Search

Limited data exist regarding the significance of peripheral arterial disease (PAD) in patients with acute coronary syndrome (ACS).We evaluated 16,922 consecutive ACS patients who were prospectively included in a national ACS registry. The co-primary endpoint included 30 days major adverse cardiovascular event (MACE) (re-infarction, stroke, and/or cardiovascular death) and 1-year mortality.PAD patients were older (70±11 vs 63±13; p0.01), male predominance (80% vs 77%; p=0.01), and more likely to sustain prior cardiovascular events. PAD patients were less likely to undergo coronary angiography (69% vs 83%; p0.001) and revascularisation (80% vs 86%; p0.001). Patients with PAD were more likely to sustain 30-day MACE (22% vs 14%; p0.001) and mortality (10% vs 4.4%; p0.001), as well as re-hospitalisation (23% vs 19%; p=0.001). After adjusting for potential confounders, PAD remained an independent predictor of 30-day MACE (odds ratio [OR], 1.6 [95% confidence interval (CI), 1.24-2.06]). Patients with compared to those without PAD had 2.5 times higher 1-year mortality rate (22% vs 9%; p0.001). Co-existence of PAD remained an independent predictor of 1-year mortality after adjustment for potential confounders by multivariable regression analysis (OR, 1.62; 95% CI, 1.4-1.9). PAD was associated with a significant higher 1-year mortality rate across numerous sub-groups of patients including type of myocardial infarction (ST-elevation myocardial infarction vs non-ST-elevation myocardial infarction), and whether the patient underwent revascularisation.Acute coronary syndrome with concomitant PAD represents a high-risk subgroup that warrants special attention and a more tailored approach.

Cardiogenic shock complicating acute myocardial infarction is a complex clinical condition associated with dismal prognosis. Routine early target vessel revascularization remains the most effective treatment to substantially improve outcomes, but mortality remains high. Temporary circulatory support devices have emerged with the aim to enhance cardiac unloading and improve end-organ perfusion. However, quality evidence to guide device selection, optimal installation timing, and post-implantation management are scarce, stressing the importance of multidisciplinary expert care. This review focuses on the contemporary use of short-term support devices in the setting of cardiogenic shock following acute myocardial infarction, including the common challenges associated this practice.

Background Despite the COVID-19 pandemic, cardiovascular disease is still the main cause of death in developed countries. Of these deaths, acute coronary syndromes (ACS) account for a substantial percentage of deaths. Improvement in ACS outcomes, are achieved by reducing the time from symptom onset until reperfusion or total ischemic time (TIT). Nevertheless, due to the overwhelming reality at the beginning of the pandemic, acute coronary syndrome (ACS) care may have been compromised. Objectives We evaluated delays in TIT based on the date and timing of admissions in patients with STEMI, by a timeline follow-up form, before and during the current COVID-19 pandemic. Methods Between July 2018 and June 2020, two hundred and twelve patients diagnosed with ST-segment elevation myocardial infarction (STEMI) were admitted to our medical center. Upon presentation, cases were assigned a timeline report sheet and each time interval, from onset of symptoms to the catheterization lab, was documented. The information was later evaluated to study potential excessive delays throughout ACS management. Results Our data evidenced that during the COVID-19 pandemic ACS admissions were reduced by 34.54%, in addition to several in-hospital delays in patient's ACS management including delays in door-to-ECG time (9.43 ± 18.21 vs. 18.41 ± 28.34, p = 0.029), ECG-to-balloon (58.25 ± 22.59 vs. 74.39 ± 50.30, p = 0.004) and door-to-balloon time (57.41 ± 27.52 vs. 69.31 ± 54.14, p = 0.04). Conclusions During the pandemic a reduction in ACS admissions occurred in our hospital that accompanied with longer in-hospital TIT due to additional tests, triage, protocols to protect and prevent infection within hospital staff, and maintenance of adequate standards of care. However, door-to-balloon time was maintained under 90 min.

Background There is conflicting data regarding the association between low levels of plasma vitamin D and ischemic heart disease. We aimed to investigate the relationship between plasma vitamin D levels and heart valve calcification in hospitalized patients with ischemic heart disease versus non-ischemic heart disease controls. Methods A prospective case-control study comprising two age and gender-matched groups. The study group included consecutive patients hospitalized due to acute coronary syndrome; the control group included consecutive non-ischemic heart disease patients hospitalized for noncardiac causes. Blood samples for 25-hydroxyvitamin D level were drawn. An echocardiogram was performed during the first 3 days of hospitalization and reviewed for presence and degree of valvular calcification. Results Forty patients with acute coronary syndrome and 40 controls (age 58 ± 11 years, 64% male in both groups) were included. Mean plasma 25-hydroxyvitamin D vitamin level in the entire cohort was 24.5 ± 8 ng/ml. Valve calcification rates were similar in acute coronary syndrome versus non-acute coronary syndrome group (28 vs. 21 had valvular calcification; 18 vs. 12 had aortic valve calcification; 21 vs. 14 had mitral valve calcification, respectively; P = NS for all). We found no significant relationship between vitamin D level and valvular calcification, aortic valve calcification, or mitral valve calcification rate or degree in the entire cohort and in each group alone (P = NS for all). There was a negative correlation between 25-hydroxyvitamin D levels and age in the acute coronary syndrome group (r = -0.399, P = 0.012). Conclusions We did not find a significant relationship between plasma vitamin D levels and the rate or degree of calcification of either aortic/mitral/both valves in hospitalized patients with or without ischemic heart disease.

Graphical abstract, Highlights • Aortic dissection is a life-threatening medical emergency in patients with MFS. • Stanford type B aortic dissection is observed in one third of MFS cases. • Adequate cardiovascular surveillance can reduce the progression of aortic dilation. • Clinicians must ensure compliance to medication despite hemodynamically stability.

Contains fulltext : 286841.pdf (Publisher’s version ) (Closed access) BACKGROUND: Resistant hypertension is associated with increased cardiovascular risk. The endothelin pathway has been implicated in the pathogenesis of hypertension, but it is currently not targeted therapeutically, thereby leaving this relevant pathophysiological pathway unopposed with currently available drugs. The aim of the study was to assess the blood pressure lowering efficacy of the dual endothelin antagonist aprocitentan in patients with resistant hypertension. METHODS: PRECISION was a multicentre, blinded, randomised, parallel-group, phase 3 study, which was done in hospitals or research centres in Europe, North America, Asia, and Australia. Patients were eligible for randomisation if their sitting systolic blood pressure was 140 mm Hg or higher despite taking standardised background therapy consisting of three antihypertensive drugs, including a diuretic. The study consisted of three sequential parts: part 1 was the 4-week double-blind, randomised, and placebo-controlled part, in which patients received aprocitentan 12·5 mg, aprocitentan 25 mg, or placebo in a 1:1:1 ratio; part 2 was a 32-week single (patient)-blind part, in which all patients received aprocitentan 25 mg; and part 3 was a 12-week double-blind, randomised, and placebo-controlled withdrawal part, in which patients were re-randomised to aprocitentan 25 mg or placebo in a 1:1 ratio. The primary and key secondary endpoints were changes in unattended office systolic blood pressure from baseline to week 4 and from withdrawal baseline to week 40, respectively. Secondary endpoints included 24-h ambulatory blood pressure changes. The study is registered on ClinicalTrials.gov, NCT03541174. FINDINGS: The PRECISION study was done from June 18, 2018, to April 25, 2022. 1965 individuals were screened and 730 were randomly assigned. Of these 730 patients, 704 (96%) completed part 1 of the study; of these, 613 (87%) completed part 2 and, of these, 577 (94%) completed part 3 of the study. The least square mean (SE) change in office systolic blood pressure at 4 weeks was -15·3 (SE 0·9) mm Hg for aprocitentan 12·5 mg, -15·2 (0·9) mm Hg for aprocitentan 25 mg, and -11·5 (0·9) mm Hg for placebo, for a difference versus placebo of -3·8 (1·3) mm Hg (97·5% CI -6·8 to -0·8, p=0·0042) and -3·7 (1·3) mm Hg (-6·7 to -0·8; p=0·0046), respectively. The respective difference for 24 h ambulatory systolic blood pressure was -4·2 mm Hg (95% CI -6·2 to -2·1) and -5·9 mm Hg (-7·9 to -3·8). After 4 weeks of withdrawal, office systolic blood pressure significantly increased with placebo versus aprocitentan (5·8 mm Hg, 95% CI 3·7 to 7·9, p

Guiding catheter damage and body wire intermingling are uncommon complications of standard operational procedures. Optimal application of this device includes replacing the small guiding catheter upon excessive resistance during stent insertion.

Background Diabetic patients have an increased predisposition to thromboembolic events, in most cases originating from thrombi in the left atrial appendage (LAA). Remodeling of the LAA, which predisposes to thrombi formation, has been previously described in diabetic patients with atrial fibrillation, but whether remodeling of the LAA occurs in diabetics also in the absence of atrial fibrillation is unknown. To investigate the contribution of diabetes, as opposed to atrial fibrillation, to remodeling of the LAA, we went from humans to the animal model. Methods We studied by echocardiography the structure and function of the heart over multiple time points during the evolution of diabetes in the Cohen diabetic sensitive rat (CDs/y) provided diabetogenic diet over a period of 4 months; CDs/y provided regular diet and the Cohen diabetic resistant (CDr/y), which do not develop diabetes, served as controls. All animals were in sinus rhythm throughout the study period. Results Compared to controls, CDs/y developed during the evolution of diabetes a greater heart mass, larger left atrial diameter, wider LAA orifice, increased LAA depth, greater end-diastolic and end-systolic diameter, and lower E/A ratio—all indicative of remodeling of the LAA and left atrium (LA), as well as the development of left ventricular diastolic dysfunction. To investigate the pathophysiology involved, we studied the histology of the hearts at the end of the study. We found in diabetic CDs/y, but not in any of the other groups, abundance of glycogen granules in the atrial appendages , atria and ventricles, which may be of significance as glycogen granules have previously been associated with cell and organ dysfunction in the diabetic heart. Conclusions We conclude that our rodent model of diabetes, which was in sinus rhythm, reproduced structural and functional alterations previously observed in hearts of human diabetics with atrial fibrillation. Remodeling of the LAA and of the LA in our model was unrelated to atrial fibrillation and associated with accumulation of glycogen granules. We suggest that myocardial accumulation of glycogen granules is related to the development of diabetes and may play a pathophysiological role in remodeling of the LAA and LA, which predisposes to atrial fibrillation, thromboembolic events and left ventricular diastolic dysfunction in the diabetic heart.

Background Abdominal aortic aneurysm (AAA) is an asymptomatic condition characterized by progressive dilatation of the aorta. The purpose of this study is to identify important 2D-TTE aortic indices associated with AAA as predictive tools for undiagnosed AAA. Methods In this retrospective study, we evaluated the size of the ascending aorta in patients without known valvular diseases or hemodynamic compromise as predictive tool for undiagnosed AAA. We studied the tubular ascending aorta of 170 patients by 2-dimensional transthoracic echocardiography (2D-TTE). Patients were further divided into two groups, 70 patients with AAA and 100 patients without AAA with normal imaging results. Results Dilatation of tubular ascending aorta was measured in patients with AAA compared to the group with absent AAA (37.5 ± 4.8 mm vs. 31.2 ± 3.6 mm, p < 0.001, respectively) and confirmed by computed tomographic (CT) (35.6 ± 5.1 mm vs. 30.8 ± 3.7 mm, p < 0.001, respectively). An increase in tubular ascending aorta size was associated with the presence of AAA by both 2D-TTE and CT (r = 0.40, p < 0.001 and r = 0.37, p < 0.001, respectively). The tubular ascending aorta (D diameter) size of ≥33 mm or ≥ 19 mm/m2 presented with 2–4 times more risk of AAA presence (OR 4.68, CI 2.18–10.25, p = 0.001 or OR 2.63, CI 1.21–5.62, p = 0.02, respectively). In addition, multiple logistic regression analysis identified tubular ascending aorta (OR 1.46, p p = 0.013), gender (OR 0.12, p = 0.002), and LVESD (OR 1.24, p = 0.009) as independent risk factors of AAA presence. Conclusions An increased tubular ascending aortic diameter, measured by 2D-TTE, is associated with the presence of AAA. Routine 2D-TTE screening for silent AAA by means of ascending aorta analysis, may appear useful especially in older patients with a dilated tubular ascending aorta (≥33 mm).

The clinical benefit of lipid-lowering therapies is to reduce circulating levels of atherogenic particles and to ameliorate the risk of atherosclerotic cardiovascular disease (ASCVD). The completion of two major clinical trials on PCSK9 inhibitors (PCSK9i), the FOURIER and the ODYSSEY outcome trials, has marked the beginning of a new era of lipid-lowering drugs. PCSK9i, evolocumab and alirocumab, are monoclonal antibodies that inactivate the liver proprotein convertase subtilisin kexin 9 (PCSK9). Inhibition of PCSK9 increases the number of low-density lipoprotein (LDL) receptors available leading to a profound reduction in circulating LDL particles. By preventing LDL receptor destruction, PCSK9i as adjunct to statin therapy can reduce LDL-C by 50-60% above that achieved by statin therapy alone. In addition, PCSK9i in combination with high-dose statins may reduce cardiovascular events and all-cause mortality in patients with clinical ASCVD. Based on evidence from clinical trials, the 2019 European Society of Cardiology (ESC)/European Atherosclerosis Society (EAS) guidelines for the management of dyslipidemias now include the use of PCSK9i to very high-risk ASCVD patients who are not achieving treatment goals on a maximum tolerated dose of a statin and ezetimibe. However, the cost-effectiveness of PCSK9i therapy is limited to secondary prevention in high-risk patients. This review outlines the main clinical trials leading to a change in the guidelines, clinical practice as well as the future challenges of PCSK9i therapy.

OBJECTIVE To evaluate atrial and ventricular parameters using real time three-dimensional transthoracic echocardiography (RT3DTTE) in women treated with nifedipine in the early third trimester (III-T) of pregnancy. METHODS A prospective single-subject design study in a university-affiliated hospital, where each participant served as her own control. We studied 25 pregnant women at a gestational age of 25-33 weeks with TPTL prior to vs 48 hours postnifedipine treatment. Two-dimensional transthoracic echocardiography (2DTTE) and RT3DTTE were used to study 3D left atrial (LA) volumes and indexes, emptying fraction, left ventricular and LA cavities, and total vascular resistance (TVR). RESULTS Two-dimensional transthoracic echocardiography showed a significant increase in LA area (from 15.2 ± 2.62 to 16.16 ± 2.21 mm2 , P = .02) before vs after nifedipine; RT3DTTE showed a significant change in LA end-diastolic volume index (from 23.7 ± 4.2 to 26.75 ± 3.8 mL/m2 , P = .008). LA end-systolic volume and index were not significantly different before vs after nifedipine (from 24.56 ± 8 to 25.3 ± 5.5 mL, from 13.6 ± 5.3 to 14.8 ± 3.4 mL/m2 ); P > .05, respectively. E/a ratio, E-tdi, and E/E-tdi did not change significantly ([from 2.54 ± 4.46 to 2.54 ± 4.1], [from 11.9 ± 1.9 to 11.9 ± 2], [from 7.8 ± 1.4 to 7.6 ± 1.1], respectively, P > .05). Tricuspid annular plane systolic excursion (TAPSE) did not change significantly from 23.77 ± 4.2 to 23.9 ± 3.3, P = .1. There was a significant decrease in pulmonary pressure (from 25.4 ± 4.2 to 23 ± 2.5 mm Hg, P = .02), in mean arterial pressure (from 80 ± 4 to 76 ± 3 mm Hg, P

Multisite cardiac resynchronization therapy (MSCRT) with dual-vein left ventricular (LV) pacing has theoretical advantages over conventional CRT in faster and more physiological LV activation. We aimed to define indications, feasibility, safety, acute, and long-term results of MSCRT. All patients implanted with MSCRT during 2008–2014 in a single center were reviewed and analyzed. Thirty-nine patients (90% CRT-defibrillators, 64 ± 9 years, 85% male, 74% ischemic etiology) were included. Four groups of indications were recognized: (1) significant tricuspid regurgitation (TR) in patients planned for device implantation without right ventricular lead (n = 3). Follow-up (f/u) of 4 ± 3 years showed major symptomatic improvement in all, with stable LV size and function and deferral of valve surgery; (2) severe heart failure with reduced ejection fraction (HFrEF) and refractory ventricular tachycardia (VT) (n = 4). Except for 1 early death for acute renal failure, all others showed no VT episodes and HF improvement (f/u 4.5 ± 0.5 years); (3) severe HFrEF and wide QRS (≥ 150 ms) or failure of biventricular pacing to narrow QRS during implantation (n = 5). One patient had periprocedural mortality. The others had major clinical improvement; (4) severe HF and narrow QRS/RBBB (n = 27). 23/24 patients with available f/u of 3 ± 1.7 years improved clinically and 57% had EF improvement. In 3 patients, LV1 was disabled and one had LV2 dislodgement. MSCRT is feasible, safe, and valuable in selected patients with a need to avoid RV lead during device implantation, refractory VT with no other solution, severe HFrEF with wide QRS or CRT non-responsiveness, and severe HF without LBBB. Randomized controlled studies are required.

Coronary Artery Ectasia (CAE) is a phenomenon characterized by locally or diffuse coronary artery dilation of one or more coronary arteries. In the present study, the prevalence of acquired coronary ectasia and coronary risk factors for CAE was analyzed in patients undergoing cardiac catheterization for suspected ischemic heart disease. We retrospectively analyzed 4000 patients undergoing coronary angiography for suspected coronary artery disease at our cardiac catheterization unit, and a total of 171 patients were selected. The study group was divided into three groups, 65 patients with CAE, 62 patients with significant obstructive coronary artery disease, and 44 patients with normal coronary angiograms as a control group. A negative correlation was observed between high-density lipoprotein cholesterol (HDL-C) and the presence of CAE (r = &ndash, 0.274, p &lt, 0.001). In addition, HDL-C (OR, 0.858, CI, 0.749&ndash, 0.984, p = 0.029), low-density lipoprotein cholesterol (LDL-C)/HDL-C ratio (OR, 1.987, CI, 1.542&ndash, 2.882, p = 0.034), and hemoglobin (OR, 2.060, CI, 1.114&ndash, 3.809, p = 0.021) were identified as independent risk factors for the development of CAE. In fact, we observed that a one-unit increase in HDL-C corresponded to a 15% risk reduction in CAE development and that each unit increase in hemoglobin could potentially increase the CAE risk by 2-fold. Low HDL-C could significantly increase the risk of developing CAE in healthy individuals. Elevated hemoglobin could predispose to subsequent dilation and aneurysm of the coronary artery. This work suggests that disordered lipoprotein metabolism or altered hemoglobin values can predispose patients to aneurysmal coronary artery disease.

Background Diabetes mellitus (DM) is a common and increasingly prevalent condition in patients with atrial fibrillation (AFib). The left atrium appendage (LAA), a small outpouch from the LA, is the most common location for thrombus formation in patients with AFib. Hypothesis In this study, we examined LAA remodeling differences between diabetic and nondiabetic patients with AFib. Methods This retrospective study analyzed data from 242 subjects subdivided into two subgroups of 122 with DM (diabetic group) and 120 without DM (nondiabetic group). The study group underwent real-time 3-dimensional transesophageal echocardiography (RT3DTEE) for AFib ablation, cardioversion, or LAA device closure. The LAA dimensions were measured using the "Yosefy rotational 3DTEE method." Results The RT3DTEE analysis revealed that diabetic patients display larger LAA diameters, D1-lengh (2.09 ± 0.50 vs 1.88 ± 0.54 cm, P = .003), D2-width (1.70 ± 0.48 vs 1.55 ± 0.55 cm, P = .024), D3-depth (2.21 ± 0.75 vs 1.99 ± 0.65 cm, P = .017), larger orifice areas (2.8 ± 1.35 and 2.3 ± 1.49 cm2 , P = .004), and diminished orifice flow velocity (37.3 ± 17.6 and 43.7 ± 19.5 cm/sec, P = .008). Conclusions Adverse LAA remodeling in DM patients with AFib is characterized by significantly LAA orifice enlargement and reduced orifice flow velocity. Analysis of LAA geometry and hemodynamics may have clinical implications in thrombotic risk assessment and treatment of DM patients with AFib.

The output settings of echocardiographic systems should be set to the full (original) frame rate and lossless compression (e.g., run-length encoding) in order to transmit echocardiographic videos so that they retain their original quality. In addition, monitors and display cards of echocardiography systems and workstations should be able to support an adaptive refresh rate for displaying video at an arbitrary frame rate, including a high frame rate (90+ fps) without dropping frames and preserving the original frame duration. Currently, the only available option for echocardiography monitors is 144-165 Hz (or higher) based on adaptive frame rate G-Sync or FreeSync technology monitors. These monitors should be accompanied by compatible display cards. Echocardiography systems and workstation video playback software should support G-Sync or FreeSync adaptive frame rate technology to display echocardiography videos at their original frame rates without the effects of jitter and frame drops. Echocardiography systems should support an online display of the videos on the workstations during acquisition with the original quality. The requirements for web-based workstations are the same as for desktops workstations. Hospital digital networks should provide transmission and long-term archiving of the echocardiographic videos in their original acquisition quality.

Background Intra-aortic balloon pump (IABP) counterpulsation provides mechanical support for patients with cardiogenic shock . The aim of the study is to evaluate the clinical characteristics and outcomes of patients with cardiogenic shock receiving IABP before and after the European Society of Cardiology (ESC) downgraded the use of IABP from a class I to a class IIb in 2012. Methods Data was obtained from the Acute Coronary Syndrome Israeli Survey (ACSIS) registry, a prospective observational national survey conducted once every two years. From a total of 15,200 patients with acute coronary syndrome (ACS), 524 patients were identified with acute myocardial infarction (AMI)-complicated with cardiogenic shock. The groups were further subdivided based on whether the IABP was implanted before or after the change in guideline recommendation. Results The study indicates a 24% reduction in IABP use since 2002. Until 2012, a reduction in clinical outcomes including 7-days, 30-days and in-hospital mortality, was observed in patients with IABP compared to the patients with conventional therapy. Conversely, after the ESC changed the guidelines, the clinical outcomes were not improved by IABP treatment. Additionally, the conventional therapy group presented with higher baseline ejection fraction , received less effective treatment, reperfusion and/or pharmacological therapy than patients with IABP. Conclusion The use of IABP as management for cardiogenic shock has diminished over time since the guidelines were modified. After the change in guidelines, the use of IABP is restricted to high-risk, severely compromised and hemodynamically deteriorated patients hence limiting beneficial outcomes.

Introduction Prevention of acute decompensated heart failure (ADHF) hospitalizations has both medical and economic implications, yet remains an unmet need. Increases in pulmonary and perhaps upper airway fluid content may be detectable remotely by voice analysis. The Cordio HearO™ system is a mobile application with cloud-based computing, designed to identify distinct speech measures (SM) in standard audio recordings which may be indicative of HF clinical status and provide early warning of impending decompensation. Hypothesis Cordio HearO™ speech analysis can identify clinical worsening of heart failure (HF) patients prior to hospitalization. Methods In this ongoing multicenter, observational study, we recruited 173 New York Heart Association Class II-III, stable stage C chronic heart failure patients. The patients recorded five sentences (2-5 sec each) each day in their native language (English, Hebrew, Arabic or Russian), using Cordio HearO™ operating on standard smartphone devices. Patients have been followed for 3 to 23 months. The current analysis explored the association between different SM parameters and episodes of HF decompensation requiring hospitalization. Results A total of 196,610 recordings, collected over 47,376 patient days of follow up were analyzed during which 13 patients required hospitalization for ADHF. 10 (76.9%) (95% CI: 54.02% - 99.83%) of these episodes were detected by Cordio HearO™ software an average of 12.2 (range 8 to 17 days) days prior to admission. The estimated false-positive event rate per year was 1.47 (95% CI: 1.28 - 1.68). Conclusions Cordio HearO™ novel speech analysis technology may be a useful tool in remote monitoring of HF patients, providing an early warning of impending episodes of decompensation, thus having the potential to reduce ADHF hospitalizations and improve patient quality of life and economic outcomes. Ongoing and future studies will continue to define the role of speech measures in the management of heart failure patients.

In this work, we present a new data mining (DM) approach (called tuned clustering analysis), which integrates clustering, and tuned clustering analysis. Usually, clusters which contain borderline results may be dismissed or ignored during the analysis stage. As a result, hidden insights that may be represented by these clusters, may not be revealed. This may harm the overall DM quality and especially, important hidden insights may be uncovered. Our new approach offers an iterative process which assist the data miner to make appropriate analysis decisions, and avoid dismissing possible insights. The idea is to apply an iterative DM process: clustering, analyzing, presenting new insights, or tuning and re-clustering those clusters which have borderline values. Clusters with borderline values are chosen and a new sub-database is built. Then, the sub-database is split, based on the attribute with the highest Entropy value. The tuning iterations, continues until new insights were found, or if the clusters quality are below a certain threshold. We demonstrated the tuned clustering analysis on real Echo heart measurements, using km-Impute clustering algorithm. During the implementation, initial clusters were produced. Although the quality of the clusters was high, no new medical insights were revealed. Therefore, we applied a clustering tuning and succeeded in finding new medical insights such as the influence of gender and the age on cardiac functioning and clinical modifications, with regard to resilience to diastolic disorder. Applying our approach has successfully managed to reveal new medical insights which were restored from borderline value clusters. This stands in contrast to traditional analysis methods, in which these potential insights may be missed or ignored.

Atherosclerosis is the main cause of cardiovascular (CV) morbidity and mortality in the western world. Detection and treatment of risk factors (such as hypertension, dyslipidemia and diabetes mellitus) reduce CV events. We have shown cost utility in reducing these CV risk factors in community clinics and community centers.In this paper we focused on community workplaces.We included 1011 workers in 15 worksites in the study. All workers were analyzed for CV risk factors and included in 6 months of intervention in their worksite in order to reduce the burden of CV risk factors.Significant reduction was noted in the percentage of high risk patients from 43.7% to 27.8% to 24.7% after 3 and 6 months respectively (p0.05), in the percentage of workers with high weight circumference, high blood pressure, smokers, and in high body mass index (30g/m2 ).Interventions in community workplaces can improve the CV risk factors profile and thus should be implemented as broadly as possible.

Lifestyle factors, including nutrition, play an important role in the etiology of Cardiovascular Disease (CVD). This position paper, written by collaboration between the Israel Heart Association and the Israel Dietetic Association, summarizes the current, preferably latest, literature on the association of nutrition and CVD with emphasis on the level of evidence and practical recommendations. The nutritional information is divided into three main sections: dietary patterns, individual food items, and nutritional supplements. The dietary patterns reviewed include low carbohydrate diet, low-fat diet, Mediterranean diet, and the DASH diet. Foods reviewed in the second section include: whole grains and dietary fiber, vegetables and fruits, nuts, soy, dairy products, alcoholic drinks, coffee and caffeine, tea, chocolate, garlic, and eggs. Supplements reviewed in the third section include salt and sodium, omega-3 and fish oil, phytosterols, antioxidants, vitamin D, magnesium, homocysteine-reducing agents, and coenzyme Q10.

Ischemic mitral regurgitation (MR) is common and increases heart failure and mortality after myocardial infarction.1,2 It is caused by left ventricle (LV) remodeling and subsequent papillary muscle (PM) displacement, with secondary mitral leaflet tethering. It can be seen classically in global LV dilatation and dysfunction or with more local remodeling involving the posterior PM and inferoposterior basal to mid LV wall.3 We report a case in which mitral leaflet tethering and severe MR occurred without either of these typical scenarios. An 82-year-old woman presented to the emergency department for recent-onset progressive exertional dyspnea, orthopnea, and lower extremity edema. She had known hypertension with LV hypertrophy, normal systolic function, mitral annular calcification, and mild mitral regurgitation by echocardiogram 6 months previously. Medical history was notable for hyperlipidemia, transient ischemic attack, and family history of coronary artery disease. Initial evaluation revealed overt heart failure with elevated NT-proBNP (> 9000 pg/mL). Chest X-ray showed bilateral pleural effusions and pulmonary vascular redistribution (Figure 1). Cardiac troponins were negative, but ECG showed new T-wave inversions suggestive of anteroseptal ischemia (Figure 2). Echocardiogram revealed …

BACKGROUND Alteration of diastolic function is considered a sensitive means for detecting changes in the normal cardiac adaptation to pregnancy. Our aim was to evaluate volumetric and functional atrial parameters, using real time three-dimensional echocardiography (RT3DE) in women in early and late third trimester of pregnancy. METHODS We studied pregnant women in early third trimester (III-E = gestational age 26-33 weeks), in late third trimester (III-L = gestational age 34-40 weeks), and control nonpregnant women (C). Two-dimensional (2D-Echo) and RT3DE were used to study 3D left atrial (LA) systolic and diastolic stroke volumes and index (LASVI, LAEDVI), emptying fraction, left ventricular and LA cavities. RESULTS Although the LA end systolic volume index increased significantly (from 19.42 ± 0.1 to 24.7 ± 3.5 mm(2), P < 0.01), the EF did not change significantly. This was mainly achieved by increasing atrial contraction (A-wave), maintaining cardiac output by increasing heart rate. A decrease in diastolic E-wave, increased atrial kick (A-wave) with reduced E/A ratio, was noted as the pregnancy progressed. Pulmonary pressure increased from 16.9 ± 6.6 to 20.5 ± 2.9 mmHg (P < 0.01), Using 2D-Echo revealed no change in LA diameter from control to III-E and III-L, respectively (from 17.1 ± 2.3 to 16.7 ± 2.6, 17.5 ± 2.2 mm) and area (from 11.7 ± 3.1 to 16.5 ± 2.3, 17.6 ± 1.6 cm(2)). However, using RT3DE, a significant increase in the LASVI, LAEDVI, and LA stroke volume index (from 12.02 ± 2.5 to 14.7 ± 3.2, and 15.1 ± 2.7 mL/m(2)) was detected. CONCLUSIONS Enlargement of the LA volume with unchanged blood pressure values, as found using RT3DE, may be part of the adaptation to increased blood volume during pregnancy.

Background— Mitral regurgitation (MR) generally accompanies inferobasal myocardial infarction (MI), with leaflet tethering by displaced papillary muscles. Mitral regurgitation is also reported with anteroapical MI without global dilatation or inferior wall motion abnormalities. We hypothesized that anteroapical MI extending to the inferior apex displaces the papillary muscles, tethering the mitral leaflets to cause MR. Methods and Results— In the retrospective part of the study, consecutive anteroapical MI patients were studied. Moderate-severe MR occurred in 9% of 234 patients with only anteroapical MI versus 17% of 242 with inferoapical extension ( P P P r =0.70) and its diminished systolic shortening ( r =−0.65). In the animal study, 9 sheep with left anterior descending coronary artery ligation were analyzed. Four sheep that developed MR had inferoapical MI extension with tethering length increasing over 1.5 months (2.1±0.4 to 2.9±0.4 cm, P P not statistically significant). In MR sheep, the normal decrease in tethering length from diastole to systole was eliminated ( P Conclusions— Anteroapical MI with inferoapical extension can mechanically displace papillary muscles, causing MR despite the absence of basal and midinferior wall motion abnormalities. This suggests the possibility of repositioning treatments for this condition.

Objectives We examined whether mitral regurgitation (MR) augments post-myocardial infarction (MI) remodeling. Background MR doubles mortality after MI, but its additive contribution to left ventricular (LV) remodeling is debated and has not been addressed in a controlled fashion. Methods Apical MIs were created in 12 sheep, and 6 had an LV-to-left atrial shunt implanted, consistently producing regurgitant fractions of ∼30%. The groups were compared at baseline, 1, and 3 months. Results Left ventricular end-systolic volume progressively increased by 190% with MR versus 90% without MR (p Conclusions In this controlled model, moderate MR worsens post-MI remodeling, with reduced contractility. Pro-hypertrophic pathways are initially upregulated but subsequently fall below infarct-only levels and baseline; with sustained caspase 3 elevation, transformation to a failure phenotype occurs. Extracellular matrix turnover increases in MR animals. Therefore, MR can precipitate an earlier onset of dilated heart failure.

Introduction: Dyskinesis is diagnosed by outward systolic bulging, but a similar inferior wall (IW) motion is sometimes observed in patients without infarction. Such diastolic flattening of the IW is followed by systolic rounding and outward bulging, consistent with extrinsic diastolic compression that is overcome by systolic contraction. Hypothesis: Pseudodyskinesis (PD) (paradoxical IW motion) is associated with preserved systolic wall thickening and does not reflect ischemic dysfunction. Methods: We compared 100 consecutive patients having a pattern of PD on transthoracic echocardiography with control groups of 50 patients with documented inferior myocardial infarction and 50 healthy individuals. Percent systolic thickening of the inferior, anterior, septal, and lateral left ventricular (LV) walls was measured in a midventricular short-axis view, and LV cross-sectional shape was evaluated by the ratio of two perpendicular diameters. Diaphragmatic position was evaluated on chest radiograph. Results: Systolic IW thickening was not significantly different in PD from that of normal (58.2 6.2% vs 53.0 4.6%) and of non-IW in the same patients (50.4 6.8%). The LV was circular (diameter ratio 1.0) in systole and diastole in healthy individuals; in PD, it was noncircular in diastole consistent with IW compression (P < .01), and circular in systole; in inferior myocardial infarction, it was circular in diastole and noncircular in systole (P < .01) consistent with decreased IW contraction. The left hemidiaphragm was more elevated in PD (78% vs 8.5%, P < .01). Conclusions: In PD, the IW thickens normally to produce a circular LV cavity in systole. This motion, consistent with extrinsic compression, is important to distinguish from inferior myocardial infarction. (J Am Soc Echocardiogr 2007;20:1374-1379.)

Pulmonary vein isolation (PVI) using the irrigated multi-electrode ablation system (nMARQ™) remains challenging in complex atrial anatomy cases and when CARTOMERGE™ technology is not available, due to absence of a leading guide-wire.Our objective was to assess feasibility and safety of PVI using nMARQ™ catheter with intra-procedural contrast injections through the deflectable sheath compared to nMARQ™ alone.This is a prospective non-randomized observational study of 78 consecutive patients who underwent PVI only with nMARQ™. The first group (n=37, 64±10.5 years, 62% male, 13.5% persistent AF) underwent the procedure with the guidance of signal mapping, fluoroscopy, and electro-anatomical mapping (EAM) alone. Since 12/2013 an automatic closed-loop contrast media injector was added to improve catheter location (n=41, 62.5±11 years, 71% male, 34% persistent AF).Total procedure time was 78±19 and 85.5±18.5 minutes, and mean fluoroscopy time was 30±9 and 29.5±8.7 minutes for the first and second groups, respectively (NS); acute success rate was 97% and 97.5%, with a mean of 14.7±5 and 17.6±5.4 RF applications, respectively (p=0.02); and mean total burning time of 10.3±3.6 and 12±4 minutes, respectively (p=0.08). Mean contrast used was 60±18 mL versus 203±65 mL, with no effect on renal function or major complications. One year freedom from AF was 77% and 83%, respectively (p=0.5).Addition of contrast injections to standard nMARQ™ procedure is feasible and safe. It has no benefit in routine use but further studies may confirm its potential added value to EAM in catheter localization by newly trained operators and in selective cases of large/common PV anatomy.

Aims We compare our experience with available circular multi-electrode catheters for atrial fibrillation (AF) ablation: PVAC®, a phased radiofrequency system, and nMARQ™, an irrigated tip-CARTO-based technology. Methods and results Prospective observational study of 175 consecutive patients with follow-up duration of at least 5 months who underwent pulmonary vein isolation (PVI) for symptomatic AF using PVAC® ( n = 93, age 61.4 ± 9.8 years; 60% male, 13% persistent AF) vs. nMARQ™ ( n = 82, age 63.2 ± 10.6 years; 67% male, 24% persistent AF). Procedure and radiation times were 94 ± 27 and 33 ± 13 min for PVAC® and 81 ± 18 and 30 ± 8.5 for nMARQ™ ( P = 0.0008 and P = 0.18), respectively. The number of applications and the total burning time (min) were 20 ± 7 and 19 ± 6.7 for PVAC® and 16 ± 5.6 and 11 ± 4 for nMARQ™ ( P < 0.0001 for both), respectively. In two nMARQ™ patients with small atria and pulmonary veins (PVs) and in two PVAC® patients with large PVs, the procedure failed; switching to the alternative technology was successful. Acute success rate was 97% for PVAC® and 95% for nMARQ™. There was one tamponade in nMARQ™ group and non-significant different minor complications for both techniques. One-year freedom from AF was 79 and 80.7% with PVAC® vs. nMARQ™, after one PVI, and 88 vs. 87.7% after two PVIs. Conclusion Both technologies have short procedure and fluoroscopy times, comparable complication rates, and comparable acute and 1-year success rates. The number of applications and total procedure and burning times were shorter with nMARQ™. nMARQ™ was more suitable for larger atria and PVs. Thus, a patient-based pre-ablation anatomy definition is probably warranted for appropriate selection of technology type.

Owing to high prevalence of arterial hypertension (AH) and allergic rhinitis (AR), these diseases frequently coexist. The study aimed to assess whether improvement of AR by conventional treatment can improve blood pressure (BP) control in this population. Sixty-eight subjects of both sexes aged 35-60 years with AR and AH were randomized into two groups to receive in addition to their antihypertensive medications: treatment group (n=34) Fluticasone nasal 50 microg/spray b.i.d. and Fenoxifenadine 180 mg tablets q.d., and control group (n=34) 0.9% NaCl nasal drops b.i.d. Office BP and AR severity (using the Relative Quality of Life Questionnaire (RQLQ)) and high-sensitive C-reactive protein (hs-CRP) were measured at study entry and after 8 weeks in both groups, without changing of antihypertensive medications. In Treatment group an improvement in RQLQ, significant reduction of systolic BP (SBP) (DSBP 7.4 +/- 4.3 mm Hg, P=0.006) and reduction of hs-CRP level (DCRP 2.05 +/- 1.08; P=0.028) were observed, whereas diastolic BP (DBP) remained unchanged (DDBP 0.9 +/- 1.7 mm Hg, P=0.7). There was a significant correlation between DRQLQ and DSBP (r=0.86; P=0.019) and between DCRP and DSBP (r=0.56; P=0.027). No statistically significant changes of RQLQ, BP and CRP were observed in the control group. In patients with coincidence of AH and AR, medications meant to improve AR attenuate low-grade systemic inflammation and can lower SBP, but not DBP.

Hypertensive response at peak-exercise and during the recovery phase of exercise stress test (ET) is associated with poor cardiovascular prognosis. We investigated whether decrease in blood pressure (BP) from peak to post-exercise would identify a subgroup at higher cardiovascular risk.Eighty-six non-hypertensive patients (0-4 cardiovascular risk factors) with hypertensive reaction at peak-ET (systolic180 mm Hg and/or diastolic100 mm Hg) were divided based on BP 5 min after exercise termination into two groups: Normal response (NrmR) (160/90 mm Hg), Hypertensive response (HypR) (/=160/90 mm Hg). Five years later the prevalence of cardiovascular risk factors and cardiovascular morbidity and mortality was assessed for each group.Both groups had similar pre- and peak-exercise BP. However the HypR group had higher post-exercise BP (systolic: 163+/-13 vs. 125+/-14 mm Hg, respectively, p0.01, and diastolic: 74+/-6 vs. 75+/-4 mm Hg, respectively, p0.01), smaller decrease in BP after exercise (Delta systolic: 46.9+/-3.1 vs. 73.9+/-3.6 mm Hg, respectively, p0.01, Delta diastolic: 12.4+/-1.5 vs. 26.5+/-2.2 mm Hg, respectively, p0.01), and higher post- than pre-exercise BP (Delta systolic: 24.5+/-3.5 vs. -6+/-4.1 mm Hg, respectively, p0.01, A diastolic: 19+/-2.1 vs. -13+/-2.3 mm Hg, respectively, p0.01). Five years later, HypR group had higher prevalence of abnormal cholesterol serum level (p0.01), hypertension (p0.01) and combined ischemic heart disease and cerebrovascular disease (RR 1.32, 95% CI=1.13-1.54, p0.01).During ET evaluation, it is important to evaluate the BP at 5 min after exercise because reduced BP drop, at this routinely measured point, identifies a subgroup with higher cardiovascular risk.

Hormone replacement therapy (HRT) was given for many years in order to relieve menopausal symptoms and was used for as long as symptom control was necessary. The Heart and Estrogen/Progestin Replacement Study (HERS) and Women's Health Initiative (WHI) studies showed that HRT should not be given for primary or secondary prevention of coronary heart disease (CHD). However, what about those patients during acute myocardial infarction who are already taking HRT? Is the 'don't stop don't start' rule still true? A 58-year-old white female, on HRT was admitted with acute myocardial infarction (MI). We tried to answer the above questions in light of the new information:Based on current evidence available from HERS and WHI trials, it is not advisable to initiate HRT in women with established CHD for the sole purpose of preventing first or recurring coronary events. A statement by the American Heart Association recommends that the decision to continue or stop HRT in women with CV disease should be based on established benefits and risks, taking patients preference into account. The WHI study did not change this policy in the acute phase. In most cases, we believe HRT should be continued for some period (our decision for 3 months long was arbitrary), and discontinued gradually. We believe that this should be the policy until we have a double-blind placebo-control data to revise.

Background— Mitral valve prolapse (MVP) is a common disorder associated with mitral regurgitation, endocarditis, heart failure, and sudden death. To date, 2 MVP loci have been described, but the defective genes have yet to be discovered. In the present study, we analyzed a large family segregating MVP, and identified a new locus, MMVP3 . This study and others have enabled us to explore mitral valve morphological variations of currently uncertain clinical significance. Methods and Results— Echocardiograms and blood samples were obtained from 43 individuals who were classified by the extent and pattern of displacement. Genotypic analyses were performed with polymorphic microsatellite markers. Evidence of linkage was obtained on chromosome 13q31.3-q32.1, with a peak nonparametric linkage score of 18.41 ( P D13S132 . Of the 6 related individuals with mitral valve morphologies not meeting diagnostic criteria but resembling fully developed forms, 5 carried all or part of the haplotype linked to MVP. Conclusions— The mapping of a new MVP locus to chromosome 13 confirms the observed genetic heterogeneity and represents an important step toward gene identification. Furthermore, the genetic analysis provides clinical lessons with regard to previously nondiagnostic morphologies. In the familial context, these may represent early expression in gene carriers. Early recognition of gene carriers could potentially enhance the clinical evaluation of patients at risk of full expression, with the ultimate aim of developing interventions to reduce progression.

The association of left atrial volume at rest and the left atrial emptying fraction with exercise capacity during stress echocardiography was examined in patients with normal left ventricular function and without ischemia. The left atrial emptying fraction, along with body mass index, was found to be an independent predictor of poor exercise capacity (5 METs).

This study was designed to assess the circadian variation of the efficacy of thrombolytic therapy (TT) in 163 patients with acute myocardial infarction. Statistical analysis of the results suggests the existence of circadian variation in the efficacy of thrombolytic therapy with marked early morning resistance and significantly better late daytime results. There is a strong relationship between the normal physiologic rhythms of biochemical, hemodynamic, and hematologic parameters, observed in patients with CAD and the circadian fluctuations of efficacy of TT. Obviously the efficacy of TT is influenced by more evident impact of chronorisk factors during the early morning hours.

Background Blood pressure (BP) reduction is crucial in reducing cardiovascular (CV) morbidity and mortality in the community. Subjects aged 20–65 seldom visit the primary care clinics, so they are unlikely to be detected without an active outreach screening program. The aim of the project was to prepare a professional doctor–nurse screening team, who will instruct those found to be at high risk in control of their risk factors, in order to reduce CV morbidity and mortality. Methods During a 10-year period (1980–1990), teams examined 12,202 subjects, (mean age 51 ± 7 years, range 20–65 years) accounting for 23.4% of the total regional population. High risk subjects underwent an intensive CV risk factor control program. Results Subjects (3,506 or 28.6%) were found to have one or more CV risk factors (hypertension, obesity, smoking, hypercholesterolemia). During an average of 2 years, follow-up BP, weight reduction, and smoking cessation remained statistically significant. Total cholesterol was unchanged. Over this period, the standardized mortality ratio (SMR) in the area for acute MI fell from 100 to 76 (P < 0.01), for CV disease from 129 to 107 (P < 0.0001), and for hypertension from 121 to 87 (P < 0.1 NS). The project saved many life-years at no additional net cost to society, and cost effectiveness analysis showed positive results. Conclusions A community approach with mainly nonpharmacological treatment is feasible and cost effective in reducing CV morbidity and mortality.

Blood pressure (BP) reduction is crucial in reducing cardiovascular morbidity and mortality. The IBPC (Israeli Blood Pressure Control) program was initiated in order to enhance the control of modifiable risk factors among high-risk hypertensive patients under follow-up by general practitioners in Israel. The cost effectiveness of an intervention program is an important factor in the decision-making process of its implementation and therefore was evaluated here. The objective of this evaluation is to estimate the costs, monetary savings and benefits in terms of QALYs (quality-adjusted life years) that would be expected if the program were to be expanded to 100 clinics nationwide, enabling around 14800 persons to be treated.Hypertensive patients were screened in 30 general practice clinics, supervised by specialists in family medicine, each seeing 1000-5000 patients; 50-250 hypertensive patients were diagnosed at each participating clinic. BP levels, body mass index (BMI), lipid and glucose levels, as well as target organ damage and medications were recorded for all patients.A total of 4948 (2079, 42% males) were registered. Mean age was 64.8 +/- 12 years. After 1 year of follow-up versus baseline, the various parameters were as follows: BP control was achieved in 46.4% vs 29% of all hypertensive patients. LDL control (JNC VI criteria) was achieved in 41.7% vs 31.2% of all patients. Fasting plasma glucose control (glucose126 mg/dl) was achieved in 22% vs 19% of diabetic patients and 5.2% vs 3.1% of the diabetics had fasting plasma glucose levels200 mg/dl. Obesity (BMI30 kg/m2) was noted in 36.7% vs 43.8% at baseline. The cost utility analysis of the reduction in risk factors was calculated based on the international dicta applied to the reduction in risk factors as a result of treatment. For 100 clinics nationwide and 14800 persons to be treated the net saving to health services would be $977993 and the increase in QALYs would be 602 years.Better risk factor control in hypertensive patients by general practitioners could reduce morbidity and mortality as well as be cost effective.

There are three major mechanical complications of acute myocardial infarction: rupture of the left ventricular free wall, rupture of the interventricular septum, and development of mitral regurgitation. Each of these complications is associated with extremely high mortality. Reviewing the scientific literature, we found descriptions of sporadic cases of both of those complications combined. We report an unusual case of simultaneous rupture of free wall and interventricular septum.