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Shotan A.,Heart Institute | Garty M.,Recanati Center | Blondhein D.S.,Heart Institute | Meisel S.R.,Heart Institute | And 8 more authors.
European Heart Journal | Year: 2010

AimsAtrial fibrillation (AF) and heart failure (HF) commonly coexist, and each adversely affects the other. The aim of the study was to prospectively evaluate the impact of AF and its subtypes on management, and early and long-term outcome of hospitalized HF patients.Methods and resultsData were prospectively collected on HF patients hospitalized in all public hospitals in Israel as part of a national survey (HFSIS). Atrial fibrillation patients were subdivided into intermittent and chronic AF subgroups. During March-April 2003, we enrolled 4102 HF patients, of whom 1360 (33.2) had AF [600 (44.1) intermittent, 562 (41.3) chronic]. Patients with AF were older (76.9 ± 10.5 vs. 71.7 ± 12.6 years, P = 0.0001), males, with preserved LV systolic function. Crude mortality rates for AF patients were progressively and consistently higher during hospitalization and during the 4-year follow-up period, especially in the chronic AF group (P = 0.0001). After covariate adjustment, AF was associated with increased 1-year mortality [HR 1.19, 95 CI (1.03-1.36)].ConclusionAF was present in a third of hospitalized HF patients, and identified a population with increased mortality risk, largely due to co-morbidities.


Ben-Mordechai T.,Neufeld Cardiac Research Institute | Holbova R.,Neufeld Cardiac Research Institute | Landa-Rouben N.,Neufeld Cardiac Research Institute | Harel-Adar T.,Ben - Gurion University of the Negev | And 7 more authors.
Journal of the American College of Cardiology | Year: 2013

Objectives This study sought to investigate the hypothesis that the favorable effects of mesenchymal stromal cells (MSCs) on infarct repair are mediated by macrophages. Background The favorable effects of MSC therapy in myocardial infarction (MI) are complex and not fully understood. Methods We induced MI in mice and allocated them to bone marrow MSCs, mononuclear cells, or saline injection into the infarct, with and without early (4 h before MI) and late (3 days after MI) macrophage depletion. We then analyzed macrophage phenotype in the infarcted heart by flow cytometry and macrophage secretome in vitro. Left ventricular remodeling and global and regional function were assessed by echocardiography and speckle-tracking based strain imaging. Results The MSC therapy significantly increased the percentage of reparative M2 macrophages (F4/80+CD206+) in the infarcted myocardium, compared with mononuclear- and saline-treated hearts, 3 and 4 days after MI. Macrophage cytokine secretion, relevant to infarct healing and repair, was significantly increased after MSC therapy, or incubation with MSCs or MSC supernatant. Significantly, with and without MSC therapy, transient macrophage depletion increased mortality 30 days after MI. Furthermore, early macrophage depletion produced the greatest negative effect on infarct size and left ventricular remodeling and function, as well as a significant incidence of left ventricular thrombus formation. These deleterious effects were attenuated with macrophage restoration and MSC therapy. Conclusions Some of the protective effects of MSCs on infarct repair are mediated by macrophages, which are essential for early healing and repair. Thus, targeting macrophages could be a novel strategy to improve infarct healing and repair. © 2013 by the American College of Cardiology Foundation.


Kuperstein R.,Leviev Heart Center | Kuperstein R.,Tel Aviv University | Goldenberg I.,Tel Aviv University | Goldenberg I.,University of Rochester | And 8 more authors.
Circulation: Heart Failure | Year: 2014

Background - Left atrial volume (LAV) is an important marker of heart failure (HF) severity. We hypothesized that LAV independently correlates with clinical outcomes in patients who receive cardiac resynchronization therapy with a defibrillator (CRT-D) and can be used for improved risk assessment in this population. Methods and Results - The benefit of CRT-D versus defibrillator-only therapy in reducing the risk of HF or death was assessed by LAV (dichotomized at the upper quartile >52 mL/m2) among 1785 patients enrolled in the Multicenter Automatic Defibrillator Implantation Trial with Cardiac Resynchronization Therapy (MADIT-CRT) study. Landmark analysis was used to evaluate the relationship between LAV response to CRT-D and subsequent clinical outcomes. Multivariable analysis showed that patients with a higher baseline LAV experienced 69% (P<0.001) and 59% (P=0.02) increased hazard for HF or death and for all-cause mortality, respectively, independently of baseline left ventricular volume. CRT-D was associated with a significant reduction in LAV compared with defibrillator-only therapy (-28% versus -10%, respectively; P<0.001). Landmark analysis showed that after CRT-D implantation each 1% reduction in LAV was independently associated with a corresponding 4% reduction in the hazard of subsequent HF or death (P<0.001). The assessment of LAV change after CRT implantation improved prediction of clinical response to the device compared with assessment of the corresponding changes in left ventricular volume. Conclusions - LAV is an independent correlate of clinical outcomes in mildly symptomatic HF patients treated with CRT-D. CRT exerts pronounced reverse remodeling effects on the left atrium that independently correlate with improved clinical outcomes after device implantation. © 2013 American Heart Association, Inc.


Benderly M.,Gertner Institute for Epidemiology and Health Policy Research | Benderly M.,Tel Aviv University | Haim M.,Rabin Medical Center | Boyko V.,Gertner Institute for Epidemiology and Health Policy Research | And 2 more authors.
Journal of Cardiac Failure | Year: 2013

Background: Low socioeconomic status (SES) is associated with increased coronary heart disease (CHD) risk. Little is known about the relationship between SES and heart failure (HF) incidence among CHD patients. Methods and Results: The association among education, occupation, and HF risk was studied in 2,951 CHD patients, free of HF at baseline, participating in a clinical trial, correcting for the competing risk of death. Over 8 years of close follow-up, 511 patients developed HF. These patients were older, and had higher frequency of metabolic risk factors and advanced CHD than HF-free counterparts. Age-adjusted HF incidence rate/1,000 person-years increased from 20.4 to 30.0 among patients with academic and elementary education, respectively. The rate for "blue collar" occupation was 25.1 compared with 18.5 among "academic"/ "white collar" occupations combined. Adjusting for sex, obesity, diabetes, metabolic syndrome, peripheral vascular disease, hypertension, and myocardial infarction number, the HF hazard ratios [HRs] were 0.85 (95% confidence interval [CI] 0.70-1.03) and 0.76 (95% CI 0.58-0.99) for high-school and academic education versus elementary education, respectively. HR for "blue collar" compared with "academic"/"white collar" occupations was 1.30 (95% CI 0.97-1.74). Conclusions: SES indicators (mainly education) are associated with HF incidence among CHD patients. The association is only marginally explained by possible confounders or known mediators such as hypertension and myocardial infarction. © 2013 Elsevier Inc.


Beinart R.,Heart Institute | Abu Sham'a R.,Heart Institute | Segev A.,Heart Institute | Hod H.,Heart Institute | And 5 more authors.
American Heart Journal | Year: 2010

Background: Acute coronary syndrome (ACS) is associated with activation of platelets and the coagulation system which could influence the incidence of early stent thrombosis (EST). We aimed to determine the incidence and predictors of EST in patients undergoing coronary stenting during ACS. Methods: The study comprised 1202 consecutive patients, drawn from a nationwide ACS survey, who underwent coronary stenting during ACS and were followed up for 30 days. Early stent thrombosis was based on the Academic Research Consortium definition. Results: Thirty patients (2.5%) sustained EST. The occurrence of EST in patients with unstable angina/non-ST-elevation myocardial infarction and ST-elevation myocardial infarction (STEMI) was 0.9% and 3.9%, respectively (P < .05), and was even higher (5.2%) in STEMI patients who underwent primary percutaneous coronary intervention. On multivariate analysis, STEMI (OR 6.3, 95% CI 2.1-18, P = .0008), multivessel disease (OR 5.9, 95% CI 1.9-21, P = .003) and Killip class ≥2 (OR 2.9, 95% CI 1.3-6.6, P = .008) were independent correlates of EST. The use of bare versus drug-eluting stents was not associated with any significant difference in EST. Conclusions: Patients presenting with STEMI who are hemodynamically unstable and have multivessel coronary disease undergoing coronary stenting during ACS, are at increased risk of EST. © 2010 Mosby, Inc. All rights reserved.


Kopel E.,Neufeld Cardiac Research Institute | Klempfner R.,Neufeld Cardiac Research Institute | Goldenberg I.,Neufeld Cardiac Research Institute | Goldenberg I.,Tel Aviv University
European Journal of Heart Failure | Year: 2014

Aims: Influenza vaccine is a well-recommended secondary prevention measure for improving survival in patients with coronary artery disease, but it has generally been less studied in heart failure. We ask whether having influenza vaccination is associated with survival among patients with acute heart failure (HF). Methods and results: This was a prospective population-based cohort study accompanied by an analysis of two cross-sectional population samples for external validation of baseline characteristics differences. We analysed all 1964 ambulatory patients with acute HF aged ≥50 years who were admitted to the Heart Failure Survey in Israel (HFSIS). We used the Israel Health Survey (IHS) 2009 and the Behavioural Risk Factor Surveillance System (BRFSS) 2003-2004 surveys (274 535 participants) for external validation. In the HFSIS, the multivariate-adjusted hazard ratios for in-hospital, 1 and 4 year mortality outcomes of influenza-vaccinated patients were 0.71 (P = 0.19), 0.81 (P = 0.04), and 0.83 (P = 0.006), respectively. In the IHS validation sample, a recent physician visit [odds ratio (OR) 1.61; 95% confidence interval (CI) 1.43-1.80] or having supplementary health insurance (OR 1.39; 95% CI 1.19-1.61) were associated with higher likelihood of being vaccinated against influenza. In the BRFSS validation sample, having > 1 healthcare providers (OR 2.31; 95% CI 2.22-2.40) or having any healthcare coverage were associated with higher likelihood of being vaccinated (OR 1.59; 95% CI 1.54-1.65). Conclusions: Influenza vaccine might improve survival among patients with acute HF. This association, however, could be affected by unmeasured confounding and bias due to baseline medical surveillance and socioeconomic differences between vaccinated and non-vaccinated patients. © 2013 European Society of Cardiology.


Neuman Y.,Meir Medical Center | Pereg D.,Meir Medical Center | Boyko V.,Neufeld Cardiac Research Institute | Behar S.,Neufeld Cardiac Research Institute | Mosseri M.,Meir Medical Center
Catheterization and Cardiovascular Interventions | Year: 2011

Objectives: We aimed to study the trends in management and outcome of post CABG patients presenting with acute MI. Background: Primary angioplasty is the treatment of choice in patients with acute myocardial infarction. Saphenous vein grafts used for CABG are large-diameter conduits that tend to accumulate a large mass of thrombus when they are the culprit artery for acute myocardial infarction (MI). We hypothesized that performing PCI in these patients is more complex and possibly results in worse outcome compared to non-CABG patients. Methods: Data for patients with STEMI was obtained from five acute coronary syndromes Israeli biennial Surveys (ACSIS) during 2000-2008. Baseline characteristics, management and outcome of post-CABG patients were compared to non-post CABG patients during 2006-2008 surveys. Results: A total of 9,781 patients were included. About 1,002 (10.2%) were post-CABG. Reperfusion therapy for post-CABG patients (34-48%) was consistently lower compared to non-CABG patients (57-65%). Angiographic outcome in patients with STEMI who underwent primary PCI (17 post-CABG, mean age 66.6 ± 9.1 and 821 non-CABG, age 60.1 ± 12.9) was successful (TIMI flow 3) in 86 and 88%, respectively. Thirty-day mortality was 5.9 and 5.1% (P = 0.89) and MACE rates were 17.6 and 12.5%, respectively (P = 0.54). Conclusions: Use of primary PCI in post-CABG patients was lower than in non-CABG patients but increased steadily and to a similar extent in both groups. Angiographic and clinical outcome was similar despite assumingly larger thrombus burden in post CABG patients. Therefore, primary angioplasty is appropriate also in post-CABG patients presenting with STEMI. © 2011 Wiley-Liss, Inc.


Korn-Lubetzki I.,Shaare Zedek Medical Center | Molshatzki N.,Stroke Center | Benderly M.,Neufeld Cardiac Research Institute | Steiner I.,Rabin Medical Center
European Neurology | Year: 2013

Background: Our clinical experience suggests that the outcome of cerebellum-brainstem ischemic strokes is better than that of hemispheric ischemic strokes. Methods: Within the setting of 2 national Israeli prospective stroke surveys, we analyzed risk factors, etiology, severity at presentation, and prognosis of first ischemic cerebellum-brainstem stroke (259 patients), comparing with strokes within the anterior circulation (1,029 patients). Results: Patients with cerebellum-brainstem strokes were younger and had less frequently atrial fibrillation and congestive heart failure. Cardioembolic etiology was significantly less prevalent (p < 0.001). Severity at presentation was milder (p < 0.001). At discharge, worsening of the modified Rankin Scale was present in a smaller number of patients (p < 0.001); more returned to their home (p < 0.001). Six-month and 1-year mortality were lower (p < 0.001 for both). Adjusted logistic regression models showed that patients with cerebellum-brainstem strokes had 50% smaller chances of dying (OR 0.55; 95% CI 0.31-0.98) and a smaller chance of worsening of the modified Rankin Scale at discharge (OR 0.61; 95% CI 0.46-0.82). Conclusions: Cerebellum-brainstem strokes are less frequently cardioembolic, have a less severe presentation, and carry a better immediate and long-term prognosis. © 2012 S. Karger AG, Basel.


Gerber Y.,Tel Aviv University | Myers V.,Tel Aviv University | Goldbourt U.,Tel Aviv University | Goldbourt U.,Neufeld Cardiac Research Institute | And 4 more authors.
European Journal of Epidemiology | Year: 2011

The benefits of leisure time physical activity (LTPA) in cardiovascular prevention are well established. While cardiac rehabilitation programmes have been demonstrated as improving myocardial infarction (MI) prognosis, the strength of the association between LTPA and post-MI survival has yet to be quantified. We evaluated long-term survival after MI of inactive, irregularly active, and regularly active patients and examined trajectories of LTPA and their relationship to mortality risk. Consecutive patients aged ≥65 years (n = 1,521), discharged from 8 hospitals in central Israel after first MI in 1992-1993, were followed through 2005. Extensive clinical and sociodemographic data, including self-reported LTPA habits, were obtained at baseline and at 4 subsequent interviews. Pre-MI inactive patients (54%) had lower socioeconomic status, higher prevalence of risk factors and comorbidities and more severe MI. The point prevalence rate of regular LTPA at all follow-up interviews was approximately 40% and 18% were regularly active throughout the entire follow-up. Over a median follow-up of 13.2 years, 427 deaths occurred. After multivariable adjustment, no association was observed between pre-MI LTPA and death. However, with LTPA categories modelled as time-dependent variables, providing an estimation of cumulative assessment and accounting for changes in LTPA post-MI, a strong inverse graded association was revealed (multivariable-adjusted hazard ratios, 0.56 [95% CI: 0.42-0.74] for regular and 0.71 [95% CI: 0.54-0.95] for irregular activity vs. none). Similar estimates were obtained among pre-MI sedentary patients. In summary, after MI, regularly active patients had about half the risk of dying compared with inactive patients, irrespective of pre-MI habits. © 2010 Springer Science+Business Media B.V.


Lubovich A.,Bnai Zion Medical Center | Hamood H.,Bnai Zion Medical Center | Behar S.,Neufeld Cardiac Research Institute | Rosenschein U.,Bnai Zion Medical Center
Israel Medical Association Journal | Year: 2011

Background: Rapid reperfusion of an infarct-related artery is crucial for the successful treatment of ST elevation myocardial infarction. Every effort should be made to shorten doorto- balloon time. Objectives: To investigate whether bypassing the emergency room (ER) has a positive influence on door-to-balloon time in patients presenting with ST elevation myocardial infarction (STEMI) and whether the reduction in door-to-balloon time improves patients' clinical outcome. Methods: We analyzed data of 776 patients with STEMI from the 2004 and the 2006 Acute Coronary Syndrome Israeli Survey (ACSIS) registry. The ACSIS is a biennial survey on acute myocardial infarction performed in all 25 intensive cardiac care units in Israel during a 2-month period. Twentyfive percent of patients (193 of 776) arrived directly to the intensive cardiac care unit (ICCU) and 75% (583 of 776) were assessed first in the ER. We compared door-to-balloon time, ejection fraction, 30 days MACE (major adverse cardiac and cerebrovascular events) and 30 days mortality in the two study groups. Results: There was significantly shorter door-to-balloon time in the direct ICCU group as compared with the ER group (45 vs. 79 minutes, P < 0.002). Patients in the direct ICCU group were more likely to have door-to-balloon time of less than 90 minutes in accordance with ACC/AHA guidelines (88.7% vs. 59.2%, P < 0.0001). Moreover, patients in the direct ICCU group were less likely to have left ventricular ejection fraction < 30% (5.4% vs. 12.2%, P = 0.045) and less likely to have symptoms of overt congestive heart failure. Lastly, 30 days MACE was significantly lower in the direct ICCU group (22 vs. 30%, P < 0.004). Conclusions: There is significant reduction of the door-toballoon time in the direct ICCU admission strategy. This reduction translates into improvement in clinical outcome of patients. It is reasonable to apply the direct ICCU strategy to patients with STEMI.

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