Time to coronary catheterization in patients with non-ST-segment elevation acute coronary syndrome and high Global Registry of Acute Coronary Events score.

AIMS: Current guidelines recommend an early (<24 h) invasive coronary angiography (ICA) strategy in non-ST-segment elevation acute coronary syndrome (NSTE-ACS) patients with Global Registry of Acute Coronary Events (GRACE) score over 140. Evidence for this recommendation is based on older trials. METHODS AND RESULTS: Between 1 February 2016 and 31 July 2021, 1767 patients with a primary diagnosis of NSTE-ACS without indication for urgent ICA underwent ICA during index hospitalization. Six hundred and fifty-five patients underwent early invasive ICA (within 24 h) and 1112 underwent late ICA (between 24 h and 1 week). One hundred and seven patients had a GRACE risk score of 140 or above and 1660 had a GRACE risk score under 140. The primary composite outcome was all-cause mortality, stroke, and recurrent myocardial infarction (MI). Median time from admission to ICA was 13.3 h (IQR 6.0-20.6) for the early group and 59.9 h for the late group (IQR 23.5-96.3). There was no difference between the early and late ICA groups in the primary composite outcome [late catheterization >24 h hazard ratio 1.196, 95% confidence interval (CI) 0.969-1.475, P -value 0.096]. A multivariable Cox regression model for the composite outcome revealed no difference between the early and late ICA groups (late catheterization >24 h hazard ratio 1.0735, 95% CI 0.862-1.327, P -value 0.512) with no effect for performing early ICA in patients with GRACE score over 140 (hazard ratio 1.291, 95% CI 0.910-1.831, P -value 0.151). CONCLUSION: An early ICA strategy in patients with NSTE-ACS patients and GRACE risk score over 140, compared with late ICA, was not associated with improved composite outcome of death, myocardial infarction, and stroke at 1 year.

The association between phosphate level at admission and early mortality in acute pancreatitis.

BACKGROUND: Abnormal phosphate levels are associated with adverse outcomes in critical illness. However, there is scarce evidence on phosphate's impact on acute pancreatitis outcomes, and the few studies examining this subject are relatively small and show conflicting data. We sought to determine the association between phosphate level at admission and the clinical course and outcomes of acute pancreatitis. METHODS: In this retrospective single-center observational study, we included all adult patients admitted with a primary diagnosis of acute pancreatitis between January 2008 and June 2021. Phosphate levels at admission were classified as normal (2.8-4.5 mg/dl), low (below 2.8 mg/dl), or high (above 4.5 mg/dl). RESULTS: Out of 2308 cases, 1868 patients had documented phosphate levels at admission and were thus included in our final analysis. 1096 (59%) had normal phosphate levels, 686 (37%) had hypophosphatemia, and 86 (4.6%) had hyperphosphatemia on admission. 30-day mortality rates were 3.4%, 3.8%, and 19% in normal, low, and high phosphate levels, respectively. In univariate analysis, hyperphosphatemia was significantly associated with 30-day mortality, with an OR of 6.54 (95% CI 3.39-12.2, p < 0.001; AUC = 0.58). In a multivariate analysis adjusting for age, MAP, GFR, BUN, and pH, hyperphosphatemia remained a statistically significant independent predictor of early mortality (OR-2.93, 95% CI 1.28-6.51, p = 0.009). Hypophosphatemia was not significantly associated with 30-day mortality in univariate analysis, OR of 1.13 (95% CI 0.67-1.87, p = 0.6). CONCLUSION: Hyperphosphatemia at admission was independently associated with increased 30-day mortality in patients with acute pancreatitis. Hypophosphatemia at admission was not significantly associated with 30-day mortality.

Elevated thrombin generation levels in the left atrial appendage in patients with atrial fibrillation.

Background: Atrial Fibrillation (AF) is the most common sustained tachi-arrhythmia. Thrombus formation in the left atrial appendage (LAA) increases the risk of stroke and systemic embolism in patients with AF. Objectives: The aim of this study was to compare thrombin generation in the LAA to the LA among patients with AF. Methods: A cross-sectional study of consecutive patients with AF undergoing pulmonary veins catheter ablation. Blood samples from the femoral vein (FV), right atrium (RA), left atrium (LA), and LAA were collected during the catheter ablation procedures. Thrombin generation was assessed by a Calibrated Automated Thrombogram. The LAA-calibrated automated thrombogram parameters were compared with the RA, LA, and FV. Results: A total of 47 consecutive patients were enrolled in the study. The endogenous thrombin potential and peak height were significantly higher in the LAA compared with the LA, the mean differences and 95% CI between the LA and LAA were -378.9 (-680.5, -77.2) (nM∗min) and -66.7 (-119.6, -13.8) (nM) in the endogenous thrombin potential and peak height respectively. Conclusion: In patients with AF undergoing catheter ablation, the LAA demonstrated increased thrombin generation compared with the LA. This finding might contribute to the understanding of why the LAA is more predisposed to thrombus formation than the LA. Clinical Trials Registration: NCT03795883.

Generalizable and robust deep learning algorithm for atrial fibrillation diagnosis across geography, ages and sexes.

To drive health innovation that meets the needs of all and democratize healthcare, there is a need to assess the generalization performance of deep learning (DL) algorithms across various distribution shifts to ensure that these algorithms are robust. This retrospective study is, to the best of our knowledge, an original attempt to develop and assess the generalization performance of a DL model for AF events detection from long term beat-to-beat intervals across geography, ages and sexes. The new recurrent DL model, denoted ArNet2, is developed on a large retrospective dataset of 2,147 patients totaling 51,386 h obtained from continuous electrocardiogram (ECG). The model's generalization is evaluated on manually annotated test sets from four centers (USA, Israel, Japan and China) totaling 402 patients. The model is further validated on a retrospective dataset of 1,825 consecutives Holter recordings from Israel. The model outperforms benchmark state-of-the-art models and generalized well across geography, ages and sexes. For the task of event detection ArNet2 performance was higher for female than male, higher for young adults (less than 61 years old) than other age groups and across geography. Finally, ArNet2 shows better performance for the test sets from the USA and China. The main finding explaining these variations is an impairment in performance in groups with a higher prevalence of atrial flutter (AFL). Our findings on the relative performance of ArNet2 across groups may have clinical implications on the choice of the preferred AF examination method to use relative to the group of interest.

Coronary computed tomography angiography in the evaluation of acute chest pain in patients with elevated high sensitive cardiac troponin I (hs-cTn) level.

Aims CCTA is a well-established and safe imaging modality for the diagnosis of CAD and is gate keeping for invasive coronary angiography (ICA). We aimed to examine CCTA performance in patients presenting with ACP and dynamic hs-cTn elevation compatible with MI but not exceeding 7 folds of the URL. We also examined the performance of GRACE and PTP consortium scores in this population of patients.

Adherence to Guidelines in Heart Failure, Is It Valid for Elderly Patients?

BACKGROUND: Current guidelines for the treatment of heart failure with reduced ejection fraction (HFrEF) are based on studies that have excluded or underrepresented older patients. OBJECTIVES: To assess the value of guideline directed medical therapy (GDMT) in HFrEF patients 80 years of age and older. METHODS: A single-center retrospective study included patients hospitalized with a first and primary diagnosis of acute decompensated heart failure (ADHF) and ejection fraction (EF) of ≤ 40%. Patients 80 years of age and older were stratified into two groups: GDMT, defined as treatment at hospital discharge with at least two drugs of the following groups: beta-blockers, angiotensin converting enzyme inhibitor (ACEI), angiotensin receptor blocker (ARB), or mineralocorticoid antagonists; and a personalized medicine group, which included patients who were treated with up to one of these drug groups. The primary outcomes were 90-day all-cause mortality, 90-day rehospitalization, and 3-years mortality. RESULTS: The study included 1152 patients with HFrEF. 254 (22%) patients who were at least 80 years old. Of the group, 123 were GDMT at discharge. When GDMT group was compared to the personalized medicine group, there were no statistically significant differences in terms 90-day mortality (17% vs. 13%, P = 0.169), 90-day readmission (51 % vs. 45.6%, P = 0.27), or 3-year mortality (64.5% vs. 63.3%, P = 0.915). CONCLUSIONS: Adherence to guidelines in the older adult population may not have the same effect as in younger patients who were studied in the randomized clinical trials. Larger prospective studies are needed to further address this issue.

The Association Between Opioid Use and Opioid Type and the Clinical Course and Outcomes of Acute Pancreatitis.

OBJECTIVES: Basic science studies suggest that opioids aggravate disease severity and outcomes in acute pancreatitis. We sought to determine the association of opioid use and opioid type with the clinical course and outcome of acute pancreatitis. METHODS: In this retrospective single-center observational study, we included all adult patients admitted with acute pancreatitis between 2008 and 2021. Patients were classified into 3 groups based on analgesia type: morphine, noonmorphine opioid, and nonopioid. RESULTS: We included 2308 patients. Of the patients, 343 (14.9%) were treated with morphine, 733 (31.8%) were treated with nonmorphine opioids, and 1232 (53.4%) patients were in the nonopioid group. The incidence of 30-day mortality did not differ significantly between study groups: 3.9%, 2.9%, and 4.4% in the nonopioid, nonmorphine-opioid, and morphine groups, respectively ( P = 0.366).In multivariate analysis, the composite end point consisting of 30-day mortality, invasive ventilation, emergent abdominal surgery, and need for vasopressors was significantly more likely to occur in the morphine group than in the nonopioid group (adjusted odds ratio, 1.69; 95% confidence interval, 1.1-2.598; P = 0.01). CONCLUSIONS: Mortality among acute pancreatitis patients did not differ significantly between patients receiving morphine, nonmorphine opioids, and nonopioids. However, morphine treatment was associated with higher rates of some serious adverse events.

The prognostic value of heart rate at discharge in acute decompensation of heart failure with reduced ejection fraction.

AIMS: The effect of elevated heart rate (HR) on morbidity and mortality is evident in chronic stable heart failure; data in this regard in acute decompensated heart failure (ADHF) setting are scarce. In this single-centre study, we sought to address the prognostic value of HR and beta-blocker dosage at discharge on all-cause mortality among patients with heart failure and reduced ejection fraction and ADHF. METHODS AND RESULTS: In this retrospective observational study, 2945 patients were admitted for the first time with the primary diagnosis of ADHF between January 2008 and February 2018. Patients were divided by resting HR at discharge into three groups (HR < 70 b.p.m., HR 70-90 b.p.m., and HR > 90 b.p.m.). Evidence-based beta-blockers were defined as metoprolol, bisoprolol, and carvedilol. The doses of prescribed beta-blockers were calculated into a percentage target dose of each beta-blocker and divided to four quartiles: 0 < Dose ≤ 25%, 25% < Dose ≤ 50%, 50% < Dose ≤ 75%, and >75% of the target dose. Cox regression was used to calculate the hazard ratio for various HR categories and adjusting for clinical and laboratory variables. At discharge, 1226 patients had an HR < 70 b.p.m., 1347 patients had an HR at range 70-90 b.p.m., and 372 patients with an HR > 90 b.p.m. The 30 day mortality rate was 2.2%, 3.7%, and 12.1% (P < 0.001), respectively. Concordantly, 1 year mortality rate was 14.6%, 16.7%, and 30.4% (P < 0.001) among patients with HR < 70 b.p.m., HR 70-90 b.p.m., and HR > 90 b.p.m., respectively. The adjusted hazard ratio was significantly increased only in HR above 90 b.p.m. category (hazard ratio, 2.318; 95% confidence interval, 1.794-2.996). CONCLUSIONS: Patients with ADHF and an HR of <90 b.p.m. at discharge had significantly a lower 1 year mortality independent of the dosage of beta-blocker at discharge. It is conceivable to discharge these patients with lower HR.

Risk of Worsening Renal Function Following Repeated Exposures to Contrast Media During Percutaneous Coronary Interventions.

Background Multiple contrast media exposures are common, but their cumulative effect on renal function is unknown. We aimed to investigate the renal consequences of repeated exposures to contrast media with coronary interventions. Methods and Results We studied 2942 patients who underwent between 1 and 9 procedures. The primary end point was a persistent creatinine increase of ≥50% above baseline at ≥90 days after the last procedure. The effect of cumulative contrast media dose was assessed using Cox models, with cumulative exposure as a time-dependent variable, and propensity score matching. The primary end point occurred in 190 patients (6.5%), with 6.1%, 6.8%, and 6.2% of patients with 1, 2 or 3, and ≥4 procedures, respectively (P=0.75). In the multivariable Cox model, baseline renal function, diabetes, anemia, acute coronary syndrome, and heart failure were independent predictors of the primary end point (all P≤0.01), whereas cumulative contrast dose was not (hazard ratio [HR], 1.29 [95% CI, 0.89-1.88] for the fourth contrast quartile [>509 mL] versus first contrast quartile [<233 mL]). Propensity score matching yielded 384 patient pairs with similar characteristics and either 1 or 2 to 9 contrast exposures (median cumulative dose, 160 and 480 mL, respectively). Despite large differences in the cumulative contrast exposure, there were similar rates of the primary end points (7.3% versus 6.3%, respectively; HR, 0.76 [95% CI, 0.44-1.32]). Conclusions In patients with multiple exposures to contrast media, worsening of renal function over time is associated with known risk factors for the progression of kidney disease but not with cumulative contrast volume.

Role of a thrombin generation assay in the prediction of infection severity.

Thrombin plays a central role in sepsis pathophysiology. The correlation of thrombin generation (TG) assays with infection severity and prognosis, and whether it can be used as a clinical tool, have been poorly explored and are the subjects of our research. We recruited 130 patients with systemic infection between 2016 and 2019. Patients were divided according to infection severity by using the sequential organ failure assessment (SOFA) and quickSOFA (qSOFA) scores. The hemostatic state was analyzed by Calibrated Automated Thrombogram. The primary end points were TG values and the secondary end point was in-hospital mortality. Patients with qSOFA ≥ 2 had a longer lag time (5.6 vs. 4.6 min) and time to peak (8 vs. 6.9 min) than those with lower scores (p = 0.014 and 0.01, respectively). SOFA ≥ 2 had a longer lag time (5.2 vs. 4.3 min), time to peak (7.5 vs. 6.7 min) and lower endogenous thrombin potential (ETP) (1834 vs. 2015 nM*min), p = 0.008, 0.019, and 0.048, respectively. Patients who died (11) had lower ETP (1648 vs. 1928 nM*min) and peak height (284 vs. 345 nM), p = 0.034 and 0.012, respectively. In conclusion TG assays may be a valuable tool in predicting infection severity and prognosis.

Acute and severe ribavirin-associated hyperuricemia and acute kidney injury: An underrecognized adverse effect.

PURPOSE: To report a case of ribavirin-associated severe hyperuricemia in an immunocompromised patient treated for respiratory syncytial virus (RSV) infection. SUMMARY: A 21-year-old male with a past medical history of B-cell acute lymphoblastic leukemia was in full remission after allogenic bone marrow transplantation complicated with chronic graft-versus-host disease. He was hospitalized due to fever, malaise, and respiratory symptoms. A diagnosis of RSV upper respiratory tract infection complicated by secondary pneumonia was made, and oral ribavirin (600 mg in 3 divided doses daily) and intravenous levofloxacin (750 mg once daily) were initiated. On day 2 of the hospital admission, the patient's uric acid levels had increased from a baseline of 4 to 6 mg/dL to 19.3 and 22.2 mg/dL after the fourth and fifth doses of ribavirin, respectively, and his serum creatinine steadily had increased from a baseline of 0.7 to 0.8 mg/dL to 1.6 mg/dL. Ribavirin was discontinued after the sixth dose, and a single dose of intravenous rasburicase (7.5 mg) was administered. On day 3, the patient's serum uric and creatinine concentrations had decreased to 4.7 mg/dL and 1.1 mg/dL, respectively. He continued to recover on antibiotics and was discharged with normal uric acid and serum creatinine levels. CONCLUSION: We report a case of severe hyperuricemia and acute kidney injury that developed early after initiation of ribavirin for RSV infection and suspected bacterial pneumonia in an immunocompromised patient without hepatitis C, requiring ribavirin discontinuation and rasburicase administration. To our knowledge, this is the first reported case of severe hyperuricemia in a patient treated with ribavirin for RSV infection rather than chronic hepatitis C. Clinicians should be aware of the possibility of acute and severe hyperuricemia following ribavirin administration.

Risk of Acute Kidney Injury after Intravenous Contrast Media Administration in Patients with Suspected Pulmonary Embolism: A Propensity-Matched Study.

BACKGROUND: Although computed tomography pulmonary angiography (CTPA) is the preferred diagnostic procedure in patients with suspected pulmonary embolism (PE), some patients undergo ventilation/perfusion (V/Q) lung scan due to concern of contrast-associated acute kidney injury (AKI). METHODS: The study used a cohort of 4,565 patients with suspected PE. Patients who received contrast during CTPA were compared with propensity score-matched unexposed control patients who underwent V/Q lung scanning. AKI was defined as ≥50% increase in serum creatinine during the first 72 hours after either CTPA or V/Q lung scan. RESULTS: Classification and regression tree analysis demonstrated that baseline creatinine was the strongest determinant of the decision to use CTPA. Propensity-score matching yielded 969 patient pairs. There were 44 AKI events (4.5%) in patients exposed to contrast media (CM) and 33 events (3.4%) in patients not exposed to CM (risk difference: 1.1%, 95% confidence interval [CI]: -0.6 to 2.9%; odds ratio [OR]: 1.39, 95% CI: 0.86-2.26; p = 0.18). Using different definitions for AKI and extending the time window for AKI diagnosis gave similar results. In a sensitivity analysis with the inverse probability weighting method, the OR for AKI in the CTPA versus V/Q scan was 1.14 (95% CI: 0.72-1.78; p = 0.58). CONCLUSION: Intravenous contrast material administration was not associated with an increased risk of AKI in patients with suspected PE. Given the diagnostic superiority of CTPA, these results are reassuring with regard to the use of CTPE in patients with suspected PE perceived to be at risk for AKI.

SOFA score and short-term mortality in acute decompensated heart failure.

Acute decompensated heart failure (ADHF) is one of the leading causes for hospitalization and mortality. Identifying high risk patients is essential to ensure proper management. Sequential Organ Function Assessment Score (SOFA) is considered an excellent score to predict short-term mortality in sepsis and other life-threatening conditions. To assess the capability of SOFA score in predicting short-term mortality in ADHF. We retrospectively identified patients with first hospitalization with primary diagnosis of ADHF between the years (2008-2018). The SOFA score was calculated for all patients. A total 3232 patients were included in the study. The SOFA score was significantly associated with in-hospital mortality and 30-day mortality. The odds ratios for 1-point increase in the SOFA score were 1.86 (95% CI 1.68-1.96) and 1.627 (95% CI 1.523-1.737) respectively. The SOFA Score demonstrated a good predictive accuracy. The areas under the curve of receiver operating characteristic curves for in-hospital mortality and 30-day mortality were 0.765 (95% CI 0.733-0.798) and 0.706 (95% CI 0.676-0.736) respectively. SOFA score is associated with increased risk of short-term mortality in ADHF. SOFA can be used as a complementary risk score to screen high risk patients who need strict monitoring.

Appetite and ghrelin levels in iron deficiency anemia and the effect of parenteral iron therapy: A longitudinal study.

BACKGROUND: Iron deficiency anemia (IDA) is associated with decreased appetite. The ghrelin hormone is one of the major regulators of appetite. OBJECTIVES: To evaluate appetite and ghrelin levels in patients with IDA, and to investigate the change in appetite and ghrelin following intravenous iron therapy. METHODS: A total of 56 IDA patients and 51 controls were included in the study. Both appetite and ghrelin were assessed at baseline and following intravenous iron therapy. These were assessed at corresponding time intervals in the control group. Appetite was assessed by the SNAQ score (Simplified Nutritional Appetite Questionnaire) and fasting ghrelin levels were assessed by acylated ghrelin (AG), unacylated ghrelin (UAG) and their respective ratio AG/UAG. RESULTS: IDA patients had significantly lower SNAQ scores, yet higher AG levels and higher AG/UAG ratios compared to healthy controls; the mean SNAQ scores were 12.56 ± 3.45 and 16.1 ± 2, respectively (P<0.01); the median AG levels were 57.5 pg/ml and 43 pg/ml respectively (P = 0.007); and the median AG/UAG ratios were 0.48 and 0.25 respectively (P = 0.04). On multivariate linear regression analysis, IDA remained independently associated with decreased SNAQ score (ß = -0.524, P<0.001) and increased acylated ghrelin (ß = 0.289, P = 0.013). After IDA was treated, SNAQ scores increased significantly by a mean of 2 points. AG and AG/UAG ratios decreased significantly by a mean of -18.44 pg/ml and -0.2 respectively. The control group showed no significant change in SNAQ scores or ghrelin at corresponding time intervals. CONCLUSIONS: IDA patients have a reduced appetite and paradoxically elevated ghrelin hormone activity compared to healthy controls. Treating IDA enhances appetite and lowers ghrelin levels. Future studies are needed to explore the mechanism of this paradoxical ghrelin activity.

Calibrated Automated Thrombogram During Pregnancy in Unexplained Recurrent Miscarriages: A Pilot Study.

BACKGROUND: Recurrent miscarriages are associated with a high prevalence of thrombophilia. Use of a calibrated automated thrombogram (CAT) can serve as a universal test for thrombophilia. OBJECTIVES: To examine whether thrombin generation measured by CAT is elevated during the first trimester in women with unexplained recurrent miscarriages. METHODS: This study comprised 25 pregnant women with recurrent pregnancy loss referred for thrombophilia screening and treated with low-molecular-weight heparin (LMWH). Thrombin generation parameters were measured in women who had miscarriages or live births and who were diagnosed as positive or negative for thrombophilia. RESULTS: Of the pregnancies, 76% resulted in live birth and 24% ended in miscarriages. Among the women, 76% were positive for thrombophilia. Thrombin generation parameters between pregnancies that ended in miscarriage compared to live births were not significantly different, and CAT parameters failed to predict pregnancy outcome. Although the CAT parameters demonstrated a trend toward a hypercoagulable state in women with thrombophilia, there was no statistical significance (P > 0.05). CONCLUSIONS: Women with unexplained pregnancy loss demonstrated similar thrombin generation in the first trimester, regardless of the pregnancy outcome. CAT parameters failed to predict pregnancy outcome in women with recurrent unexplained pregnancy loss. Our results should be interpreted with caution due to the small number of participants.

Blood urea nitrogen variation upon admission and at discharge in patients with heart failure.

AIMS: Heart failure (HF) is one of the leading causes for hospitalization and mortality. After first admission with acute decompensated HF, some patients are in high risk for short-term and long-term mortality. These patients should be identified, closely followed up, and treated. It has been observed that blood urea nitrogen (BUN) on admission is a predictive marker for short-term mortality. Recently, it has been shown that higher BUN levels on discharge are also a bad prognostic predictor. However, the prognostic value of BUN alteration during hospital stay was not investigated; therefore, we aimed to investigate the effect of BUN variation during hospitalization on mortality. METHODS AND RESULTS: A retrospective study included patients with first hospitalization with the primary diagnosis of HF. The patients were divided into four groups on the basis of the values of BUN on admission and discharge, respectively: normal-normal, elevated-normal, normal-elevated, and elevated-elevated. Four thousand seven hundred sixty-eight patients were included; 2567 were male (53.8%); the mean age was 74.7 ± 12.7 years. The 90 day mortality rate in the normal-normal group was 7% lower than that in the elevated-normal (14.6%) and normal-elevated (19.3%) groups; P value < 0.01. The 90 day mortality in the elevated-elevated group (28.8%) was significantly higher than that in the other groups; P < 0.001. During the 36 month follow-up, these results are maintained. While sub-dividing BUN levels into <30, 30-39, and >40 mg/dL, higher BUN levels correlated with higher 90 day mortality rate regardless of creatinine levels, brain natriuretic peptide, or age. Moreover, BUN on admission and on discharge correlated better with mortality than did creatinine and glomerular filtration rate at the same points. CONCLUSIONS: The BUN both on admission and on discharge is a prognostic predictor in patients with HF; however, patients with elevated levels both on admission and on discharge have the worst prognosis. Moreover, worsening or lack of improvement in BUN during hospitalization is a worse prognostic predictor. To the best of our knowledge, this is the first trial to discuss the BUN change during hospitalization in HF.

Enhanced thrombin generation in patients with arterial hypertension.

BACKGROUND: Arterial hypertension is associated with greater risk of cardiovascular diseases and thrombotic complications, suggesting that hypertension is a prothrombotic state. OBJECTIVES: To investigate the relationship between arterial hypertension and thrombin generation, and between blood pressure level and thrombin generation in hypertensive patients. METHODS: A total of 165 hypertensive patients and 47 healthy adults controls were include in the study. Thrombin generation was assessed in both groups by the Calibrated Automated Thrombogram (CAT) method. Ambulatory blood pressure monitoring (ABPM) was also performed for all patients in the hypertensive group. RESULTS: Hypertensive patients had significantly higher levels of ETP and peak heights compared to healthy controls; means of ETP 1720.6 ±â€¯267 and 1544.7 ±â€¯302, respectively (P < 0.001) and means of peak height were 297.26 ±â€¯48 and, 273 ±â€¯53, respectively (P < 0.001). On multivariate linear regression analysis, hypertension remained independently associated with increased ETP (ß = 0.185, P = 0.047). Analysis restricted to the hypertensive group with ABPM measurement showed statistically significant correlations between all measures of diastolic blood pressure (DBP) and ETP, and multivariate analysis showed that awake DBP was significantly associated with ETP (ß = 0.194 for each 1-mm Hg increase in awake DBP, P = 0.012). Furthermore, hypertensive patients with cardiovascular complications had statistically elevated levels of peak height compared to hypertensive patients without cardiovascular complications. CONCLUSIONS: Hypertensive patients possess enhanced thrombin generation compared healthy controls. Diastolic blood pressure level is independently correlated with increased thrombin generation in hypertensive patients. These findings suggest that arterial hypertension is a prothrombotic state.

The Prevalence of Thrombophilia in Women With Recurrent Fetal Loss and Outcome of Anticoagulation Therapy for the Prevention of Miscarriages.

OBJECTIVE: To estimate the prevalence of thrombophilia in women with recurrent miscarriages and to assess the effect of antithrombotic therapy. DESIGN: A retrospective cohort study between the years 2004 and 2010. SETTING: A hypercoagulation community clinic in northern Israel. PATIENTS: Four hundred ninety pregnant women referred for thrombophilia screening. MAIN OUTCOME MEASURES: Screening results for thrombophilia and antithrombotic treatment with enoxaparin, aspirin, or both and pregnancy outcomes. RESULTS: The most common thrombophilia in our study group was factor V Leiden mutation with a prevalence of 20.9% followed by protein S deficiency with a prevalence of 19%. Live birth rate was higher in the group of women who received enoxaparin regardless of whether a specific thrombophilia could be found. This finding was more pronounced in women who had ≥4 miscarriages. CONCLUSION: The prevalence of thrombophilia was higher in our study group than in the general population. Furthermore, treatment with enoxaparin might improve the rate of live births in women with or without evidence of thrombophilia, especially in women with ≥4 miscarriages.