Amir Sandach

Predictors of long-term (4-year) mortality in elderly and young patients with acute heart failure.

The present study was designed to identify and compare predictors of short‐ and long‐term mortality in elderly and young patients hospitalized with acute heart failure (HF).

Aspirin, Warfarin and a Thienopyridine for Acute Coronary Syndromes

Background: Although clopidogrel and aspirin (dual therapy, DT) are used for acute coronary syndrome (ACS), sometimes treatment with warfarin (triple therapy, TT) is required. Aim: To determine the incidence, complications, and outcomes of TT. Methods: We analyzed Israeli surveys of ACS from 2000 to 2004. Results: In these surveys, 5,706 (96%) were discharged alive from hospital. Post-ACS TT and DT were 76 patients (1.3%) and 2,661 patients (46.7%), respectively. The TT group was older with more prior cardiac disease. During hospitalization, the TT patients received more intravenous anticoagulant and antithrombotic agents, and had more heart failure, arrhythmias, ischemia, and major bleeding (2.6 vs. 0.6%, p = 0.03). There were no differences in adjusted 30-day and 6-month mortality between the 2 groups. Conclusion: TT is feasible among ACS patients who require concomitant warfarin treatment.

Prevalence and significance of unrecognized renal insufficiency in patients with heart failure

AIMS Renal insufficiency (RI) is a strong predictor of adverse outcome in patients with heart failure (HF). We aimed to determine the prevalence of RI being unrecognized and its significance in patients hospitalized with HF. METHODS AND RESULTS We analysed data from a prospective survey of 4102 hospitalized patients with HF. RI [defined as estimated glomerular filtration rate (eGFR) <60 mL/min/1.73 m2] was present in 2145 (57%) patients but, based on medical records, was unrecognized in 872 [41%, 95% confidence interval (CI) 39-43%] of them. Patients with unrecognized RI were more likely to be women, elderly, and with better functional class, compared with patients with recognized RI. In-hospital and 1 year mortality was significantly higher among patients with recognized and unrecognized RI compared with patients without RI: 6.5 and 7.1 vs. 2.1%, and 38.8 and 30.9 vs. 18.8% (P < 0.001), respectively. After adjustment, recognized and unrecognized RI comparably predicted increased in-hospital mortality: odds ratio (OR) and 95% CI of 2.34 (1.43-3.87), P < 0.001, and 2.30 (1.45-3.72), P < 0.001. After 1 year, recognized RI remained an independent predictor for mortality: OR 1.79 (1.45-2.20), P < 0.001, whereas there was a trend for increased mortality predicted by unrecognized RI: OR 1.22 (0.97-1.53), P = 0.08. CONCLUSION A high proportion of RI remains unrecognized among hospitalized patients with HF. As co-morbid RI has important prognostic and therapeutic implications, patients with HF may benefit from routine assessment of GFR.

Relation of Bundle Branch Block to Long-Term (Four-Year) Mortality in Hospitalized Patients With Systolic Heart Failure

There is controversy regarding type of bundle branch block (BBB) that is associated with increased mortality risk in patients with heart failure (HF). The present study was designed to explore the association between BBB pattern and long-term mortality in hospitalized patients with systolic HF. Risk of 4-year all-cause mortality was assessed in 1,888 hospitalized patients with systolic HF (left ventricular ejection function <50%) without a pacemaker in a prospective national survey. Cox proportional hazards regression modeling was used to compare mortality risk in patients with right BBB (RBBB; 10%), left BBB (LBBB; 14%), and no BBB (76%) on admission electrocardiogram. At 4 years of follow up, mortality rates were highest in patients with RBBB (69%), intermediate in those with LBBB (63%), and lowest in those without BBB (50%, p <0.001). Multivariate analysis demonstrated a significant 36% increased mortality risk in patients with RBBB versus no BBB (p = 0.002) but no significant difference in mortality risk for patients with LBBB versus no BBB (hazard ratio 1.04, p = 0.66). RBBB versus LBBB was associated with a 29% (p = 0.035) increased risk for 4-year mortality in the total population and with a 58% (p = 0.015) increased risk in patients with ejection fraction <30%. In conclusion, RBBB but not LBBB on admission electrocardiogram is associated with a significant increased long-term mortality risk in hospitalized patients with systolic HF. Deleterious effects of RBBB compared to LBBB appear to be more pronounced in patients with more advanced left ventricular dysfunction.

Use of intravenous morphine for acute decompensated heart failure in patients with and without acute coronary syndromes

Background: Current guidelines regarding the use of intravenous morphine (IM) in the management of patients with acute decompensated heart failure (ADHF) are discordant; whereas the American guidelines reserve IM for terminal patients, the European guidelines recommend its use in the early stage of treatment. Our aim was to determine the impact of IM on outcomes of ADHF patients. Methods: Stepwise logistic regression and propensity score analysis of ADHF patients with and without use of IM was performed in a national heart failure survey. Results: Of the 4102 enrolled patients, we identified 2336 ADHF patients, of whom 218 (9.3%) received IM. IM patients were more likely to have acute coronary syndromes, acute rather than exacerbation of chronic heart failure, and diabetes mellitus and dyslipidemia. They had higher heart rate, were less likely to receive diuretics and more likely to receive aspirin and statins. Unadjusted in-hospital mortality rates were 11.5% versus 5.0% for patients who did or did not receive IM, and the adjusted odds ratio (OR) for in-hospital death was: 2.0 (1.1–3.5, P = 0.02). Using propensity analysis, we identified 218 matched pairs of patients who did or did not receive IM. In multivariable analysis accounting for the propensity score (c-statistic 0.82), IM was not associated with increased in-hospital death (OR: 1.2 (0.6–2.4), P = 0.55). Conclusion: IM was used sparingly in our ADHF cohort, and was independently associated with increased in-hospital death in multivariable analysis, but not in propensity score analysis. Thus, IM may be used in ADHF, but with caution. Further randomized trials are warranted.

Contemporary treatment and adherence to guidelines in women and men with acute coronary syndromes

BACKGROUND Historically gender differences existed in treatment and outcome of patients with acute myocardial infarction (MI). AIM To assess gender aspects of contemporary treatment and adherence to ACC/AHA Class-I Treatment Guidelines in patients with acute coronary syndrome (ACS). METHODS We studied 2024 consecutive patients (519 women, 26%); 1026 (51%) with ST-elevation (STE)-MI and 998 (49%) patients with non-STE (NSTE), during a nationwide ACS-survey, conducted during 2-months in 2004. RESULTS Women were older than men (71 vs. 59 in STEMI; 71 vs. 64 years in NSTE-ACS patients), and had worse cardiovascular risk profiles. In STEMI-patients, acute reperfusion was less frequent in women than in men (53% vs. 63%, respectively, p=0.01; non-significant after age-adjustment). At discharge, fewer women received ACE-inhibitors/ARBs (71% vs. 75%, respectively; OR(age-adj)=0.69[0.48-0.98]). Among NSTE-ACS patients, fewer women received IIb/IIIa-inhibitors (12% vs. 21%, respectively, p=0.007; OR(age-adj)=0.58[0.36-0.96]) and clopidogrel at discharge (49% vs. 59%, respectively, p=0.005; OR(age-adj) 0.75[0.56-1.01]). No gender differences were noted in utilization of aspirin, beta-blockers or statins. Age-adjusted and covariate-adjusted mortality rates were comparable in women and men with STEMI (at 7-days 4.3% vs. 4.1%; OR(adj)=0.95[0.47-1.87] and at 1-year 13.8% vs. 9.8%, hazard ratio [HR(adj)]=1.11[0.73-1.70], respectively); in women and men with NSTE-ACS (at 7-days 1.3% vs. 2.1%, OR(adj)=0.65[0.20-1.76], and at 1-year 12.0% vs. 11.3%; HR(adj)=1.19[0.80-1.77], respectively). CONCLUSIONS In 2004, adherence to ACC/AHA Class-I Treatment Guidelines in ACS-patients was satisfactory. Relative underutilization of acute reperfusion was noted among STEMI patients, without gender differences after age-adjustment. At discharge, less women received ACE-inhibitors/ARBs. Among NSTE-ACS patients, less women than men received IIb/IIIa-inhibitors, and clopidogrel at discharge. Contemporary ACS management was associated with similar adjusted outcome in women and men.

Usefulness of Mild Therapeutic Hypothermia for Hospitalized Comatose Patients Having Out-of-Hospital Cardiac Arrest

Mild therapeutic hypothermia has proved beneficial after out-of-hospital cardiac arrest in the adult population, when the initial rhythm is ventricular fibrillation (VF). In this study, data from 110 consecutive patients with out-of-hospital cardiac arrest due to VF (n = 86) or to non-VF rhythm (n = 24), admitted to an intensive cardiac care unit with restoration of spontaneous circulation and who remained unconscious on admission, were analyzed. Patients were cooled using an external cooling system. Of the patients with VF, 66% had favorable outcomes (Glasgow-Pittsburgh Cerebral Performance Category 1 or 2), and 30% died. Of the patients with non-VF, 8% had favorable outcomes (p <0.001 vs VF), and 63% died (p = 0.004 vs VF). In patients with VF, those with poor outcomes were older than those with favorable outcomes (odds ratio [OR] 1.61, 95% confidence interval [CI] 1.03 to 2.7, p = 0.001) and had previous ejection fractions <35% (OR 7.72, 95% CI 1.8 to 33, p = 0.002). Outcomes were also worse when patients presented to the emergency room with seizures (OR 20.96, 95% CI 2.48 to 177.42, p = 0.003) or hemodynamic instability (OR 14.4, 95% CI 3.47 to 60, p <0.0001). In the non-VF group, the 2 patients with good outcomes were younger than those with unfavorable outcomes (39 ± 16 vs 65 ± 12 years, respectively, p = 0.04), with good left ventricular function on presentation (100% vs 4.5%, p = 0.0001) and with short asystole and/or short time from collapse to restoration of spontaneous circulation. In conclusion, mild therapeutic hypothermia in the adult population is more effective in patients with VF compared to those with non-VF. Good prognostic factors for patients with non-VF could be young age, good left ventricular function, and short anoxic time.

Outcomes of acute heart failure associated with acute coronary syndrome versus other causes

Background: By and large, prior registries and randomized trials have not distinguished between acute heart failure (AHF) associated with acute coronary syndrome (ACS) versus other causes. Aims: To examine whether the treatments and outcomes of ACS-associated AHF are different from non-ACS-associated AHF. Methods: We examined in a prospective, nationwide hospital-based survey the adjusted outcomes of AHF patients with and without ACS as its principal cause. Results: Of the 4102 patients in our national heart failure survey, 2336 (56.9%) had AHF, of whom 923 (39.5%) had ACS-associated AHF. These patients were more likely to receive intravenous inotropes and vasodilators and to undergo coronary angiography and revascularization, but less likely to receive intravenous diuretics. The unadjusted in-hospital, 30-day, one-year, and four-year mortality rates for AHF patients with or without ACS were 6.5% versus 5.0% (P = 0.13), 10.3% versus 7.5% (P = 0.02), 26.6% versus 31.0% (P = 0.02), and 55.3% versus 63.3% (P = 0.0001), respectively. In the multivariate analysis, the adjusted mortality risk for patients with ACS at the respective time points were 1.46 (0.99–2.10), 1.67 (1.22–2.30), 1.02 (0.86–1.20), and 0.93 (0.82–1.04). Conclusions: Patients with ACS-associated AHF seem to have a unique clinical course and perhaps should be distinguished from other AHF patients in future trials and registries.

Prior heart failure among patients with acute coronary syndromes is associated with a higher incidence of in–hospital heart failure

Background. There are few data regarding the impact of prior heart failure (P‐HF) on the presentation, course and outcomes of acute coronary syndromes (ACS). Methods and Results. We prospectively analyzed all ACS patients admitted in all cardiology wards in Israel during February and March, 2004. Of the 2098 patients, 156(7.4%) had P‐HF. These patients were older (75 [66.5–81] versus 63 [53–74] years, (P<0.001)) and more often female (38.5% versus 25.0%, P<0.001)), with a higher prevalence of coronary artery disease risk factors, prior cardiac disease and procedures, and other co‐morbidities. They more often presented with atypical angina and heart failure and less with ST‐elevation (18.6% versus 51.3%, p<0.0001). In‐hospital heart failure developed more frequently (15.4% versus 6.1%, p = 0.00001), including cardiogenic shock (7.1% versus 2.9%, p = 0.005), as did persistent atrial fibrillation (6.4% versus 0.7%, p<0.001), but not ischemic complications. After adjustment for differences, P‐HF was not independently associated with 30 day or six‐month mortality, but at one‐year follow‐up, it was (OR 1.16, 95% CI 1.0–2.5). P‐HF was also independently associated with increased incidence of heart failure upon admission or thereafter in‐hospital (OR = 4.3, 95% CI 2.8–6.6). Conclusions. P‐HF ACS patients had high‐risk features, lower incidence of ST‐elevation, and higher one‐year adjusted mortality. P‐HF was also independently associated with in‐hospital heart failure, suggesting they should be monitored vigilantly.

Right Precordial Lead (V4R) ST-Segment Elevation is Associated With Worse Prognosis in Patients With Acute Anterior Myocardial Infarction

To the Editor: The importance of ST-segment elevation (STE) in the right precordial leads during acute inferior myocardial infarction is well established. However, little is known about the significance of STE in the right precordial leads in patients presenting with acute anterior STE myocardial