Gilad Margolis

Prognostic implications of fluid balance in ST elevation myocardial infarction complicated by cardiogenic shock

Background: Positive fluid balance has been associated with adverse outcomes in patients admitted to general intensive care units. We analysed the relationship between a positive fluid balance and its persistence over time in terms of in-hospital outcomes among ST elevation myocardial infarction (STEMI) patients complicated by cardiogenic shock. Methods: We retrospectively studied fluid intake and output for 96 hours following hospital admission in 48 consecutive adult patients with STEMI complicated by cardiogenic shock, all undergoing primary angioplasty. Daily and accumulated fluid balance was registered at up to 96 hours following admission. 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 in-hospital adverse outcomes, as well as 30-day all-cause mortality. Results: A positive fluid balance was present in 19/48 patients (40%). Patients with positive fluid balance were older and more likely to be treated by intra-aortic balloon counter-pulsation and antibiotics. These patients were more likely to develop acute kidney injury and to need new intubation and were less likely to have renal function recovery as well as successful weaning from mechanical ventilation (p < 0.05 for all). Patients with positive fluid balance had higher 30-day mortality (68% vs. 10%; p < 0.001). In a multivariate Cox regression model, for every 1-L increase in positive fluid balance, the adjusted risk for 30-day mortality increased by 24% (hazard ratio: 1.24, 95% confidence interval: 1.07–1.42; p = 0.003). Conclusions: A positive fluid balance was strongly associated with higher 30-day mortality in STEMI complicated by cardiogenic shock.

Outcome of patients undergoing TAVR with and without the attendance of an anesthesiologist

BACKGROUND During the last few years there is a shift from performing Transcatheter Aortic Valve Replacement (TAVR) under general anesthesia towards conscious sedation and local anesthesia only. In the vast majority of centers, sedation is guided by a qualified anesthesiologist. In our center, all TAVR procedures are being performed under local anesthesia and mild sedation, however, since September 2014, a large portion of TAVR procedures are being performed under local anesthesia without the presence of an anesthesiologist. Here we compare 30days outcome of patients undergoing TAVR with and without the presence of anesthesiologist in the catheterization laboratory. METHODS AND RESULTS From September 2014 through April 2016, 324 patients (mean age 82.8±6) with severe symptomatic aortic stenosis were assigned to transfemoral TAVR with (150 patients) or without (174 patients) the attendance of an anesthesiologist. Baseline clinical and echocardiographic characteristics were similar between the groups. No difference in procedural and 30-day mortality, vascular complications, and major/life threatening bleeding were observed between the groups (p>0.1, for all). CONCLUSIONS The presence of an anesthesiologist in the catheterization laboratory during transfemoral TAVR procedures did not significantly change 30-day outcome.

Differential Effects of Colchicine on Cardiac Cell Viability in an in vitro Model Simulating Myocardial Infarction.

Objectives: We aimed to examine the effects of colchicine, currently in clinical trials for acute myocardial infarction (AMI), on the viability of cardiac cells using a cell line model of AMI. Methods: HL-1, a murine cardiomyocyte cell line, and H9C2, a rat cardiomyoblast cell line, were incubated with TNFα or sera derived from rats that underwent AMI or sham operation followed by addition of colchicine. In another experiment, HL-1/H9C2 cells were exposed to anoxia with or without subsequent addition of colchicine. Cell morphology and viability were assessed by light microscopy, flow cytometry and Western blot analyses for apoptotic markers. Results: Cellular viability was similar in both sera; however, exposing both cell lines to anoxia reduced their viability. Adding colchicine to anoxic H9C2, but not to anoxic HL-1, further increased their mortality, at least in part via enhanced apoptosis. Under any condition, colchicine induced detachment of H9C2 cells from their culture plates. This phenomenon did not apply to HL-1 cells. Conclusions: Colchicine enhanced cardiomyoblast mortality under in vitro conditions mimicking AMI and reduced their adherence capability. HL-1 was not affected by colchicine; nevertheless, no salvage effect was observed. We thus conclude that colchicine may not inhibit myocardial apoptosis following AMI.

Shift Work and the Risk of Coronary Artery Disease: A Cardiac Computed Tomography Angiography Study

Aims: Shift work disrupts the normal circadian rhythm and is associated with risk factors for coronary artery disease (CAD) and a higher incidence of CAD morbidity and mortality. Cardiac computed tomography angiography (CCTA) is a robust noninvasive modality for assessing the presence, extent, and severity of CAD. We sought to investigate whether shift workers are prone to a higher burden of CAD compared to non-shift workers. Methods: We conducted a historically prospective study in consecutive patients who underwent CCTA and answered a telephonic questionnaire. Due to significant differences in age and gender, we compared 89 well-matched pairs of shift workers and non-shift workers with the use of propensity scores. Results: Our cohort consisted of 349 participants, of whom 94 (26.9%) were shift workers. The mean age was 50.7 years, and 62.5% were males. After pairing, we showed that shift workers had a higher prevalence of CAD than non-shift workers (74.2 vs. 53.9%, respectively, p = 0.01), and a lower prevalence of coronary calcium scores of zero (46.8 vs. 63.4%, respectively, p = 0.034). Stenosis >50% was more prevalent in shift workers than in non-shift workers (20.2 vs. 11.2%, respectively, p = 0.006), and the extent of CAD (defined as the presence of ≥1-vessel disease) tended to be higher in shift workers than in non-shift workers (25.8 vs. 13.5%, respectively, p = 0.06). Conclusions: In this CCTA study, we showed in a well-matched cohort of consecutive patients that shift workers had a higher prevalence and extent of CAD than non-shift workers.

Clinical Outcome of Isolated Tricuspid Regurgitation in Patients with Preserved Left Ventricular Ejection Fraction and Pulmonary Hypertension

Background: The outcome of tricuspid regurgitation (TR) remains unclear because of heterogeneity of etiology and the contradictory results of outcome studies. The aim of this study was to evaluate the clinical outcomes of TR in patients with pulmonary hypertension (PH) and normal left systolic function, stratified to patients with post‐ or precapillary PH. Methods: In patients with no left valvar disease (isolated) functional TR, preserved left systolic function (ejection fraction ≥ 50%), and PH (systolic pulmonary pressure > 50 mm Hg), TR was assessed both qualitatively (grade) and semiquantitatively using the vena contracta method, and retrospective analysis of long‐term outcomes was conducted. Patients with severe comorbid diseases were excluded. Results: The study included 245 patients (age 80.5 years, 37% men, ejection fraction 57%, all with pulmonary systolic pressure > 50 mm Hg). At least moderate to severe TR was diagnosed in 178 patients, and their outcomes were compared with those of 67 patients with the same characteristics and less than mild TR. At least moderate to severe TR was associated with lower survival, independent of all characteristics, right ventricular size or function, comorbidity, or pulmonary pressure (P = .03 for grade and P = .02 for vena contracta). Cox proportional‐hazard analysis with interaction terms for TR severity and etiology of PH (post‐ vs precapillary) showed that the etiology of PH did not affect the association of TR with outcome (P = .90 for the interaction term). Conclusions: At least moderate to severe isolated TR is independently associated with excess mortality in patients with preserved systolic function and PH, warranting heightened attention to diagnosis and grading. This is irrespective of etiology (pre‐ or postcapillary) of PH. Semiquantitative assessment of TR by vena contracta is an independent associate of outcome, superior to standard qualitative assessment. HighlightsIn patients with preserved EF and PH, moderate to severe TR is associated with mortality.This adverse association is irrespective of whether PH is post‐ or precapillary.Vena contracta is superior to qualitative grading.TAPSE is superior to all other measures of RV function.No adverse consequence could be detected regarding vena contracta < 6.

Relation of subclinical serum creatinine elevation to adverse in-hospital outcomes among myocardial infarction patients

Background: Acute kidney injury is associated with adverse outcomes after acute ST elevation myocardial infarction (STEMI). It remains unclear, however, whether subclinical increase in serum creatinine that does not reach the consensus criteria for acute kidney injury is also related to adverse outcomes in STEMI patients undergoing primary percutaneous coronary intervention. Methods: We conducted a retrospective study of 1897 consecutive STEMI patients between January 2008 and May 2016 who underwent primary percutaneous coronary intervention, and in whom acute kidney injury was not diagnosed throughout hospitalization. We investigated the incidence of subclinical acute kidney injury (defined as serum creatinine increase of ≥ 0.1 and < 0.3 mg/dl) and its relation to a composite end point of adverse in hospital outcomes. Results: Subclinical acute kidney injury was detected in 321 patients (17%). Patients with subclinical acute kidney injury had increased rate of the composite end point of adverse in-hospital events (20.3% vs. 9.7%, p<0.001), a finding which was independent of baseline renal function. Individual components of this end point (occurrence of heart failure, atrial fibrillation, need for mechanical ventilation and in-hospital mortality) were all significantly higher among patients with subclinical acute kidney injury (p< 0.05 for all). In a multivariable regression model subclinical acute kidney injury was independently associated with higher risk for adverse in-hospital events (odds ratio 1.92.6, 95% confidence interval: 1.23–2.97, p=0.004). Conclusions: Among STEMI patients treated with primary percutaneous coronary intervention, small, subclinical elevations of serum creatinine, while not fulfilling the consensus criteria for acute kidney injury, may serve as a significant biomarker for adverse outcomes.

Prognostic Implications of Chronic Kidney Disease on Patients Presenting with ST-Segment Elevation Myocardial Infarction with versus without Stent Thrombosis

Background: Limited data is present regarding long-term outcomes in chronic kidney disease (CKD) patients presenting with stent thrombosis (ST). We evaluated the possible implications of CKD on long-term mortality in patients presenting with ST-segment elevation myocardial infarction (STEMI) and treated with primary percutaneous coronary intervention (PCI), and its interaction with the presence of ST. Methods: We retrospectively studied 1,722 STEMI patients treated with primary PCI. Baseline CKD was categorized as an estimated glomerular filtration rate <60 mL/min/1.73 m2 at presentation. The presence of ST was determined using the Academic Research Consortium definitions. Patients were evaluated for the presence of CKD and ST, as well as for long-term mortality. Results: A total of 448/1,722 (26%) patients had baseline CKD. Patients with CKD were older and had more comorbidities and a higher rate of ST (4 vs. 7%, respectively, p < 0.001). In a univariate analysis, long-term mortality was significantly higher among those with CKD compared to those without CKD (17.6 vs. 2.7%, p < 0.001). The presence of ST did not alter long-term mortality in both CKD and no-CKD patients. In a Cox regression model, CKD was an independent predictor of long-term mortality (hazard ratio 2.04, 95% confidence interval 1.17-3.56, p = 0.01), while ST as a covariate was not significantly associated with long-term mortality. Conclusion: Among STEMI patients, CKD, but not ST, is a predictor of long-term mortality.

Outcomes of early and reversible renal impairment in patients with ST segment elevation myocardial infarction undergoing percutaneous coronary intervention

Objective: Acute kidney injury (AKI) is a frequent complication in patients with ST segment elevation myocardial infarction (STEMI) undergoing percutaneous coronary intervention (PCI). While AKI occurring post-PCI has been well studied, the incidence and clinical significance of early renal impairment evident on hospital admission prior to PCI and which resolves towards discharge has not been investigated. Methods: We retrospectively studied 2339 STEMI patients treated with primary PCI. The incidence of renal impairment and in-hospital complications as well as short and long-term mortality were compared between patients who did not develop renal impairment, patients who developed post-PCI AKI and those who presented with renal impairment on admission but improved their renal function during hospitalization (improved renal function). Improved renal function was defined as continuous and gradual decrease of ⩾ 0.3 mg/dL in serum creatinine levels obtained at hospital admission. Results: One hundred and nineteen patients (5%) had improved renal function and 230 patients (10%) developed post-PCI AKI. When compared with patients with no renal impairment, improved renal function and post-PCI AKI were associated with more complications and adverse events during hospitalization as well as higher 30-day mortality. Long-term mortality was significantly higher among those with post-PCI AKI (63/230, 27%) following STEMI than those without renal impairment (104/1990, 5%; p<0.001), but there was no significant difference in long term mortality between patients with no renal impairment and those with improved renal function (5% vs. 7.5%, p=0.17). Conclusion: In STEMI patients undergoing primary PCI, the presence of renal impairment prior to PCI which resolves towards discharge is not uncommon and is associated with adverse short-term outcomes but better long-term outcomes compared with post-PCI AKI.

INCIDENCE AND OUTCOMES OF EARLY LEFT VENTRICULAR THROMBUS FORMATION FOLLOWING ST-ELEVATION MYOCARDIAL INFARCTION TREATED WITH PRIMARY PERCUTANEOUS CORONARY INTERVENTION

Background: Since the advent of primary percutaneous coronary intervention (PCI) for the treatment of ST-elevation myocardial infarction (STEMI), studies have reported a declining incidence of left ventricular thrombus (LVT) following STEMI. The majority of LVT were found prior to hospital discharge

The awareness to metabolic syndrome among hospital health providers

BACKGROUND Metabolic syndrome (MetS) was shown to be related to a variety of diseases. High level of vigilance for the diagnosis of MetS is expected among health providers. We evaluated the level of awareness to MetS among physician and nurses working in a central hospital. METHODS AND RESULTS A specially designed anonymous questionnaire was used, including both open and multiple choice questions set to evaluate the participants awareness to MetS. The study included 126 participants, 71% physicians and 29% nurses. Mean age was 36.2±3.8 years. Among physicians, 68.5% were residents and 45.5% were internists. 98% of the participants stated that they were familiar with the term MetS and that they treat MetS patients regularly. Most participants knew the correct number of criteria included in MetS definition and the number of criteria needed for MetS diagnosis (84% and 90%, respectively). However, only 12% were able to discriminate correctly all MetS cases from non-MetS ones. Physicians performed better than nurses (15.6% and 3.1%, respectively, P=0.003). Neither, field of practice nor seniority was found to have a significant influence on the results. The frequency of recommendation for MetS risk factor modulation in the discharge files was also analyzed. Such recommendations were scarcely given, with cardiology department being the exception (80% of discharge files from cardiology department compared with less than 20% in other departments). CONCLUSION Though hospital workers showed high level of awareness to the existence of MetS, they failed to differentiate correctly MetS cases from non-MetS ones.