Elevated neutrophil-to-lymphocyte Ratio (NLR) has been associated with increased mortality in patients with acute heart failure (HF) as well as in neoplastic diseases. We investigated the association between NLR and mortality or cardiac transplantation in a retrospective cohort of 527 patients presented to the Cleveland Clinic for evaluation of advanced HF therapy options between 2007 and 2010. Patients were divided according to low, intermediate, and high tertiles of NLR, and were followed longitudinally for time to all-causes mortality or heart transplantation (primary outcome). The median NLR was 3.9 (IQR 2.5, 6.5). In univariate analysis, intermediate and highest tertiles of NLR had a higher risk than the lowest tertile for the primary outcome and all-causes mortality. Compared to the lowest tertile, there was no difference in the risk of heart transplantation for intermediate and high tertiles. In multivariate analysis, when compared to the lowest tertile, the intermediate and high NLR tertiles remained significantly associated with the primary outcome (HR=1.61 [95%CI 1.10 to 2.37] and HR=1.55 [95%CI 1.02 to 2.36], respectively), and all-causes mortality (HR=1.83 [95%CI 1.07 to 3.14] and HR=2.16 [95%CI 1.21 to 3.83], respectively). In conclusion, elevated NLR is associated with increased mortality or heart transplantation risk in patients with advanced HF.

Elevated baseline cardiac troponin level identified chronic stable heart failure patients who are at a higher risk of mortality and combined adverse cardiovascular outcomes. There was no statistically significant difference between high- and low-sensitivity cardiac troponins.

Obesity and heart failure are two of the leading causes of morbidity and mortality in the world. The relationship between obesity and cardiovascular diseases is complex and not fully understood. While the risk of developing heart failure has been shown to be higher in patients who are obese, there is a survival advantage for obese and overweight patients compared with normal weight or low weight patients. This phenomenon was first described by Horwich et al. and was subsequently confirmed in other large trials. The advantage exists irrespective of the type, aetiology, or stage of heart failure. Patients with morbid obesity (body mass index >40 kg/m2), however, do not have the same survival advantage of their obese counterparts. There are several alternative indices of obesity available that may be more accurate than body mass index. The role of weight loss in patients with heart failure is unclear; thus, providing sound clinical advice to patients remains difficult. Future prospective trials designed to evaluate the link between obesity and heart failure will help us understand more fully this complex relationship.

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These data indicate that BNP is an independent predictor of LAAT in AF and may complement the role of the CHADS2 score in predicting stroke risk.

Presence of preoperative diastolic dysfunction was associated with greater postoperative mortality and major adverse cardiac events, regardless of LVEF. Mortality was significantly greater in grade III diastolic dysfunction.

BackgroundLeft ventricular diastolic impairment and consequently elevated filling pressure may contribute to stasis leading to left atrial appendage thrombus (LAAT) in nonvalvular atrial fibrillation (AF). We investigated whether transthoracic echocardiographic parameters can predict LAAT independent of traditional clinical predictors.MethodsWe conducted a retrospective cohort study of 297 consecutive nonvalvular AF patients who underwent transthoracic echocardiogram followed by a transesophageal echocardiogram within one year. Multivariate logistic regression analysis models were used to determine factors independently associated with LAAT.ResultsNineteen subjects (6.4%) were demonstrated to have LAAT by transesophageal echocardiography. These patients had higher mean CHADS2 scores [2.6 ± 1.2 vs. 1.9 ± 1.3, P = 0.009], higher E:e’ ratios [16.6 ± 6.1 vs. 12.0 ± 5.4, P = 0.001], and lower mean e’ velocities [6.5 ± 2.1 cm/sec vs. 9.1 ± 3.2 cm/sec, P = 0.001]. Both E:e’ and e’ velocity were associated with LAAT formation independent of the CHADS2 score, warfarin therapy, left ventricular ejection fraction (LVEF), and left atrial volume index (LAVI) [E:e’ odds-ratio = 1.14 (95% confidence interval = 1.03 – 1.3), P = 0.009; e’ velocity odds-ratio = 0.68 (95% confidence interval = 0.5 – 0.9), P = 0.007]. Similarly, diastolic function parameters were independently associated with spontaneous echo contrast.ConclusionThe diastolic function indices E:e’ and e’ velocity are independently associated with LAAT in nonvalvular AF patients and may help identify patients at risk for LAAT.

2Obese patients have been noted to have better prognosis in many conditions including heart failure. We hypothesize that this favorable prognosis for obesity may not be seen in patients with morbid obesity and advanced heart failure. A total of 501 consecutive patients with advanced heart failure referred for heart transplant evaluation to the Cleveland Clinic were studied. Patients were categorized into 3 groups based on their body mass index score as nonobese (≤30 kg/m 2 ), obese (30.1-40 kg/m 2 ), and morbidly obese (≥40 kg/m 2 ). There were fewer cardiovascular risk factors in the morbidly obese group. Unadjusted event-free survival rates were 48.4%, 57.4%, and 28.6% in the nonobese, obese, and morbidly obese groups, respectively (P=.02). In univariate analysis, both the nonobese group (hazard ratio [HR], 1.44; 95% confidence interval [CI], 1.09-1.91; P=.01) and the morbidly obese group (HR, 2.46; 95% CI, 1.40-4.30; P=.002) had significantly higher risk of all-cause mortality/transplantation compared with the obese group. This difference persisted in multivariate analysis after adjustment for confounding factors. Our study re-emphasizes the presence of an obesity paradox even in patients with very advanced heart failure. This favorable prognosis, however, may not be relevant in patients with morbidly obesity. Cardiovascular risk factors may not contribute to this phenomenon ª2013 Wiley Periodicals, Inc.Obesity is a growing epidemic and is one of the major public health concerns of the current era. Most epidemiologic studies define obesity based on body mass index (BMI). Recently published data were concerning as they showed that approximately 35% of the US adult population were obese, with a mean BMI of 28.7 kg/m 2 . 1 Obesity is defined as a BMI ≥30 kg/m 2 , and severe obesity (BMI ≥40 kg/m 2 ) is termed morbid or extreme obesity.2 Obesity has been linked to multiple medical problems including diabetes, hypertension, dyslipidemia, heart failure (HF), atrial fibrillation, and other cardiovascular comorbidities. Recent data suggest that adipose tissue works as a separate organ and affects cardiovascular health by multiple mechanisms such as increased inflammatory markers and increased cardiac output.3 Obesity has not only been associated with morbidity, but in a very large study using pooled data, it has been clearly associated with increased allcause mortality. 4 In 2002, however, Gruberg and colleagues made an interesting observation they called an obesity paradox. They noted that the mortality rate was significantly lower in obese patients undergoing percutaneous coronary intervention.5 Similar findings have been noted in many other patient populations, for instance, in patients with cancer, renal failure, and chronic obstructive lung disease.3 Similar findings were noted in HF patients in a large meta-analysis involving 28,209 patients.6 Nevertheless, few studies have evaluated prognostic implications of morbid obesity in the HF population. HYPOTHESISWe expected to see the phenomenon of an obesity paradox...