.001). Independent predictors of LVEF recovery were trastuzumab therapy and a higher baseline LVEF. Although long-term mortality rates were similar in the groups with sub-acute and late-onset cardiotoxicity, improvement of LVEF was independently associated with reduced mortality. CONCLUSIONS: Our findings suggest that early detection and treatment of oncological cardiotoxicity play an important role in LVEF recovery and long-term prognosis.

Donor-recipient ethnic mismatching impacts short- and long-term results of heart transplantation.

BACKGROUND: The impact of donor-recipient ethnic matching on heart transplantation (HT) has been poorly studied with inconclusive results. We aimed to investigate the impact of ethnic matching on HT outcomes in Israeli multiethnic patients. METHODS: The study comprised 168 patients who underwent HT from 1990-2017. Patients and their donors were ethnically categorized to Jews and Arabs. Primary end points were all-cause in-hospital and late mortality; secondary end points included primary graft dysfunction (PGD), rejections, and vasculopathy. RESULTS: Donor-recipient ethnic matching was found in 111 patients, while 57 were ethnically mismatched. Baseline characteristics were similar in both groups. Ethnic mismatching was associated with >7-fold (P = 0.018) increased risk for in-hospital mortality and >8-fold (P < 0.001) increased risk for PGD. Kaplan-Meier survival analysis showed that overall survival at 10 years was significantly higher among matched patients (73% vs 43%, log-rank P < 0.001). Multivariate analysis showed that ethnic mismatching was associated with an approximately fourfold higher risk for death (P < 0.01). These findings were validated by propensity score analysis. The ethnic mismatched group experienced significantly higher rejection rates compared with the matched group with lower survival free of rejections (log-rank P = 0.029). No differences in vasculopathy were found. CONCLUSIONS: Donor-recipient ethnic mismatch is an important independent predictor of early- and long-term outcomes following HT, and is associated with increased risk for PGD, rejections, and mortality. These findings will help to design tailored treatment protocols leading to improved outcomes after HT.

Early Referral to Coronary Artery Bypass Grafting Following Acute Coronary Syndrome, Trends and Outcomes from the Acute Coronary Syndrome Israeli Survey (ACSIS) 2000-2010.

BACKGROUND: Limited information exists on whether changes in medical practices over the study decades have affected the outcomes of acute coronary syndrome (ACS) patients who undergo early coronary artery bypass surgery (CABG) during index hospitalisation. METHODS: Data on trends for early CABG referral and associated outcomes were obtained among 11,485 ACS patients enrolled in the biennial Acute Coronary Syndrome Israeli Surveys (ACSIS) 2000-2010. RESULTS: Among 11,485 patients, 566 (5%) were referred to early CABG. These patients displayed higher risk characteristics, including Killip class >II, anterior myocardial infarction, greater left ventricular dysfunction, and more frequent use of mechanical ventilation and intra-aortic balloon pump (all p<0.01). Nevertheless, mortality rates of patients referred to early CABG vs. treated with percutaneous coronary intervention (PCI) or medically, was similar (11.4% vs. 10.2%; log-rank p-value=0.40). There was a significant decline in the referral trend over the study decade (6.7% - 1.7%; p<0.001). One year survival was similar between patients referred to early CABG during the late (years: 2006-2010) vs. early (years: 2000-2005) period (85.7% vs. 90%; log-rank p-value=0.15), whereas, among patients who didn't undergo early CABG, and underwent percutaneous coronary intervention (PCI) or medical management only, enrolment during the late periods was associated with a significant survival benefit (91.5% vs. 88.1%; log-rank p-value<0.001). CONCLUSIONS: Over the study decade there was a significant decline in referral for early CABG, without a difference in the one-year mortality between the early and non-early CABG group.