Eran Leshem-Rubinow

Frequency and correlates of early left ventricular thrombus formation following anterior wall acute myocardial infarction treated with primary percutaneous coronary intervention.

The introduction of primary percutaneous coronary intervention (PPCI) for the treatment of patients with acute ST-segment elevation myocardial infarctions has resulted in a significant decrease in the prevalence of diagnosed left ventricular (LV) thrombus. However, reported rates are still as high as 10% to 20% in patients when followed up to 30 days. The aim of this study was to assess the frequency and predictors of early (<7 days after admission) LV thrombus formation in patients with acute anterior ST-segment elevation myocardial infarctions treated with PPCI. The cohort included 429 consecutive patients with documented acute anterior ST-segment elevation myocardial infarctions, who were treated with PPCI from January 2006 to July 2012. All patients underwent cardiac echocardiography on the first or second day of admission and repeat echocardiography 5 to 7 days after admission. Correlates of LV thrombus were estimated using a logistic multivariate regression model. LV thrombus formations were found in 18 of 429 patients (4%) during hospitalization. The first echocardiographic study diagnosed 11 of 18 LV thrombus formations. Patients with identified LV thrombus had significantly lower LV ejection fractions than those without LV thrombus at admission (p = 0.005) and at discharge (p <0.001). Lower admission LV ejection fractions, Thrombolysis In Myocardial Infarction (TIMI) flow grade ≤1 before angioplasty, and a longer time from symptom onset to PPCI were independent predictors of early LV thrombus formation. In conclusion, late reperfusion, a lower LV ejection fraction, and a lower TIMI score significantly increased the risk for early LV thrombus formations, even in the era of PPCI. Early echocardiographic assessment is warranted when admission test results identify at-risk patients.

Vitamin D deficiency prevalence and cardiovascular risk in Israel

Eur J Clin Invest 2011; 41 (3): 263–268

Relation of time to coronary reperfusion and the development of acute kidney injury after ST-segment elevation myocardial infarction.

Time to coronary reperfusion and acute kidney injury (AKI) are powerful prognostic markers in patients with ST-segment elevation myocardial infarction (STEMI) who underwent percutaneous coronary intervention (PCI); however, no information to date is present regarding the association between time to reperfusion and AKI. We evaluated whether time to reperfusion predicts the risk of developing AKI in patients with STEMI who underwent primary PCI. Medical records of 417 patients admitted to our department from January 2008 to July 2013, for STEMI, and treated with primary PCI were reviewed. Patients were stratified by time to coronary reperfusion tertiles, and their records were assessed for the occurrence of AKI after PCI. Mean age was 61 ± 13 years, and 346 patients (83%) were men. The cut-off points for the time to reperfusion tertiles were <120, 120 to 300, and >300 minutes. Patients having longer time to reperfusion had significantly more AKI complicating the course of STEMI (3% vs 11% vs 13%, p = 0.007) and had significantly higher serum creatinine change throughout hospitalization (0.13 vs 0.18 vs 0.21 mg/dl, p = 0.003). In a multivariable regression model, time to coronary reperfusion emerged as an independent predictor of AKI and to the maximal change in serum creatinine. In conclusion, longer time to coronary reperfusion is an independent risk factor for the development of AKI in patients with STEMI who underwent primary PCI.

Norton Scale, Hospitalization Length, Complications, and Mortality in Elderly Patients Admitted to Internal Medicine Departments

Background: The Norton scale is used for assessing pressure ulcer risk. The association between admission Norton scale scores (ANSS), hospitalization length, complications, and mortality in elderly patients admitted to internal medicine departments has never been studied. Objective: To determine if ANSS are associated with hospitalization length, complications, in-hospital mortality, and 1-year mortality in elderly patients admitted to an internal medicine department. Methods: Medical charts of consecutive elderly (≥65 years) patients admitted to a single internal medicine department between January and March 2009 were studied for ANSS, demographics, comorbidities, hospitalization length, complications during hospitalization, in-hospital mortality, and 1-year mortality. Complications during hospitalization included acute coronary syndrome, major arrhythmias, major bleeding, stroke, systemic infections, organ failure, thromboembolism, etc. ANSS ≤14 were considered low. Results: The final cohort included 259 elderly patients: 54.4% were women, the mean age was 81.6 years, and the mean hospitalization length was 3.7 days. Overall, 7.3% of the patients had complications other than pressure ulcers, 3.9% died during hospitalization, and 28.6% died within 1 year. The mean ANSS was 15.4, and 37.8% of the patients had low ANSS. Patients with low ANSS had longer hospitalization (4.7 vs. 2.9 days; p = 0.002), a higher incidence of complications during hospitalization (odds ratio: 3.9; p = 0.006), and higher rates of in-hospital mortality (odds ratio: 7.0; p = 0.007) relative to patients with high ANSS. Regression analysis showed that ANSS were independently negatively associated with hospitalization length, complications during hospitalization, and in-hospital mortality (p < 0.0001, p = 0.003, and p = 0.018, respectively) regardless of age, gender, comorbidities, and pressure ulcer appearance. Rates of 1-year mortality were similar in patients with low and high ANSS. Conclusions: The Norton scale may be used for predicting hospitalization length, complications during hospitalization other than pressure ulcers, and in-hospital mortality in elderly patients admitted to an internal medicine department.

Forced diuresis with matched hydration in reducing acute kidney injury during transcatheter aortic valve implantation (Reduce-AKI): study protocol for a randomized sham-controlled trial

BackgroundAcute kidney injury (AKI) is observed in up to 41% of patients undergoing transcatheter aortic valve implantation (TAVI) and is associated with increased risk for mortality. The aim of the present study is to evaluate whether furosemide-induced diuresis with matched isotonic intravenous hydration using the RenalGuard system reduces AKI in patients undergoing TAVI.Methods/DesignReduce-AKI is a randomized sham-controlled study designed to examine the effect of an automated matched hydration system in the prevention of AKI in patients undergoing TAVI. Patients will be randomized in a 1:1 fashion to the RenalGuard system (active group) versus non-matched saline infusion (sham-controlled group). Both arms receive standard overnight saline infusion and N-acetyl cysteine before the procedure.DiscussionThe Reduce-AKI trial will investigate whether the use of automated forced diuresis with matched saline infusion is an effective therapeutic tool to reduce the occurrence of AKI in patients undergoing TAVI.Trial registrationClinicaltrials.gov: NCT01866800, 30 April 30 2013.

Lower Admission Hemoglobin Levels Are Associated With Longer Symptom Duration in Acute ST‐Elevation Myocardial Infarction

An acute‐phase response in patients with acute myocardial infarction could contribute to the development of anemia.

Usefulness of Urine Output Criteria for Early Detection of Acute Kidney Injury after Transcatheter Aortic Valve Implantation

Background: Previous studies demonstrated that acute kidney injury (AKI) following transcatheter aortic valve implantation (TAVI) is frequent and associated with adverse outcomes. However, these studies only applied the serum creatinine (sCr) criteria while ignoring the urine output criteria. We hypothesized that adding the urine output criteria might contribute to an earlier diagnosis of AKI. Methods: We included 143 patients with severe aortic stenosis who underwent transfemoral TAVI between December 2012 and April 2014. Urine output was assessed hourly for at least 24 h following TAVI, and sCr was assessed at least daily until discharge. Based on the Valve Academic Research Consortium-2 (VARC-2), AKI was determined using both sCr and urine output criteria. We compared the incidence of AKI and time to AKI diagnosis based on these two methods. Results: The mean age was 81 w 6 years (range 61-94) and 56% were male. AKI occurred in 27 (19%) patients, 13 (9%) of whom had AKI defined by sCr criteria. Twenty (14%) patients had AKI defined by urine output criteria, only 6 of whom had AKI also defined by sCr criteria. The use of urine output criteria resulted in earlier identification of AKI (18 w 4 vs. 64 w 57 h, p = 0.02) and was associated with lower sCr elevation in patients having AKI defined by only urine output criteria (0.03 w 0.12 vs. 0.37 w 0.06 mg/dl, p < 0.001). Conclusion: The use of the VARC-2 urine output criteria significantly increased the incidence of AKI and shortened the time to AKI diagnosis. i 2014 S. Karger AG, Basel

The development of anemia of inflammation during acute myocardial infarction

BACKGROUND Anemia is associated with an unfavorable outcome in acute myocardial infarction (AMI). An acute phase response could contribute to the development of anemia in AMI patients. METHODS We have performed a cross-sectional analysis on prospectively collected data at a tertiary hospital catheterization laboratory. Multi-adjusted linear regression models were fitted for hemoglobin as the dependent variable. ANOVA tests were used to determine interactions between time cutoffs of the respective hemoglobin and the concentrations of two inflammatory proteins, namely C-reactive protein and fibrinogen. Anemia indices were analyzed in a subgroup of 138 male AMI patients for whom frozen serum samples were available. RESULTS Enrolled were 1017 patients (340 with unstable angina pectoris [UAP] and 677 with AMI). Correlates of hemoglobin in the AMI group included age, male gender, the inflammatory proteins, as well as time from symptom onset to angiography (r(2)=0.47; p<0.001). A significant decrease in the concentration of hemoglobin with a parallel increase in the inflammatory proteins was observed between the time cutoff from symptom onset to angiography only in the AMI group for males and females, respectively. A pattern suggestive of anemia of inflammation including higher ferritin, lower transferring, lower transferrin saturation, and lower serum iron concentrations has been observed in anemic AMI patients ( all p<0.05). CONCLUSIONS Inflammation-sensitive proteins are associated with lower hemoglobin concentrations in AMI patients. We therefore suggest the possibility that at least part of the hemoglobin drop in AMI prior to angiography is related to the anemia of inflammation.

Admission Glucose Levels and the Risk of Acute Kidney Injury in Nondiabetic ST Segment Elevation Myocardial Infarction Patients Undergoing Primary Percutaneous Coronary Intervention

Background: Hyperglycemia upon admission is associated with an increased risk for acute kidney injury (AKI) in ST segment elevation myocardial infarction (STEMI) patients undergoing primary percutaneous coronary intervention (PCI). However, the relation of this association to the absence of diabetes mellitus (DM) is less studied. We evaluated the effect of acute hyperglycemia levels on the risk of AKI among STEMI patients without DM who were all treated with primary PCI. Methods: We retrospectively studied 1,065 nondiabetic STEMI patients undergoing primary PCI. Patients were stratified according to admission glucose levels into normal (<140 mg/dl), mild (140-200 mg/dl), and severe (>200 mg/dl) hyperglycemia groups. Medical records were reviewed for the occurrence of AKI. Results: The mean age was 61 ± 13 years and 81% were males. Hyperglycemia upon hospital admission was present in 402 of 1,065 patients (38%). Patients with severe admission hyperglycemia had a significantly higher rate of AKI compared to patients with no or mild hyperglycemia (20 vs. 7 and 8%, respectively; p = 0.001) and had a significantly greater serum creatinine change throughout hospitalization (0.17 vs. 0.09 and 0.07 mg/dl, respectively; p = 0.04). In multivariate logistic regression, severe hyperglycemia emerged as an independent predictor of AKI (OR = 2.46, 95% CI 1.16-5.28; p = 0.018). Conclusion: Severe admission hyperglycemia is an independent risk factor for the development of AKI among nondiabetic STEMI patients undergoing primary PCI.

Association of Angiotensin-Converting Enzyme Inhibitor Therapy Initiation With a Reduction in Hemoglobin Levels in Patients Without Renal Failure

OBJECTIVE To investigate whether treatment initiated with an angiotensin-converting enzyme inhibitor (ACE-I) or an angiotensin II receptor blocker (ARB) for patients with ischemic heart disease, hypertension, or diabetes causes a reduction in hemoglobin (Hb) levels. PATIENTS AND METHODS This was a retrospective cohort analysis using the computerized database of a large health maintenance organization. Included were all adults with a first purchase of an ACE-I, an ARB, or a calcium channel blocker (CCB) between January 1, 2004, and December 31, 2009, defined as the index date. Measures of Hb levels before and 1 year after the index date were reviewed, and the change was calculated. All the analyses were stratified by pharmaceutical class. The main exposure variables were the proportion of days covered (PDC) by these drugs and the mean enalapril dosage (for enalapril users only). RESULTS Levels of Hb before and after treatment were available for 14,754 patients taking ACE-Is, 751 taking ARBs, and 3087 taking CCBs. A high PDC was significantly associated with greater yearly reductions in Hb levels compared with a low PDC for CCB use, but was more pronounced for ACE-I and ARB use. A high PDC was also associated with a higher odds of developing anemia in ACE-I users (odds ratio [OR], 1.59; P<.001) and ARB users (OR, 2.21; P=.05). In nonanemic enalapril users, every 10-mg increment in daily dose was associated with an OR of 1.45 for the development of anemia (P<.001). The association remained after excluding nonadherent patients. CONCLUSION Levels of Hb are reduced during the first year of use of ACE-Is and to a lesser extent with use of ARBs. This association is dose dependent and is not explained by patient adherence.