Yacov Shacham

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.

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.

Red blood cell distribution width (RDW) and long-term survival in patients with ST elevation myocardial infarction.

INTRODUCTION High RDW values are associated with adverse prognosis in many clinical conditions including short and medium term outcome of patients with ST Elevation Myocardial Infarction (STEMI). The aim of the present study was to evaluate the association between RDW and long term mortality in STEMI patients undergoing primary angioplasty (PPCI). MATERIAL AND METHODS A cohort of 535 STEMI patients undergoing PPCI were divided into two groups (RDW > 14%, RDW ≤ 14%) using CHAID and CART methods. The association between RDW and 5-year all-cause mortality was assessed using Coxs proportional hazards analysis. RESULTS A total of 37 patients died during follow up of 5 years (mean: 1059, median: 1013, range 2-2130 days). RDW > 14% was associated with increased risk of all-cause mortality (HR = 5, CI 95% 2.7- 9.9, p < 0.001). In multivariate analysis, RDW > 14 remained significantly associated with increased risk for all-cause mortality (HR = 3.8, CI 95% 1.8- 7.99, p < 0.001). Patients with RDW above 14% did not have lower ejection fraction, higher CPK or more conventional risk factors. CONCLUSION RDW value above 14 is independently associated with increased long term all-cause mortality in patients with STEMI undergoing PPCI.

Acute kidney injury among ST elevation myocardial infarction patients treated by primary percutaneous coronary intervention: a multifactorial entity

Acute kidney injury is a frequent complication among ST segment elevation myocardial infarction (STEMI) patients undergoing primary percutaneous coronary intervention (PCI), and is associated with adverse outcomes. While contrast nephropathy is considered the most important reason for worsening of renal function, recent data have suggested the role of other important factors among this specific patient population. In the present review, we examine the various factors leading to renal impairment in STEMI patients and place the findings in the context of this specific patient population in the era of primary PCI. These factors include contrast nephropathy, time to coronary reperfusion, cardiac pump function and hemodynamics as well as various inflammatory and metabolic markers.

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

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.

Hyperglycemia in patients referred for cardiac catheterization is associated with preexisting diabetes rather than a stress-related phenomenon: a prospective cross-sectional study.

An increased serum glucose level in patients with acute coronary syndrome (ACS) is associated with adverse clinical outcome. This hyperglycemia has been attributed, at least in part, to acute stress reaction. Our objective was to determine whether hyperglycemia is a stress‐related phenomenon or whether it represents a more sustained and possibly significant background dysglycemia.

Comparison of C-Reactive Protein and Fibrinogen Levels in Patients Having Anterior Wall ST-Segment Elevation Myocardial Infarction With Versus Without Left Ventricular Thrombus (From a Primary Percutaneous Coronary Intervention Cohort)

We tested the hypothesis that admission serum inflammatory biomarkers may predict risk of early left ventricular (LV) thrombus formation in patients with first-ever anterior wall ST-segment elevation myocardial infarction (STEMI). Medical records of 207 patients admitted to our department between January 2006 and April 2012 for first-ever diagnosed anterior wall STEMI and treated with primary percutaneous coronary intervention (PPCI) were reviewed. Serum C-reactive protein (CRP) and fibrinogen levels were determined from blood samples taken before PPCI. Patients underwent an initial cardiac echocardiography on days 1 or 2 of admission and a second echocardiography on days 5 to 7 of hospitalization. An early LV thrombus was detected on the second echocardiogram in 11 patients (11 of 207, 5%), 6 of whom had also displayed an LV thrombus already during their first echocardiogram. Patients with an LV thrombus had significantly higher mean serum CRP levels than those without an LV thrombus (48 mg/L vs 8.4 mg/L, p = 0.001), and a trend for higher fibrinogen levels was also observed (398 ± 135 mg/dl vs 312 ± 82 mg/dl, p = 0.063). Following adjustment to other variables and the performance of multiple logistic regression, the CRP (relative risk 4.63, p = 0.004) and fibrinogen (relative risk 1.006, p = 0.033) levels were independent predictors of LV thrombus formation. We conclude that admission serum CRP and fibrinogen levels are independent predictors for early LV thrombus formation complicating a first-ever anterior wall STEMI.

Norton scale for predicting prognosis in elderly patients undergoing trans-catheter aortic valve implantation: A historical prospective study

BACKGROUND The Norton scale is traditionally used to assess the risk of pressure ulcers. However, recent studies have shown its prognostic utilization in elderly patients with diverse medical conditions. The association between low admission Norton scale scores (ANSS), complications, and mortality in elderly patients following trans-catheter aortic valve implantation (TAVI) has never been studied. We aimed to determine if low ANSS (≤16) is associated with complications and 30-day and 1-year mortality in elderly patients undergoing TAVI. METHODS The medical charts of elderly (≥70 years) TAVI patients at the Tel-Aviv Medical Center, a tertiary medical center, were studied for the following measurements: ANSS, demographics, co-morbidities, complications during hospitalization, and 30-day and 1-year mortality. Complications included: an atrio-ventricular block, stroke, and vascular complications. RESULTS The cohort included 302 elderly patients: 179 (59.3%) were women; the mean age was 83.3±5.1 years. Following TAVI, 112 (37.1%) patients had complications other than pressure ulcers, 10 (3.3%) patients died within 30 days, and 42 (13.9%) patients died within one year. Overall, 36 (11.9%) patients had low ANSS. 1-year mortality rates were almost three times higher in patients with low ANSS relative to patients with high ANSS (27.8% vs. 12.0%; the relative risk 1.1; p=0.018). A stepwise logistic regression analysis showed that ANSS was independently inversely associated with 1-year mortality (p=0.018). Complications and 30-day mortality rates were similar in both groups. CONCLUSIONS Low ANSS are associated with 1-year mortality after TAVI. The Norton scale may therefore be used as an additional tool for elderly patient selection before TAVI.