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Minimal attention has been paid to understanding the implications of the chronicity of heart failure (HF) diagnosis on prognosis of hospitalized patients with acute HF (AHF). We aimed to assess the differences in outcomes between hospitalized patients with AHF that are new-onset (de-novo) AHF and acutely decompensated chronic HF (ADCHF). We analyzed data of 2,328 patients with AHF, who were enrolled in the HF survey in Israel. Patients were classified into de-novo AHF and ADCHF. A total of 721 (31%) patients were classified as de-novo AHF and 1,607 (69%) patients were classified as ADCHF. Patients with de-novo AHF were more likely to be younger, with fewer co-morbidities represented by lower Charlson index, and less likely to have past myocardial infarction as well as coronary revascularization. At 30 days mortality rates were similar in both groups (9% vs 8% in de-novo AHF and ADCHF, respectively). Survival analysis showed that at 1 and 10 years the all-cause mortality rates were significantly higher in patients with ADCHF (33% vs 22% and 90% vs 72%, 1 and 10 years, log-rank p < 0.001, respectively). Consistently, multivariable analysis showed that patients with ADCHF had an independently 58% and 48%, higher mortality risk at 1 and 10 years, respectively, (1-year hazard ratio = 1.58; 95% confidence interval 1.05 to 2.38, p = 0.03; 10-year hazard ratio = 1.48; 95% confidence interval = 1.23 to 2.77; p < 0.001). In conclusion, previous history of HF is an independent predictor of 1-year and 10-year mortality after hospitalization for AHF. Distinction between de-novo AHF and ADCHF may improve our understanding and risk stratification of patients with AHF.

In patients with reduced ejection fraction, mild heart failure, and prolonged QRS duration, CRT with a defibrillator improved survival, as compared with defibrillator therapy alone. The survival benefit was limited to patients with left bundle-branch block. The Multicenter Automatic Defibrillator Implantation Trial with Cardiac Resynchronization Therapy (MADIT-CRT) showed the safety and effectiveness of cardiac-resynchronization therapy (CRT) with a defibrillator (CRT-D) in patients with asymptomatic or mildly symptomatic heart failure, a reduced ejection fraction, and a prolonged QRS duration. 1 The study showed that treatment with CRT-D was associated with a 34% relative reduction in the risk of nonfatal heart-failure events or death from any cause, as compared with implantable cardioverter–defibrillator (ICD) therapy alone over a median follow-up period of 2.4 years. The benefit of CRT-D in the trial was primarily driven by a significant relative reduction of . . .

Clinical and experimental data support a critical role for inflammation in cardiovascular disease. The purpose of the current study was to examine the relation between an inflammatory marker, neutrophil-to-lymphocyte ratio (NLR), and incident atrial fibrillation (AF) in asymptomatic adults. We investigated 21,118 self-referred men and women who were annually screened in a tertiary medical center. All subjects were free of AF at baseline and had their serum NLR calculated at the first annual visit. Subjects were divided into 2 groups based on their baseline NLR: Low (<2.83; n = 17,524) and high (≥2.83; n = 3,594; Upper Sextile). The primary endpoint was new onset AF during follow-up. Mean age of study population was 48 ± 10 years and 72% were men. A total of 563 (2.7%) incident events occurred during an average follow-up of 7.5 ± 5 years. Unadjusted Cox regression analysis demonstrated that each 1 unit increase in NLR was associated with a significant 14% increase in risk of occurrence of a first AF event (95% confidence interval 1.06 to 1.23, p < 0.001) and 20% increased risk of death. Kaplan-Meier's survival analysis showed that the cumulative probability of incident AF was significantly higher among subjects with high NLR compared with low NLR group (p = 0.006). Interaction analysis with adjustment to clinical parameters showed that NLR-related risk was age-dependent, such that in the younger age-group (< =50 years) high NLR group had two folds increased risk for AF event compared with low NLR group (95% confidence interval 1.08 to 3.51; p = 0.027) whereas among older subjects the rate of events was similar between both NLR groups (p = NS; p for interaction = 0.024). In conclusion, our findings suggest that high NLR is associated with increased risk of new onset AF. This finding is more pronounced among young adults.

Background Female LQTS patients are at high risk for arrhythmogenic events during the postpartum period due to hormonal influence on cardiac repolarization. Methods We observed an LQT1 patient with previous cardiac events during pregnancy and 3 weeks postpartum. We obtained ECG recordings and quantified sex hormone levels. Results Peak pregnancy: QTc: 420 ± 7 ms, Estradiol: 24.18 ng/mL, Progesterone: 218 ng/mL. Seven days postpartum: QTc prolongation to 455 ± 5 ms. 22 days postpartum: QTc: 452 ± 5, Estradiol: 0.013 ng/mL, Progesterone: 0.25 ng/mL. Conclusions Estradiol and Progesterone decline rapidly after birth, correlating to QTc prolongation and elevated risk for arrhythmogenic events. Therefore, modification of pharmacological or device therapy may be considered. We present the case of an LQT1 patient with a previous cardiac event during the postpartum period. Performance of electrocardiograms and Estradiol as well as Progesterone levels revealed prolonged QT intervals postpartum correlating to declining sex hormone levels elevate the risk for arrhythmic events in this period.

Sudden cardiac death (SCD) in patients with ischemic heart disease remains a leading cause of death. Prediction of who is at risk is based on the left ventricular ejection fraction (EF). However, the majority of victims of SCD have a normal EF, and the majority of patients implanted with an implantable cardioverter- defibrillator based on their EF are never treated by their device. Several parameters could allow better prediction of SCD. Several signs on the ECG and Periodic Repolarization Dynamics have been associated with increased risk. Elevated serum biomarkers such as pro-B type natriuretic peptides and serum soluble suppression of tumorigenicity 2 protein (sST2) are predictive of SCD. On the echocardiogram, global longitudinal strain, speckle tracking and relative wall thickness have been implicated. Programmed ventricular stimulation studies and cardiac magnetic resonance are promising modalities that could be further investigated. In conclusion, the EF is an imperfect tool for predicting SCD. Using the modalities reviewed, a model could be created for better prediction of patients at risk.

Information regarding the significance of platelet (PLT) count on outcome of atrial fibrillation (AF) patients who are treated with anticoagulants is limited. We conducted a monocentric observational retrospective cohort study of AF patients treated with either warfarin (n = 6287) or non-vitamin K antagonist oral anticoagulants (NOACs) (n = 5240). Patient were divided into 3 subgroups; low, normal and high PLT for counts < 150 K/ μl, 150-450 K/ μl and > 450 K/ μl, respectively. A multivariate Cox-regression was used to evaluate the association between PLT subgroups and clinical outcomes. During follow-up [median = 40.6 months (IQR 17.6-60)], mortality (HR 1.36, 95 CI 1.1-1.74, p = 0.01) and rate of myocardial infarction (MI) (HR 2.4, 95 CI 1.28-4.57, p = 0.007) were higher in patients with high compared to normal PLT. Transient ischemic attack or cerebrovascular accident (TIA/CVA) rate was lower in patients with low compared to normal PLT (HR 0.69, 95 CI 0.51-0.93, p = 0.02). A comparison between NOACs and warfarin demonstrated a significantly better clinical outcome for patients on NOACs in both the low (lower mortality rates) and normal PLT subgroup (lower mortality, TIA/CVA and systemic emboli rates). For patients on NOACs, low and high compared to normal PLT were associated with a higher combined outcome (HR 1.12, 95 CI 1-1.38, p = 0.047), and a higher systemic emboli rate (HR 7.07, 95 CI 1.66-30.25, p = 0.008), respectively. Abnormal PLT count is associated with different clinical outcome of AF patients on anticoagulants. Further studies are needed in order assess whether PLT level should influence strategies of anticoagulation.

Background Patients undergoing cardiac resynchronization therapy with a defibrillator (CRT‐D) often experience improvements in the left ventricular ejection fraction (LVEF). This study aimed to identify predictors of ventricular tachyarrhythmias (VTA) in patients with CRT‐D devices and LVEF improvement beyond guideline recommendations for a defibrillator. Methods Patients randomized to the CRT‐D arm of the Multicenter Automatic Defibrillator Implantation Trial With Cardiac Resynchronization Therapy trial who improved their LVEF to > 35% at 12 months following CRT‐D implant were included in this analysis (N = 651). Predictors of an appropriate implantable cardioverter defibrillator (ICD) Rx VTA were evaluated by Cox proportional hazards regression modeling. Results We identified three predictors of VTA among patients treated with CRT‐D subsequent to LVEF improvement > 35%: Lower range improvement in LVEF 36%–40% versus improvement to > 40% (HR, 1.97; 95% CI, 1.21–3.20; p = 0.006); Baseline non‐LBBB ECG morphology (hazard ratio [HR], 1.93; 95% confidence interval [CI], 1.23–3.04; p = 0.004); Occurrence of VTA during the first year post‐CRT‐D (HR, 4.91; 95% CI, 2.99–8.07; p < 0.001). Conclusions We identified a sub‐group of patients with risk factors who remain at high risk of VTA despite improvement in LVEF following CRT implant. These patients require close monitoring despite improvement in LVEF beyond guideline recommendations for an ICD. In CRT‐D patients with LVEF above guideline indications, LVEF 36%–40%, absence of LBBB, and a history of VTA increase the risk for future VTA. These patients require close monitoring despite improvement beyond guideline recommendations.

Increased body mass index (BMI) and obesity are associated with increased risk of new-onset atrial fibrillation (AF) among middle-aged adults. The objective of the study is to investigate the association between BMI and the risk for new-onset AF among middle-aged adults. We investigated 18,290 men and women who were annually screened in a tertiary medical center. Participants were divided at baseline into 3 groups: normal weight (BMI ≥18 and <25 kg/m2, n = 7,692), overweight (BMI ≥25 and <30 kg/m2, n = 8,032), and obese (BMI ≥30 kg/m2, n = 2,566). The primary end point was new-onset AF during follow-up. Mean age of study population was 49 ± 11 years, and 73% were men. A total of 288 incident events (1.6%) occurred during 6 ± 4 years. Kaplan-Meier survival analysis showed that the cumulative probability of AF at 6 years was highest among obese participants, intermediate among overweight participants, and lowest among participants with normal weight (2.1%, 1.7%, and 0.8% respectively, P < .001). Multivariable Cox regression analysis showed that overweight and obesity were independently associated with increased AF risk (hazard ratio 1.54 [P = .004] and 2.41 [P < .001], respectively). Assessment of BMI change as a time-dependent covariate in the multivariable model showed that each 1 kg/m2 reduction in BMI during follow-up was associated with a significant 7% reduction in the risk for the occurrence of a first AF event (hazard ratio 0.93, 95% CI 0.88-0.99, P = .019). Consistently, similar analysis showed that each 5-kg weight loss during follow-up was independently associated with a significant 12% reduced risk of new-onset AF (95% CI 0.81-0.98, P = .02). Our findings suggest that overweight and obesity are associated with increased AF risk, whereas weight reduction is independently associated with reduced risk of de novo AF.

Background Women with congenital and acquired long QT syndrome (LQTS) have increased risk of adverse cardiac events after adolescence, mainly due to sex hormones modulating the KCNH2 cardiac potassium channel. We hypothesized that sex hormones may influence ventricular tachyarrhythmia risk during the menstrual cycle in women treated with QT‐prolonging drugs. Objective To evaluate the association between repolarization dynamics and sex hormone levels during the menstrual cycle in women treated with QT‐prolonging drugs. Methods We prospectively enrolled 41 women treated with dofetilide or sotalol (N = 20) and healthy controls (N = 21). Participants underwent three 7‐day ECG recordings during their menstrual cycles, with concurrent saliva hormone measurements. Primary ECG outcomes were QT‐Apex (early repolarization) and QT interval (total repolarization time), adjusted for heart rate. Results The mean age was 51 ± 11 years in the treatment group and 42 ± 12 years in controls. In women treated with QT‐prolonging drugs, linear mixed‐effects models (adjusted for RR interval) showed inverse correlations of QT‐Apex with progesterone‐to‐estradiol ratio (p = 0.018) and testosterone (p = 0.026), and a direct correlation with estradiol (p = 0.004). QT interval inversely correlated with progesterone‐to‐estradiol ratio (p = 0.012). No significant correlations were observed in controls. Conclusions Sex hormones are significantly associated with ventricular repolarization dynamics during the menstrual cycle in women treated with QT‐prolonging drugs, suggesting a mechanism for sex‐specific arrhythmia susceptibility. Sex hormones significantly influence ventricular repolarization in women treated with QT‐prolonging drugs, with estrogen prolonging and progesterone/testosterone shortening QT measures. These findings highlight a hormonal mechanism for sex‐specific arrhythmia risk and support closer monitoring of reproductive‐age women receiving QT‐prolonging therapies.

Although transcatheter aortic valve implantation (TAVI) for severe aortic stenosis is becoming an established technique, the impact of gender-related differences remains unclear. Two hundred twenty-four consecutive patients undergoing TAVI were prospectively followed up in a tertiary medical center. The primary end point of the present study was all-cause mortality at 2 years of follow-up. Interaction-term analysis was used to identify gender-specific predictors of mortality after TAVI. Fifty-seven percent of the study patients were women. Age was similar (82 ± 7 years). Compared with men, women had a lower frequency of coronary artery disease (CAD) and a higher baseline left ventricular ejection fraction (LVEF). The cumulative probability of all-cause mortality was significantly lower among women (8.6%) compared with men (26.8%; log-rank p value <0.001). A lower baseline LVEF (<45%) was associated with a significant, more than fourfold (p = 0.0019 and 0.048, respectively), increase in mortality risk among both men and women (p value for gender-by-LVEF interaction = 0.87). In contrast, the risk associated with the presence of previous CAD was shown to be gender related. Thus, in women, CAD was associated with a pronounced >14-fold increase in mortality risk, whereas in men, CAD was not associated with a significant mortality risk (p value for gender-by-LVEF interaction = 0.01). In conclusion, our findings suggest that risk assessment before TAVI should consider gender-specific differences in survival and risk factors.