Search

Background: Heart failure (HF) is associated with considerable mortality. The electrocardiographic frontal QRS-T angle is a simple parameter to measure, reflects changes in the direction of the repolarization sequence and predicts outcome in patients with HF. Data regarding temporal changes in the frontal QRS-T angle in patients with HF and its impact on outcome is limited. Aim: To evaluate temporal changes in the frontal QRS-T angle and its effect on survival in patients with HF. Methods: Baseline and follow-up QRS-T angle were calculated from the frontal QRS and T axis of the 12-lead surface electrocardiogram. Patients were followed for survival. Results: 2,929 HF patients were evaluated. Median interval between baseline ECG and follow-up ECG was 895 days, median follow-up time was 1526 days. Overall, the QRS-T angle tended to be stable, with minor changes in the angle over time. The median QRS-T angle change was +3° (IQR -19° to +30°). Overall survival during follow-up was 60%. Cox regression analysis after adjustment for significant predictors demonstrated that the QRS-T angle was an incremental predictor of increased mortality. A widening of the QRS-T angle during follow-up was independently associated with an increase in mortality, evident with an increase of the QRS-T angle difference above 0° (P<0.0001 for the adjusted model). Conclusion: QRS-T angle is relatively stable in patients with HF and is a powerful predictor of outcome. Widening of the QRS-T angle has predictive value and is an ominous sign. [ABSTRACT FROM AUTHOR]

The article describes the case of a 44 year old man with a long history of a narrow complex tachycardia and prior left lateral accessory pathway (LL-AP) ablation presented to the electrophysiology laboratory for a redo supraventricular tachycardia (SVT) ablation procedure. It notes that the case highlights the diagnostic challenge that occurs in case of recurrence of LL-AP in the setting of mitral annular block.

Aims Glucose abnormalities are associated with heart failure ( HF), are increasingly prevalent, and may have an impact on outcome. Our aim was to evaluate the effect of fasting glucose levels on clinical outcome in patients with HF. Methods and results Patients with a diagnosis of HF as coded at a health maintenance organization in Jerusalem, Israel were evaluated retrospectively. Impaired fasting glucose ( IFG) was defined as fasting plasma glucose levels between 100 and 125 mg/ dL. All patients were followed for cardiac-related hospitalizations and death. A total of 6067 HF patients were included. Mean follow-up was 487 days; mean age 75 ± 13 years; 48% of the patients ( n = 2,942) had diabetes; and 11.9% ( n = 722) had IFG. Overall survival during the follow-up was 82.5%. Cox regression analysis after adjustment for significant predictors including age, gender, ischaemic heart disease, hyperlipidaemia, hypertension, body mass index, glomerular filtration rate, serum urea, sodium, and haemoglobin levels demonstrated that patients with diabetes and IFG had a very similar outcome. Both were significant predictors of reduced survival compared with 'normal' glucose levels (fasting glucose levels between 92 and 99 mg/ dL) [diabetes, hazard ratio ( HR) 1.42, 95% confidence interval ( CI) 1.08-1.86, P = 0.01; IFG, HR 1.55, 95% CI 1.13-2.15, P < 0.01]. Diabetes and IFG were also predictors of increased cardiac-related hospitalizations (diabetes HR 1.31, 95% CI 1.16-1.48, P < 0.001; IFG, HR 1.17, 95% CI 1.00-1.35, P < 0.05). Conclusions Diabetes and IFG are common in patients with HF and have a similar effect on outcome including survival and cardiac hospitalizations. Glucose abnormalities including subclinical diabetes confer significant risk in patients with HF. [ABSTRACT FROM AUTHOR]

Aims Thyroid dysfunction is known to effect cardiac function and is a risk factor for developing heart failure (HF). Data regarding the clinical significance of thyroid-stimulating hormone (TSH) levels alone as a predictor of outcome in patients with HF is sparse. We evaluated the significance of TSH on clinical outcome in a large cohort of patients with chronic HF. Methods and results Patients with a diagnosis of HF at a Health Maintenance Organization ( n = 5599) were followed for cardiac-related hospitalizations and death. Median TSH levels were 2.2 mIU/L (interquartile range 1.4-3.5). We divided patients into quartiles based on TSH levels. Median follow-up time was 434 days and the overall mortality rate was 13.2%. Both a high and a low TSH level was associated with an increased mortality rate. Cox regression analysis after adjustment for other significant predictors demonstrated that the highest TSH quartile was associated with increased mortality compared with those with the lowest mortality [second quartile: TSH 1.4-2.2 mIU/L, hazard ratio (HR) 1.36, 95% confidence interval (CI) 1.08-1.71, P = 0.01]. TSH was also an independent predictor of death and cardiac-related hospitalization. Analysis of patients not on levothyroxine treatment (78%) demonstrated that TSH was an even stronger predictor of mortality (HR 1.54, 95% CI 1.17-2.03, P = 0.002). Additional analysis based on accepted clinical cut-offs of TSH demonstrated that increasing TSH levels above normal were independently associated with increased mortality and cardiac-related hospitalizations. Conclusions Increased TSH levels are associated with worse clinical outcome in patients with HF. Thyroid imbalance confers significant risk in HF and warrants attention. [ABSTRACT FROM AUTHOR]

Aims Vitamin D deficiency is a highly prevalent, global phenomenon. The prevalence in heart failure (HF) patients and its effect on outcome are less clear. We evaluated vitamin D levels and vitamin D supplementation in patients with HF and its effect on mortality. Methods and results 25-Hydroxyvitamin D [25(OH)D] levels were evaluated in HF patients from a health maintenance organization (HMO), and compared them with those of the rest of the members of the HMO. Patients with HF (n = 3009) had a lower median 25(OH)D level compared with the control group (n = 46 825): 36.9 nmol/L (interquartile range 23.2–55.9) vs. 40.7 nmol/L (26.7–56.9), respectively, P < 0.00001. The percentage of patients with vitamin D deficiency [25(OH)D <25 nmol/L] was higher in patients with HF compared with the control group (28% vs. 22%, P < 0.00001). Only 8.8% of the HF patients had optimal 25(OH)D levels (≥75 nmol/L). Median clinical follow-up was 518 days. Cox regression analysis demonstrated that vitamin D deficiency was an independent predictor of increased mortality in patients with HF [hazard ratio (HR) 1.52, 95% confidence interval (CI) 1.21–1.92, P < 0.001] and in the control group (HR 1.91, 95% CI 1.48–2.46, P < 0.00001). Vitamin D supplementation was independently associated with reduced mortality in HF patients (HR 0.68, 95% CI 0.54–0.85, P < 0.0001). Parameters associated with vitamin D deficiency in HF patients were decreased previous solar radiation exposure, body mass index, diabetes, female gender, pulse, and decreased calcium and haemoglobin levels. Conclusions Vitamin D deficiency is highly prevalent in HF patients and is a significant predictor of reduced survival. Vitamin D supplementation was associated with improved outcome. [ABSTRACT FROM PUBLISHER]

Abstract: We report a case of late stent thrombosis two years after implantation of a coronary stent graft (Jomed Covered Stent, CSG) and a week after cessation of aspirin therapy due to circumcision. Caution in adherence to anti-thrombotic therapy is warranted years following implantation of coronary stent grafts. [Copyright &y& Elsevier]

Public health infrastructures in the Occupied Territories have changed in many ways since the beginning of the Palestinian uprising (intifada) in September, 2000, and to a greater extent since the Israeli army regained control over the Palestinian population in April, 2002, after operation Defensive Shield. One area most affected is emergency medicine, including transport to hospitals. Since September, 2000, 2,122 Palestinians have been killed and 21,959 injured as a result of the confrontation.These casualties have substantially increased the number of calls on ambulances, mainly of the Palestine Red Crescent Society (PRCS). Moreover, since Palestinian private and public transport is largely prohibited, 2 patients who would otherwise use their own cars to get to hospital call PRCS ambulances. The golden hour rule--immediate medical care on the spot (airway, breathing, and haemodynamic stabilisation) and quickest transport to the nearest hospital--has become impossible to implement because of checkpoints and physical obstacles on most routes. Even if Israel were to comply with the demands of the International Committee of the Red Cross to limit the delay at each checkpoint to 15 minutes at most, critical care patients are at risk of losing their lives. In January and February, 2003, alone, the non-governmental organisation (NGO) Physicians for Human Rights-Israel (PHR-Israel) has handled 350 Palestinian patients' complaints and more than 60 complaints involving Palestinian medical workers delayed at checkpoints or denied access to their place of work.

Variants in Filamin-C (FLNC) have been associated with various hereditary cardiomyopathies. Recent literature reports a prevalence of sudden cardiac death (SCD) of 13–25% among carriers of truncating-variants, with mean age of 42±15 years for first SCD event. This study reports two familial cases of SCD and the results of cascade screening of their large family. Molecular-autopsy of the SCD victims revealed a novel truncating-variant in the FLNC gene (chr 7:128496880 [hg19]; NM_001458.5; c.7467_7474del; p.(Ser2490fs)). We screened thirty-two family members following genetic counseling, and variant carriers underwent a comprehensive workup followed by consultation with a cardiologist with expertise in the genetics of cardiac diseases. Seventeen variant carriers were identified: ages between 9 and 85 (mean 47±26). Fifteen underwent clinical evaluation. To date, none of the identified carriers has had major adverse events. In evaluated patients, ECG showed right-axis deviation in 60% (n = 9). Holter recorded frequent premature ventricular contractions (PVCs) (991±2030 per 24 h) in 33% (n = 5) with 4 patients having polymorphic PVC morphology. Three carriers had echocardiographic evidence of mild left-ventricular (LV) systolic dysfunction and another with mild LV dilatation. Cardiac magnetic-resonance (CMR) exhibited late‑gadolinium-enhancement in 10 out of 11 exams, mainly in the mid-myocardium and sub-epicardium, frequently involving the septum and the inferior-lateral wall. This large FLNC truncating variant carrier family exhibits high cardiomyopathy penetrance, best diagnosed by CMR, with variable clinical expressions. These findings present a challenge in SCD prevention management and underscoring the imperative for better risk stratification measures. • FLNC truncating variants have been associated with arrhythmogenic cardiomyopathy. • This study presents the largest known family carrying such variant. • This family reveals high penetrance with variable clinical expression among carriers. • This variability should be considered when discussing management of carriers. [ABSTRACT FROM AUTHOR]

Ventricular safety pacing (VSP) is used to avoid cross talk by delivering ventricular stimulus shortly after an atrial-paced event if ventricular-sensed event occurs. Although VSP is a protective feature that exists for decades in different pacing devices, there are some reports of unfavorable outcomes of this algorithm. More so, health care providers sometimes face difficulties in interpreting and dealing with VSP strips. This case report discusses an important pacemaker algorithm and encourages further attention to possible pitfalls and hence avoids unnecessary interventions. [ABSTRACT FROM AUTHOR]

Aims The characteristics of heart failure ( HF) patients of different ethnic backgrounds in Israel are unknown. The purpose of the present study was to evaluate the clinical characteristics of Arab vs. Jewish patients with chronic HF. Methods and results Patients with a diagnosis of HF at a health maintenance organization in Jerusalem, Israel were evaluated. All patients were followed for cardiac-related hospitalizations and death. The study cohort included 6773 HF patients; 4991 (74%) were Jewish and 1735 (26%) were Arab. The overall prevalence of HF in the Jewish vs. Arab population was similar (women, 4.3% vs. 4.7%, respectively, P = 0.06; men, 5.3% vs. 5.2%, P = 0.61). The prevalence of HF was significantly higher in Arab subjects of younger age groups (50-70 years). Arabs developed HF on average 10 years earlier and had a significantly higher rate of diabetes and obesity. Standard of care based on prescribed medications was similar between the ethnic groups. Glucose and cholesterol levels were higher in the Arab cohort. Mortality was similar between the groups at median follow-up (576 days), with the exception of cardiovascular hospitalizations and death that were higher in Arab men. Conclusions Arab subjects develop HF at a much younger age compared with their Jewish counterparts and have a higher prevalence of diabetes and obesity. Standard of care and clinical outcome are comparable. Implementation of prevention programmes to reduce risk factors, particularly diabetes and obesity, may help reduce the disparity between Arabs and Jews. [ABSTRACT FROM AUTHOR]