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Diabetes mellitus (DM) is associated with an increased risk of complications in atrial fibrillation (AF). This study aimed to assess the incidence and risks of ischemic stroke and mortality according to baseline HbA1c levels in patients with DM and AF. We conducted a cohort study using Clalit Health Services electronic medical records. The study population included all Clalit Health Services members aged ≥25 years, with the first diagnosis of AF between January 1, 2010, and December 31, 2016, who had a diagnosis of DM. The risk of stroke and all-cause death were compared according to HbA1c levels at the time of AF diagnosis:7.0%, between 7% and 9%, and ≥9%. A total of 44,451 patients with DM and AF were identified. The median age was 75 years (interquartile 65 to 83), and 52.5% were women. During a mean follow-up of 38 months, higher levels of HbA1c were associated with an increased risk of stroke with a dose-dependent response when compared with patients with HbA1c7% (Adjusted hazard ratio [aHR] =1.30 [95% confidence interval 1.10 to 2.05] for levels between 7% and 9% and 1.60 (95% confidence interval 1.25 to 2.03) for HbA1c9%, even after adjusting for CHA

Background Diabetes mellitus (DM) increases the risk of embolism in nonvalvular atrial fibrillation (NVAF). The association between pre-diabetes and risk of ischemic stroke has not been studied separately in this population. Objectives The purpose of this study was to evaluate whether pre-diabetes is associated with increased risk of stroke and death in patients with NVAF. Methods We conducted a historical cohort study using the Clalit Health Services electronic medical records. The study population included all members aged ≥25 years, with a first diagnosis of NVAF between January 1, 2010, and December 31, 2016. We compared 3 groups of individuals: those with pre-diabetes, those with diabetes, and normoglycemic patients. Results A total of 44,451 cases were identified. The median age was 75 years, and 52.5% were women. During a mean follow-up of 38 months, the incidence rates of stroke (per 100 person-years) were: 1.14 in normoglycemic individuals, 1.40 in those with pre-diabetes, and 2.15 in those with diabetes. In both univariate and multivariate analyses, pre-diabetes was associated with an increased risk of stroke compared with normoglycemic persons (adjusted hazard ratio [adjHR]: 1.19; 95% confidence interval [CI]: 1.01 to 1.4) even after adjustment for CHA2DS2-Vasc risk factors and use of anticoagulants, while diabetes conferred an even higher risk (vs. normoglycemia (adjHR: 1.56; 95% CI: 1.37 to 1.79). The risk for mortality was higher for individuals with diabetes (adjHR: 1.47; 95% CI: 1.41 to 1.54) but not for those with pre-diabetes (adjHR: 0.98; 95% CI: 0.92 to 1.03). Conclusions In this cohort of patients with incident NVAF, pre-diabetes was associated with an increased risk of stroke even after accounting for other recognized risk factors.

Funding Acknowledgements Pfizer Israel Background Diabetes mellitus (DM) is associated with increased risk of embolic complications in non-valvular atrial fibrillation (NVAF). Whether the risk of stroke in AF patients remains the same among the wide spectrum of disease is yet to be determined. Aim Among individuals with AF and DM, to assess the incidence rates and risk of ischemic stroke and mortality by baseline HbA1C levels. Methods We conducted a prospective, historical cohort study using the Clalit Health Services (CHS) electronic medical records database. The study population included all CHS members ≥ 21 years old, with a first diagnosis of NVAF between January 1, 2010 to December 31, 2016 and a minimal follow-up period of 1 year. Among those patients identified as diabetics, we compared three groups of patients according to HBA1C levels at the time of AF diagnosis: Results A total of 44,451 cases were identified. The median age was 75 years (IQR 65-83) and 52.5% were women. During a mean follow up of 38 months, the incidence of stroke per 100 person-years in the three study groups was: 1.9 in patients with HBA1C 9%. In both univariate and multivariate analyses, higher levels of HBA1C were associated with an increased risk of stroke compared with a dose-dependent response when compared to individuals with HBA1C 9% group after adjusted analysis {aHR = 1.17 (1.07- 1.28)} Conclusion: In this observational cohort of patients with incident newly diagnosed nonvalvular atrial fibrillation, HBA1C levels were associated with an increased risk of stroke in a dose-dependent manner even after accounting for other recognized risk factors for stroke in this population. Abstract Figure. Kaplan-Meier for stroke-free survival

Funding Acknowledgements Pfizer pharmaceutical corporation Background Diabetes is a known risk factor for thromboembolic events in patients with non-valvular atrial fibrillation (NVAF). Whether patients on insulin therapy are at an increased risk for stroke compered to patients treated solely by oral antidiabetic medications is not yet established. Aim To assess the risk of ischemic stroke and mortality in patients with NVAF and diabetes mellitus (DM) treated by insulin vs. oral antidiabetic treatment. Methods A prospective, historical cohort study based on the Clalit Health Services (CHS) electronic medical records database, including all individuals age ≥ 21 years with a first diagnosis of NVAF between January 2010 to December 2016 and a minimal follow-up period of 1 year. Patients were divided into two groups based on their diabetes therapy regiment (insulin vs. oral antidiabetic medications). Results Overall study population included 12,231 patients with AF and DM, of them 3510 (28.7%) had an insulin-requiring diabetes. The median age was 72.4 years (IQR 65-80) in the insulin- treated group and 75.2 (IQR 68-83) in the orally treated group, with a slight majority of women in both groups, 51.6% and 53.5% respectively. Patients in the insulin group had significantly higher co-morbidity rates including hypertension (HTN) (93.6% vs. 91.2%; p Conclusion In this cohort of patients with newly diagnosed NVAF and DM, patients on insulin are at increased risk of all cause mortality and a have a trend of increased risk of stroke after accounting for other recognized risk factors for stroke and mortality in this population.

BACKGROUND AND AIM Revascularization guidelines support routine Heart Team (HT) discussion of appropriate patients. The effect of HT on decision making and clinical outcomes has not been explored. The aim of our study is to investigate the impact of the HT on the mode and delay to revascularization. METHODS We compared data from a prospective cohort of consecutive patients with multivessel coronary artery disease (CAD) referred for HT discussion between 2016 and 2017 (HT group) with a historic control group of patients matched according to clinical and angiographic characteristics treated between 2005 and 2015 (No HT group). RESULTS There were 93 patients in each group. The HT group and the No HT groups had a similar rate of ACS as well as cardiovascular risk factors and significant left ventricular (LV) dysfunction. No difference was observed in the mean Society of Thoracic Surgery score (2.5 ± 3 vs 3 ± 3; P = .32) and the mean SYNTAX score was low and similar in both groups (21 ± 6 vs 19 ± 6; P = .59). The treatment recommendations changed greatly, with 63% of patients being referred for coronary artery bypass grafting (CABG) after HT discussion but only 23% in the No HT group (P

Funding Acknowledgements Pfizer Israel Background Diabetes mellitus is a well-established independent risk factor for embolic complications in patients with non-valvular atrial fibrillation (NVAF). The association between prediabetes and risk of ischemic stroke, however, has not been studied separately in patients with NVAF. Purpose To evaluate whether pre-diabetes is associated with increased risk of stroke and death in patients with NVAF Methods We conducted a prospective, historical cohort study using the Clalit Health Services (CHS) electronic medical records database. The study population included all CHS members ≥ 21 years old, with a first diagnosis of NVAF between January 1 2010 to December 31 2016 and a minimal follow-up period of 1 year. We compared three groups of patients: prediabetes, those with established DM, and normoglycemic individuals Results A total of 44,451 cases were identified. The median age was 75 years and 52.5% were women. During a mean follow up of 38 months, the incidence of stroke per 100 person-years in the three study groups was: 1.14 in non-diabetics, 1.40 in pre-diabetics and 2.15 in diabetics. In both univariate and multivariate analyses, pre-diabetes was associated with an increased risk of stroke compared with non-diabetics (Adjusted Hazard Ratio (HR) = 1.19 {95% CI 1.01-1.4}) even after adjusting for CHA2DS2-VASC individual risk factors and use of oral anti-coagulants while diabetes conferred an even higher risk (vs non-diabetics { HR = 1.56, 95% CI ;1.37 - 1.79}). The risk for mortality was higher for diabetics (HR =1.47, 95% CI ;1.41, 1.54}) but not for pre-diabetics (HR = 0.98 ,CI 95%; 0.92 - 1.03). Conclusion: In this observational cohort of patients with incident newly diagnosed patients with NVAF, pre-diabetes was associated with an increased risk of stroke even after accounting for other recognized risk factors. Abstract Figure. Kaplan-Meier for stroke-free survival

Funding Acknowledgements pfizer Background Diabetes mellitus (DM) is associated with increased risk of embolic complications in non-valvular atrial fibrillation (NVAF). Chronic kidney disease (CKD) has been shown in some studies to increase the risk of stroke. This finding is not consistent among all studies. Therefore the relationship between kidney function, diabetes and stroke risk is complex and warrants further investigation. Purpose To assess the incidence rates and risk of ischemic stroke and mortality by baseline Estimated Glomerular Filtration Rate (eGFR) levels among individuals with AF and DM. Methods A prospective, historical cohort study using our electronic medical records database. The study population included all members 21 years old, with a first diagnosis of NVAF between January 1, 2010 to December 31, 2016 and a minimal follow-up period of 1 year. Among those patients identified as diabetics, we compared three groups of patients according to eGFR levels at the time of AF diagnosis: eGFR ≥ 60, between 30-60 and ≤ 30 or chronic dialysis or kidney transplant. Results A total of 17,567 cases were included in the final analysis, of them, 11013 (62.7%) had eGFR ≥ 60, 4930 (28%) with eGFR between 30-60 and 1624 (9.24%) with eGFR ≤30 . The median age was 75 years (IQR 65-83) with a majority of females in all groups, 52.5%, 51.2% and 55.5% respectively. The incidence of stroke per 100 person-years in the three study groups was: 1.88 in patients with eGFR ≥ 60, 2.69 in patients with eGFR between 30-60 and 3.34 in those with eGFR ≤ 30 . Impaired renal function was associated with increased risk of stroke in univariate analysis, but not found in the adjusted model (Adjusted Hazard Ratio (AHR) = 1.04 {95% 0.89-1.23} for eGFR 30-60 and 1.16 {95% CI 0.88-1.51} for eGFR ≤ 30 compared to GFR ≥ 60). incidence of mortality per 100 person-years was 10.78 in patients with eGFR ≥ 60, 21.49 in patients with eGFR 30-60 and 41.55 in those with eGFR ≤ 30. In both univariate and multivariate analyses, decreased levels of eGFR were associated with increased mortality risk compared to subjects with normal renal function (AHR 1.22 {95%CI 1.14-1.27} and AHR 2.09 {95%CI 1.95-2.24} for eGFR between 30-60 and for eGFR ≤ 30, respectively). Conclusion In this observational prospective cohort of patients with newly diagnosed NVAF, impaired renal function was not found to be associated with increased risk of stroke. Lower eGFR levels were associated with an increased mortality risk.

This chapter will discuss differences in response to cardiac resynchronization therapy (CRT) between men and women. This chapter will specifically address data derived from registries, metaanalyses, and observational studies that compared clinical and echocardiographic data. Data will be given as to differences in response to CRT between men and women as measured by echocardiographic parameters of reverse cardiac remodeling. In addition, we will address differences in clinical response and mortality between men and women as well as the difference between men and women in regard to QRS duration above which a favorable response is seen.

Introduction Oral anticoagulation (OAC) therapy reduces the risk of ischemic stroke in patients with atrial fibrillation (AF) while increasing the risk of bleeding. Recently, non-vitamin K antagonist oral anticoagulants (NOACs) have become available with lower rates of intracranial bleeding, and some of them have presented a reduced risk of major bleeding. The purpose of this study is to evaluate the change in purchasing patterns of OACs (both warfarin and NOACs) over time in patients with AF according to stroke and bleeding risk, in the first 3 months after diagnosis. Methods and results We conducted a historical cohort study using the Clalit Health Services electronic medical records database. The study population included all members aged ≥21 years, with a new diagnosis of nonvalvular AF between 2008 and 2015. A total of 58 385 cases were identified. The mean age was 73.1 (±14.1) years, and 52.3% of the patients were women. The median CHA2 DS2 -VASc score was 4 (interquartile range, 3-5). OACs were purchased by 19 705 patients (33.8%) within the first 3 months of first diagnosis of AF, with patients at higher embolic risk as stratified by the CHA2 DS2 -VASc score and having higher purchasing rates (37.1%). Between 2008 and 2010, 29% of patients purchased a vitamin K antagonist, the only available OAC at the time. OAC purchasing increased to 41.4% between 2014 and 2015, with half of the patients purchasing an NOAC. Conclusion In this real-world, population-based cohort study of patients with newly diagnosed AF, we found a lower than expected rate of OAC prescription within 3 months of diagnosis but an encouraging increase in OAC purchasing over time. The use of NOACs has risen exponentially within just a few years, accounting for a greater pool of patients with being prescribed an OAC.

Diabetic ketoacidosis (DKA) is one of the most common and serious acute complications of diabetes and is a significant cause of morbidity and mortality. In the last decade the mortality rate from DKA has declined because of greater recognition and improvements in its management. The current available guidelines state that the most effective means of insulin delivery during DKA is a continuous infusion of regular insulin, usually referred to as continuous low-dose insulin infusion. However, the cost of this treatment is usually quite high, because patients are required to be admitted to an intensive care unit in order to be monitored closely. New analogs of human insulin that have a rapid onset of action have become available in the past decade and represent potential alternatives to the use of regular insulin in the treatment of DKA. In several trials it has been demonstrated that the use of subcutaneous rapid-acting insulin analogs represents a safe, cost-effective and technically simpler treatment that precludes intensive care unit admission without significant differences in outcome in the management of patients with mild to moderate, uncomplicated DKA. The long-acting insulin analog may have a role in facilitating the transition from continuous intravenous insulin infusion to subcutaneous maintenance therapy in patients with DKA. This avoids rebound hyperglycaemia and ketogenesis when intravenous insulin is stopped and may avoid excess length of stay.

Background Peri-partum cardiomyopathy (PPCM) is a clinical heart failure that usually develops during the final stage of pregnancy or the first months following delivery . High maternal serum uric acid concentrations have been previous associated with heart failure and preeclampsia. Objectives 1) To explored the clinical characteristics of PPCM patients; and 2) to determine the association between maternal serum uric acid concentrations and PPCM. Methods This is a retrospective population based case control study. Cases and controls were matched 1:4 (for gestational age, medical history of cardiac conditions and creatinine); conditional logistic regression was used to identify clinical parameters that were associated with PPCM. Results The prevalence of peripartum cardiomyopathy at our institution was 1–3832 deliveries (42/160,964). In a matched multivariate analysis high maternal serum uric acid concentrations were associated with PPCM (O.R 1.336, 95% C.I 1.003–1.778). Uric acid concentrations were higher within the Non-Jewish patients and mothers of male infant with PPCM in compare to those without PPCM (p value 0.003 and 0.01 respectively). Conclusion PPCM patients had increased maternal serum uric acid concentrations. This observation aligns with previous report regarding the increased uric acid concentration in women with preeclampsia and congestive heart failure, suggestive of a common underlying mechanism that mediates the myocardial damage.

The prevalence of diabetes is rising in the >65 year-old group. The challenge of defining the goals of therapy arises from the heterogeneity of the aging process and the sparse clinical data in this patient population. In light of these challenges, the clinician should be aware of the pitfalls of caring for the older diabetic patient and prioritize an individualized treatment plan to ensure an optimal glycemic control, without placing the patient at unnecessary risk. We present a review of the current guidelines and literature that deal specifically with the treatment of the older diabetic patient in order to establish the principles of treatment in this age group and help the clinician make decisions regarding the care of these patients.