Arthur Shiyovich

Decreased admission serum albumin level is an independent predictor of long-term mortality in hospital survivors of acute myocardial infarction. Soroka Acute Myocardial Infarction II (SAMI-II) project

BACKGROUNDnDecreased serum albumin level (SAL) was reported to be associated with increased risk of cardiovascular events and short term-mortality in patients with acute myocardial infarction (AMI).nnnOBJECTIVESnTo evaluate the association between SAL and long-term mortality in AMI hospital survivors.nnnMETHODSnRetrospective analysis of patients admitted in a tertiary medical center for AMI 2002-2012 and discharged alive.nnnEXCLUSION CRITERIAnactive infections, inflammatory diseases, significant liver or kidney failure, malignancy, ejection-fraction <20%, severe heart valvular-disease and missing SAL. SAL was categorized as following: <3.4, 3.4-3.7, 3.7-3.9, 3.9-4.1 and >4.1g/dL. The primary outcome was all-cause mortality for up-to 10-years post-AMI.nnnRESULTSnOut of 12,535 patients, 8750 were included. Patients with reduced SAL were older, higher rate of women, increased prevalence of severe left ventricular dysfunction, chronic renal failure, diabetes mellitus and ST-elevation AMI, 3-vessel coronary artery disease, and in-hospital complications. While the prevalence of chronic ischemic coronary disease, dyslipidemia, smokers and obesity, was lower. Mortality rates throughout the follow-up period increased as SAL decreased with 17.6%, 24%, 28.5%, 38.6%, and 57.5% for SAL of >4.1, 3.9-4.1, 3.7-3.9, 3.4-3.7 and <3.4g/dL respectively (p-for-trend <0.001). Using the SAL category of >4.1g/dL as the reference group, Adjusted Hazard Ratio values were 1.14 (p=0.107), 1.23 (p=0.007), 1.39 (p<0.001) and 1.70 (p<0.001) for the SAL categories of 3.9-4.1, 3.7-3.9, 3.4-3.7 and <3.4g/dL respectively.nnnCONCLUSIONSnDecreased SAL on admission, including levels within normal clinical range, is significantly associated with long-term all-cause mortality in hospital survivors of AMI with a dose-response type association.

Predictors of long-term (10-year) mortality postmyocardial infarction: Age-related differences. Soroka Acute Myocardial Infarction (SAMI) Project

BACKGROUNDnCardiovascular diseases are the leading cause of death in elderly people. Over the past decades medical advancements in the management of patients with acute myocardial infarction (AMI) led to improved survival and increased life expectancy. As short-term survival from AMI improves, more attention is being shifted toward understanding and improving long-term outcomes.nnnAIMnTo evaluate age-associated variations in the long-term (up to 10 years) prognostic factors following AMI in real world patients, focusing on improving risk stratification of elderly patients.nnnMETHODSnA retrospective analysis of 2763 consecutive AMI patients according to age groups: ≤65 years (n=1230) and >65 years (n=1533). Data were collected from the hospitals computerized systems. The primary outcome was 10-year postdischarge all-cause mortality.nnnRESULTSnHigher rates of women, non-ST-elevation AMI, and most comorbidities were found in elderly patients, while the rates of invasive treatment were lower. During the follow-up period, mortality rate was higher among the older versus the younger group (69.7% versus 18.6%). Some of the parameters included in the interaction multivariate model had stronger association with the outcome in the younger group (hyponatremia, anemia, alcohol abuse or drug addiction, malignant neoplasm, renal disease, previous myocardial infarction, and invasive interventions) while others were stronger predictors in the elderly group (higher age, left main coronary artery or three-vessel disease, and neurological disorders). The c-statistic values of the multivariate models were 0.75 and 0.74 in the younger and the elder groups, respectively, and 0.86 for the interaction model.nnnCONCLUSIONSnLong-term mortality following AMI in young as well as elderly patients can be predicted from simple, easily accessible clinical information. The associations of most predictors and mortality were stronger in younger patients. These predictors can be used for optimizing patient care aiming at mortality reduction.

Temporal trends in acute myocardial infarction: What about survival of hospital survivors? Disparities between STEMI & NSTEMI remain. Soroka acute myocardial infarction II (SAMI-II) project

BACKGROUNDnContemporary data on trends of acute myocardial infarction (AMI), particularly outcomes of hospital survivors by AMI type is sparse.nnnMETHODSnAnalysis of 11,107 consecutive AMI patients in a tertiary hospital in Israel throughout 2002-2012. The annual incidence of ST-segment elevation (STEMI) and non-ST-segment elevation (NSTEMI) admissions was calculated using age-gender-ethnicity direct adjustment. A multivariate prognostic model was built to evaluate in-hospital and 1-year post-discharge all-cause-mortality, adjusted for patients risk factors.nnnRESULTSnA decline in the adjusted incidence of AMI admissions (per-1000 persons) was documented (2002 vs. 2012) for STEMI: 4.70 vs. 1.38 (p<0.001) and non-significant tendency of increase for NSTEMI: 1.86 vs. 2.37 (p=0.109). The prevalence of most cardiovascular risk-factors, some non-cardiovascular comorbidities and invasive interventions increased. In-hospital mortality declined significantly for STEMI: 10.8% vs. 7.7% (p<0.001) and with no change for NSTEMI: 5.0% vs. 5.5% (p=0.137). Consistently, 1-year post-discharge mortality declined for STEMI: 13% vs. 5.9% (p<0.001) and with a non-significant increase for NSTEMI: 12.6% vs. 17.0% (p=0.377). Adjusting for the risk factors, an increase of one year was associated with a decline of in-hospital mortality for STEMI: AdjOR=0.86 (p<0.001) and for NSTEMI: AdjOR=0.92 (p<0.001). However, the risk for post-discharge mortality increased for STEMI: AdjOR=1.11 (p<0.001) and for NSTEMI: AdjOR=1.12 (p<0.001).nnnCONCLUSIONSnThroughout 2002-2012 significant decline in the incidence and of in-hospital mortality of STEMI were found. However, adjusted post-discharge mortality rates increased significantly with time. Measures for improving incidence and outcomes of AMI patients focusing on NSTEMI and hospital-survivors are warranted.

Excess long-term mortality among hospital survivors of acute myocardial infarction. Soroka Acute Myocardial Infarction (SAMI) project

OBJECTIVESnWe evaluated long-term survival after acute myocardial infarction (AMI) in unselected real life patients according to the various risk groups, and its persistence with time after AMI as compared with the matched general population.nnnSTUDY DESIGNnRetrospective study.nnnMETHODSnData were collected from 2671 AMI hospital survivors (tertiary medical centre in Israel), which included demographics, clinical characteristics of AMI, comorbidities, interventions and test results. All-cause mortality during the 10-year follow-up period was compared with age-, sex- and ethnicity/religion-matched general population using standardized mortality ratios (SMRs).nnnRESULTSnOverall mortality of AMI patients (48.6%) was higher than the general population (SMR, 2.2; Pxa0<xa00.001). Mortality rates and SMRs tended to be greater in higher risk strata of patients, Jews vs Muslims, women vs men, non-ST-elevation acute myocardial infarction (NSTEMI) vs ST-elevation acute myocardial infarction (STEMI), non-invasive treatment vs invasive treatment, and recurrent vs first AMI. Mortality rates increased with age, but SMRs were highest in the youngest group. Through the follow-up period, SMR was highest during the first year after discharge (SMR, 4.85; Pxa0<xa00.001) and higher in 7th-10th years compared with 2nd-6th years.nnnCONCLUSIONnPatients who survived hospital admission with AMI continue to be at higher (approximately twice) risk of death compared with the general population for at least 10-year follow-up period and especially throughout the first and 7th-10th years after AMI, young women, high-risk patients, Jews, NSTEMI, non-invasively treated and recurrent AMI. These findings can assist healthcare providers and decision makers prioritizing targets of secondary prevention and allocation of resources.

Decreased Norton's functional score is an independent long-term prognostic marker in hospital survivors of acute myocardial infarction. Soroka Acute Myocardial Infarction II (SAMI-II) project

BACKGROUNDnPatient function is a risk factor of mortality following acute myocardial infarction (AMI). Norton scale (NS) was originally developed to estimate the risk for pressure ulcers. It contains 5 domains: mental condition, physical condition, mobility, activity in daily living and incontinence.nnnOBJECTIVEnTo evaluate NS as long-term prognostic marker following AMI.nnnMETHODSnA retrospective study based on computerized medical records of AMI patient hospitalized in a tertiary medical center in 2004-2012. NS scores and patients characteristics were collected from computerized databases. The primary outcome was all-cause long-term (up-to 10-years) mortality.nnnRESULTSnOverall 6964 patients were included; mean age 67.3±14.1years, 68.1% males. Mean NS score was 17.8±3; of which 21.1% had low-NS (≤16). Patients with low-NS had increased prevalence of hypertension, diabetes and renal disease, 3-vessel coronary artery disease, more often Non ST-Elevation Myocardial Infarction (NSTEMI) and in-hospital complications. Throughout the follow-up period cumulative mortality rate in patients with low- and high-NS groups were 97.3% and 43% respectively (AdjHR 1.66; 95% CI: 1.521-1.826; p<0.001). Furthermore, a reduction in one point in the NS score inversely associated with increased risk for mortality (AdjHR 1.10; 95% CI: 1.12-1.22; p<0.001).nnnCONCLUSIONSnNS is an independent long-term prognostic marker for all-cause mortality in hospital survivors with a gradual dose-response effect. This data emphasizes the importance prognostic implication of the general functional status on the prognosis of AMI patients.

Ethnical disparities in temporal trends of acute myocardial infarction (AMI) throughout a decade in Israel. Soroka acute myocardial infarction (SAMI-II) project

BACKGROUNDnEthnical disparities in presentation and outcomes following AMI were reported. We evaluated the temporal-trends of AMI hospitalizations and mortality of Bedouins (Muslims) and Jews in Israel.nnnMETHODSnRetrospective analysis of 15,352 AMI admissions (10,652 patients; 11.3% Bedouins, 88.7% Jews) throughout 2002-2012. The trends in admission rates (AR) were compared using direct age-sex adjustment. The trends of in-hospital mortality (IHM) and 1-year post-discharge mortality (PDM) were adjusted for the patients characteristics.nnnRESULTSnBedouins were younger (61.7±14.3 vs. 68.8±13.7years, p<0.001), a higher rate of males. Different prevalence of cardiovascular risk factors was found. STEMI presentation, 3-vessel disease and PCI intervention were more frequently in Bedouins than Jews. Adjusted AR was lower among Jews (4.80/1000 and 3.24/1000 in 2002 and 2012 respectively) than in Bedouins (9.63/1000 and 5.13/1000). A significant decrease of adjusted AR was found in both ethnicities (p-for-trend<0.001 both), greater in Bedouins (p-for-disparity=0.017). The overall rate of IHM was higher for Jews (8.7% vs. 5.6%; p=0.001). The decline of IHM was found in both groups: an increase of one-year resulted in AdjOR=0.877; (p-for-trend<0.001) and 0.910 (p-for-trend=0.052) in Jews and Bedouins respectively (p-for-interaction=0.793). The rates of PDM were higher for Jews (13.6% vs. 9.9%; p=0.001). The risk for PDM increased in both groups: AdjOR=1.118; (p-for-trend<0.001) and 1.093; (p-for-trend=0.012) for one-year increase, for Jews and Bedouins respectively (p-for-interaction=0.927).nnnCONCLUSIONSnThroughout 2002-2012 Bedouin AMI patients differed from Jews. Adjusted incidence of AMI declined, greater in Bedouins. IHM declined and PDM increased in both groups. A culturally sensitive prevention program is warranted.

Serum calcium levels independently predict in-hospital mortality in patients with acute myocardial infarction

BACKGROUND AND AIMnSerum calcium levels (sCa) were reported to be associated with cardiovascular risk factors, incidence of coronary artery disease and acute myocardial infarction (AMI). The current study evaluated the association between sCa and in-hospital mortality among AMI patients.nnnMETHODS AND RESULTSnPatients admitted in a tertiary medical center for AMI throughout 2002-2012 were analyzed. For each patient, mean sCa, corrected to albumin, was calculated and categorized to seven equally-sized groups: <8.9, 8.9-9.12, 9.12-9.3, 9.3-9.44, 9.44-9.62, 9.62-9.86, ≥9.86xa0mg/dL. The primary outcome was all-cause in-hospital mortality. Out of 12,121 AMI patients, 11,446 were included, mean age 67.1xa0±xa014 years, 68% Males. Mean number of sCa values for patient was 4.2xa0±xa07.3. Mean sCa was 9.4xa0±xa00.53xa0mg/dL, range 5.6-13.2xa0mg/dL sCa was significantly associated with cardiovascular risk-factors, in-hospital complications, more frequent 3-vessel coronary artery disease and decreased rate of revascularization, often in a U-shaped association. Overall 794 (6.9%) patients died in-hospital. Multivariate analysis showed a significant U-shaped association between sCa and in-hospital mortality with sCaxa0below 9.12xa0mg/dL and above 9.86xa0mg/dL as independent predictors of significantly increased in-hospital mortality: ORxa0=xa02.4 (95% CI:1.7-3.3) and 1.7 (95%CI:1.2-2.4), for Ca<8.9 and Ca≥9.86xa0mg/dL respectively pxa0<xa00.01, as compared with middle rage sCa group (9.3-9.44xa0mg/dL).nnnCONCLUSIONnsCa is an independent predictor of in-hospital mortality in patients with AMI with a U-shaped association. Both increased and decreased sCa levels are associated with increased risk of in-hospital mortality.

MyoK+ardial Infarction Potassium Levels and Outcomes Following Acute Myocardial Infarction

Most total body potassium (K) is located in the intracellular space, while extracellular potassium is tightly regulated by intraand extracellular shifts and renal excretion. Changes in intraand extracellular K levels modify the electrophysiological properties of the resting membrane potential in cardiac cells and subsequently influence the generation and conduction of impulses throughout the heart. During the 1950s, hypokalemia was reported to be lower than the fibrillation threshold in isolated rabbit hearts. Subsequently, relatively small observational studies reported an association between hypokalemia and the risk of ventricular arrhythmias in patients with acute myocardial infarction (AMI). Thereafter, practice guidelines, including the American College of Cardiology/American Heart Association guidelines for management of ST-segment elevation MI (STEMI), recommended (Class I) maintaining K levels > 4.0 mEq/L although with the lowest level of evidence (C). Moreover, even higher target levels >4.5 mEq/L were suggested, yet no upper level was set. Concordantly, many hospitals implemented these guidelines by initiating treatment when serum K levels decrease below certain ‘‘goal’’ values. To our knowledge, these recommendations have not been revised, since in formal guidelines and in the most recent guidelines, this issue is not mentioned directly and only the undetermined role or possible deleterious effects of glucose– insulin–potassium (GIK) infusions are discussed. Ma et al, in this issue of Angiology, retrospectively evaluated short-term outcomes of 6613 patients presenting with STEMI, without renal insufficiency, according to K levels at presentation. Following adjustments to potential confounders, the authors found a J-shaped relationship between patient outcomes and K levels, with lowest predefined event rate with K levels of 4 to 4.5 mEq/L. Compared to the latter reference group, multivariate analysis revealed significantly higher 30-day mortality risk in patients with K level of 4.5 to 5.0 (hazard ratio [HR]: 1.52, 95% confidence interval [CI]: 1.17-1.98; P 1⁄4 .002) and even higher risk in patients with K level of 5.0 mEq/L (HR: 1.80, 95% CI: 1.22-2.66; P 1⁄4 .002). This study has some limitations, particularly the relatively low adherence with contemporary guidelines, that is, insufficient use of primary percutaneous coronary intervention (PCI; only *10% of cases) and optimal medical therapy, which might compromise applicability. Nevertheless, the findings are consistent with several recent reports showing that serum K levels, outside a relatively narrow range, are associated with worse outcomes in patients presenting with AMI. The methodology and main findings of the latter studies are summarized in Table 1. These studies, altogether included over 50 000 patients, consistently demonstrated that K levels are significantly associated with short(eg, in hospital) and long-term (up to 10 years) outcomes (eg, mortality and malignant arrhythmias) in patients presenting with AMI. A study that evaluated unstable angina patients and another study evaluating the outcome of target lesion revascularization observed consistent findings. K levels between 3.5 and 4 mEq/L (more frequently) or 4 and 4.5 mEq/L were found to be associated with lowest levels of mortality or other negative outcomes in most studies, while lower levels and even more prominently higher levels (including within normal K range) were significantly associated with worse outcomes. Furthermore, the latter association was similar regardless of K supplementation during hospitalization and seemed to be stepwise in most studies (eg, ‘‘dose response’’) further strengthening its robustness. Hence, best outcomes were reported in patients with K range for which the above-mentioned guidelines might suggest treatment to increase K levels. The exact pathophysiological mechanisms by which decreased or increased K levels are associated with deleterious prognosis in patients with AMI are uncertain. The AMI was reported to be associated with several systemic metabolic changes. These changes include increased plasma concentrations of catecholamines, free fatty acids, glucose, glycerol, cortisol, and cyclic AMP. Sekiyama et al showed a transient decrease in serum K level during the acute phase of acute coronary syndrome (ACS), followed by an increase at the stable phase (discharge). The degree of the K dip was correlated

Prediction of mortality in hospital survivors of STEMI: External validation of a novel acute myocardial infarction prognostic score

INTRODUCTION & OBJECTIVEnRecently we developed and internally-validated the Soroka Acute Myocardial Infarction (SAMI) Score for prediction of all-cause long-term mortality (c-statistic 0.83-0.94) among hospital-survivors of AMI. We aimed to perform an external-validation of the SAMI score for long-term risk-stratification of STEMI patients undergoing PCI.nnnMETHODS & SETTINGSnA prospective registry of 1273 STEMI patients treated using primary PCI and discharged alive from Rabin Medical Center in Israel between 2004 and 2014 (age 60.8u202f±u202f12.5u202fyears, 83% males) was utilized for the validation. Chi-square test and logistic regression were used for calibration, and c-statistic (ROC procedure) for discrimination assessment of the SAMI score.nnnRESULTSnAll-cause mortality following one- and 5-years post-discharge was 3.8% and 8.1%, respectively. SAMI score values ranged between (-5) and (+15) points (median 2-points). In a univariate analysis the SAMI score variables were significantly associated with 1- and 5-years mortality. Higher SAMI score was associated with increased risk for dying: a one-point increase was associated with OR of 1.33 (95%CI: 1.24-1.42, pu202f<u202f0.001) and 1.37 (95%CI: 1.29-1.44, pu202f<u202f0.001) for 1- and 5-years mortality respectively. No statistically significant difference was found in the currently observed mortality rates by groups of SAMI score and the expected mortality rates as per the SAMI score index. The c-statistics were 0.82 and 0.83 for 1- and 5-year mortality, respectively.nnnCONCLUSIONSnThe SAMI score is a simple, robust and now also externally-validated prognostic tool for prediction of long-term all-cause mortality in hospital survivors of STEMI.

Letter by Shiyovich et al Regarding Article, “Resumption of Chest Compressions After Successful Defibrillation and Risk for Recurrence of Ventricular Fibrillation in Out-of-Hospital Cardiac Arrest”

In their study, Conover et al1 investigated whether ventricular fibrillation (VF) recurrence in first 30 s post shock of cardiac arrest victims with initial rhythm of VF is related to timing of post shock chest compression (CC) resumption.nnSeveral clarifications and potential additions would help to ascertain the relationship between resumption of CC after successful defibrillation and recurrence of VF better.nnThe authors stated that defibrillation of VF was successful if VF was terminated for ≥5 s. In group CC1, CCs were resumed 1 to 5 s post shock. Considering the latter time intervals, the definition of successful defibrillation and VF recurrence in this subgroup should …