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Research Interests: Cardiology, Natural History, Medicine, Echocardiography, Prospective studies, and 15 moreHumans, Internal Medicine, Left Ventricular Assist Device, Hospitalization, Female, Male, Acute Myocardial Infarction, Middle Aged, Myocardial Infarction, Ejection Fraction, Embolism, Heart Diseases, Infarction, Left Ventricular, and Cardiovascular medicine and haematology
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Targeting ganglionated plexi (GP) during catheter ablation of atrial fibrillation (AF) is associated with improved outcome. We present a patient with speech and breathing induced atrial tachycardia (AT) originating in the superior vena... more
Targeting ganglionated plexi (GP) during catheter ablation of atrial fibrillation (AF) is associated with improved outcome. We present a patient with speech and breathing induced atrial tachycardia (AT) originating in the superior vena cava (SVC) and the right superior pulmonary vein (RSPV), near the anatomical location of the anterior right GP (ARGP). The trigger for the arrhythmia appeared to be vagal discharge from the GP, possibly induced by local stretch. Ablation with a 28 mm cryo-balloon advanced to the RSPV orifice through a patent foramen ovale (PFO) abolished the arrhythmia, probably involving the underlying parasympathetic influx to the SVC and RSPV myocardial sleeves.
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Neostigmine is a cholinesterase inhibitor which does not cross the blood brain barrier and a commonly used for reversal of nondepolarizing muscle relaxants. In the following case report, we present a patient who developed coronary artery... more
Neostigmine is a cholinesterase inhibitor which does not cross the blood brain barrier and a commonly used for reversal of nondepolarizing muscle relaxants. In the following case report, we present a patient who developed coronary artery spasm, after the administration of repeated doses of neostigmine. Ours is the first case to demonstrate such a longstanding coronary artery vasospasm that lasted several hours in response to neostigmine, resulting in myocardial damage and left ventricular dysfunction. We would like to draw the attention of the anesthesiologists to this rare effect that may lead to perioperative cardiac complications.
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We tested the clinically relevant diagnostic accuracy of a new electrocardiographic (ECG) recording system incorporating all 10 ECG electrodes in a single-size glove worn on the... more
We tested the clinically relevant diagnostic accuracy of a new electrocardiographic (ECG) recording system incorporating all 10 ECG electrodes in a single-size glove worn on the patient's left arm and placed on the chest. The PhysioGlove (PG) was designed to allow fast, reproducible, electrode placement with only minimal training. The American College of Cardiology/American Heart Association ECG recording guidelines and others have repeatedly highlighted the unacceptable progressive deterioration in ECG accuracy mainly resulting from a performer's lack of proficiency and diligence, leading to frequent electrode misplacement. We studied 428 consenting adult patients with a broad spectrum of anthropomorphic characteristics and ECG and cardiovascular pathologic entities. The chest girth was measured to ascertain the single-size PG clinical diagnostic accuracy in ≥90% of this patient population. For each patient, a PG and standard-cable electrocardiogram were consecutively recorded and interpreted by experienced electrocardiographers. The study included 3 phases: phase 1, run-in (n = 120); phase 2, comparative diagnostic accuracy (n = 208); and phase 3, randomized, blinded, diagnostic accuracy (n = 100). Of the entire study population (n = 428), 92% fit the chest girth range of 85 to 118 cm (34 to 47 in.), representing the reference standard clinical diagnostic PG chest girth range. The phase 2 PG diagnostic accuracy was 91.3% for entire chest girth range and 95.7% for the 89.4% of patients with a chest girth within the reference range. The mean PG diagnostic accuracy in phase 3 was 93% (95% confidence interval 89% to 95%). In conclusion, compared with standard-cable electrocardiograms, the PG demonstrated excellent diagnostic accuracy (93% to 95.7%) in ≥90% of a typical western adult patient population. The PG's ease of use and minimal training requirements offer a promising tool to markedly improve ECG clinical diagnostic accuracy in most adult western patients.
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Pharmacologic testing with dobutamine or dipyridamole in conjunction with echocardiography has become an accepted method for diagnosis of coronary artery disease (CAD). The sensitivity of dobutamine echo ranges from 68 to 86%, and of... more
Pharmacologic testing with dobutamine or dipyridamole in conjunction with echocardiography has become an accepted method for diagnosis of coronary artery disease (CAD). The sensitivity of dobutamine echo ranges from 68 to 86%, and of dipyridamole from 53 to 69% for diagnosis of CAD. Our purpose was to investigate whether the addition of dipyridamole to dobutamine, which may improve the test sensitivity, is safe. Ten patients with low probability of CAD underwent dobutamine echo; 5 were control patients and 5 patients had low dose dipyridamole added at the maximal dose of dobutamine. Four of the latter patients had severe hypotension, while no hypotension was observed in control patients. Our findings suggest that this combination of dobutamine and dipyridamole can be hazardous and should not be used in patients with suspected CAD.
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STEMI is thought to occur as a result of a vulnerable coronary plaque rupture. Statins possess hypolipidemic and pleotropic effects that stabilize coronary plaque. We sought to determine the association between LDL-C levels, statin use... more
STEMI is thought to occur as a result of a vulnerable coronary plaque rupture. Statins possess hypolipidemic and pleotropic effects that stabilize coronary plaque. We sought to determine the association between LDL-C levels, statin use prior to the index event on the type of acute coronary syndrome (ACS) presentation: STEMI vs. non-STEMI/unstable angina. Data was drawn from the ACS Israeli Survey (ACSIS), a biennial prospective survey of ACS patients hospitalized in all CCU/Cardiology departments during 2002-2010. Among 6790 patients, 2760 (41%) reported statin use prior to the index ACS event. The proportion of STEMI was significantly lower among statin treated vs. statin naive patients (36% vs. 57%, p<0.0001). At each LDL-C level, the proportion of STEMI was significantly lower only among statin treated patients (p<0.0001). LDL-C<70mg/dL was associated with a lower proportion of STEMI only among statin treated but not among statin naive patients (33% vs. 57%, p<0.0001). Multivariate analysis revealed that statin use was independently associated with a lower probability of presenting with STEMI (ORadj=0.73, p=0.007), but not LDL-C<70mg/dL (ORadj=1.13, p=0.32). Patients on high-intensity statin therapy (HIST) were less likely to present with STEMI as compared with low-intensity statin therapy (LIST) or statin naive patients (27%, 38%, 56%, respectively, p for trend <0.0001; HIST ORadj=0.28, p=0.01; LIST ORadj=0.48, p=0.026). Among patients admitted with ACS, statin use but not LDL-C level, was associated with a lower probability of presenting with STEMI. Patients on HIST had the lowest likelihood of presenting with STEMI.
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We sought to define reperfusion-induced ventricular arrhythmias (VAs) more precisely through simultaneous angiography, continuous ST-segment recovery, and beat-to-beat Holter analyses in subjects with anterior ST-elevation myocardial... more
We sought to define reperfusion-induced ventricular arrhythmias (VAs) more precisely through simultaneous angiography, continuous ST-segment recovery, and beat-to-beat Holter analyses in subjects with anterior ST-elevation myocardial infarction (STEMI) undergoing primary angioplasty [percutaneous coronary intervention (PCI)]. All 157 subjects with final TIMI 3 flow had continuous 12-lead electrocardiography with simultaneous Holter recording initiated prior to PCI for continuous ST-segment recovery and quantitative VA analyses. Ventricular arrhythmia bursts were detected against subject-specific background VA rates using a statistical outlier method. For temporal correlations, timing and quality of reperfusion were defined as first angiographic TIMI 3 flow with >or=50% stable ST-segment recovery. Almost all subjects had VAs [156/157 (99%)], whereas VA bursts during or subsequent to reperfusion occurred in 97/157 (62%). The majority of VA bursts (72%) arose within 20 min of reperfusion (95% CI: 26.7, 72), with onset at a median of 4 min post-reperfusion (IQR: 0-43) Bursts comprised a median of 1290 ventricular premature complexes (VPCs) (IQR: 415-4632) and persisted for a median of 105 min (IQR: 35-250). Most background VAs occurred as single VPCs; bursts typically comprised runs of three or more VPCs. Subjects with bursts had higher absolute peak ST segments and more frequent worsening of ST elevation immediately after reperfusion. Ventricular arrhythmia bursts temporally associated with TIMI 3 flow restoration and stable ST-segment recovery (reperfusion VA bursts) can be precisely defined in subjects with anterior STEMI and may constitute a unique electric biosignal of myocellular response to reperfusion.
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The absence of antegrade flow in a coronary artery during an intervention is an ominous finding requiring diagnosis of the underlying cause and rapid treatment to limit myocardial necrosis. The Twin-Pass dual access catheter allows for... more
The absence of antegrade flow in a coronary artery during an intervention is an ominous finding requiring diagnosis of the underlying cause and rapid treatment to limit myocardial necrosis. The Twin-Pass dual access catheter allows for distal coronary contrast injection without loss of wire position. The aim of this analysis was to determine the opacification and flow features of patients with abrupt arrest of antegrade flow to determine the underlying pathology. Coronary angiograms of patients with abrupt arrest of antegrade flow during an intervention that underwent distal vessel contrast injection with the Twin-Pass catheter were retrospectively analyzed for five features: antegrade flow, retrograde flow, myocardial blush, presence of contrast stasis in the vessel wall and evidence of an intraluminal filling defect. The features were then correlated with the underlying pathological process and treatment. Seven patients underwent distal contrast injections. Four specific pathologi...
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The Arterial Revascularization Therapies Study was a multicenter, randomized trial designed to compare percutaneous coronary intervention with stenting versus coronary artery bypass graft surgery in 1,205 patients with multivessel... more
The Arterial Revascularization Therapies Study was a multicenter, randomized trial designed to compare percutaneous coronary intervention with stenting versus coronary artery bypass graft surgery in 1,205 patients with multivessel coronary artery disease. The most appropriate type of treatment for these patients is still a matter of considerable debate. To evaluate the clinical characteristics of patients enrolled in the ARTS trial in Israel in comparison to those worldwide, and to assess the 1 year outcome in these patients. Between April 1997 and June 1998, a total of 1,205 patients with multivessel coronary artery disease, who were considered to be equally treatable with both modalities, were randomized to either stenting (n = 600) or CABG (n = 605) at 67 centers around the world. In Israel, 53 patients at four participating medical centers were randomized to either PCI with stents (n = 27) or CABG (n = 26). Clinical and angiographic characteristics were similar in the two groups...
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Prior studies have suggested that women are at higher risk for morbidity and mortality during coronary angioplasty, although long-term prognosis is similar after successful procedures. To examine the role of gender in coronary stenting,... more
Prior studies have suggested that women are at higher risk for morbidity and mortality during coronary angioplasty, although long-term prognosis is similar after successful procedures. To examine the role of gender in coronary stenting, including immediate procedural success as well as early and late outcomes. The study group comprised 560 consecutive patients (119 women and 441 men) who had undergone stenting over a 3 year period. The indications for coronary stenting were similar among women and men, and stents were successfully deployed at similar rates without complications (92 vs. 90% respectively). Cardiac death or myocardial infarction within 30 days of the procedure was observed in 5% of women and men, whereas none of the women, compared to 1.4% of men, had early revascularization. Bleeding complications occurred in 4% of women and 2% of men. During 10 +/- 2.8 months of follow-up, 58% of women and men underwent repeat cardiac catheterization, revealing similar rates of reste...
Research Interests: Israel, Humans, Female, Male, Risk factors, and 15 moreRecurrence, Aged, Middle Aged, Coronary Angiography, Myocardial Infarction, Morbidity, Analysis of Variance, Prognosis, Postoperative Hemorrhage, Risk Factors, Proportional Hazards Models, Logistic Models, Predictive value of tests, Patient selection, and Medical and Health Sciences
Myocardial ischemia during daily life can be induced by increased demand and by increased coronary tone. The purpose of this study was to assess the mechanism of action of mibefradil, a new T-channel calcium blocker that is a vasodilator... more
Myocardial ischemia during daily life can be induced by increased demand and by increased coronary tone. The purpose of this study was to assess the mechanism of action of mibefradil, a new T-channel calcium blocker that is a vasodilator with negative chronotropic properties. Included in this study were 114 patients with chronic stable angina pectoris and ischemic episodes during baseline 48-hour ambulatory ECG monitoring (AEM). After a placebo run-in period patients received 50 mg, 100 mg, or 150 mg of mibefradil per day and repeat 48 hours AEM was performed. Ischemic episodes were divided into 2 categories: Type I is those in which an increase in heart rate > 10% preceded the development of 1 mm ST depression; Type II is those with < or = 10% increase in heart rate. Of the 625 ischemic episodes recorded at baseline, 83% were Type I and 17% were Type II. At 50 mg mibefradil dose, there was a significant decrease in the number of Type I ischemic episodes but not of Type II. At...
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Myocardial blood flow in patients with coronary artery disease depends on the severity of the coronary narrowings and the functional status of the coronary vessels. Coronary atherosclerotic plaques, which contain high concentrations of... more
Myocardial blood flow in patients with coronary artery disease depends on the severity of the coronary narrowings and the functional status of the coronary vessels. Coronary atherosclerotic plaques, which contain high concentrations of lipids, are more sensitive to change in coronary tone. The increased tendency of these active plaques for vasoconstriction is caused by abnormal endothelial function. Because regression of significant coronary plaques is highly unlikely, effort is made to improve endothelial function, thereby improving myocardial blood flow. Reduction of the cholesterol level by lipid-lowering drugs is associated with restoration of the vasodilatory response of the coronary arteries, thereby reducing the likelihood of plaque rupture and its consequences: myocardial infarction and death. Myocardial ischemia during daily life is induced by increased demand and increased coronary tone; therefore, it was not surprising that recent studies have indicated that cholesterol l...
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The long-QT (LQT) syndrome is a genetically complex disorder that is characterized by syncope and fatal ventricular arrhythmias. LQT syndrome, as defined by a prolonged electrocardiographic QT interval, has a higher incidence in females... more
The long-QT (LQT) syndrome is a genetically complex disorder that is characterized by syncope and fatal ventricular arrhythmias. LQT syndrome, as defined by a prolonged electrocardiographic QT interval, has a higher incidence in females than in males and does not exhibit Mendelian transmission patterns in all families. Among those families that are nearly consistent with Mendelian transmission, linkage between a locus for LQT syndrome and the H-ras-1 locus on the short arm of chromosome 11 has been reported in some families but not in others. Earlier analyses suggesting that LQT syndrome might be caused by a gene in the HLA region of chromosome 6 were not confirmed by standard linkage analyses. Here, we present an analysis of HLA haplotype sharing among affected pedigree members, showing an excess of haplotype sharing in a previously published Japanese pedigree and possibly also in 15 families of European descent. The haplotypes shared by affected individuals derive from both affect...
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... Exercise and During Daily Activity Dan Tzivoni, MD, Shmuel Banai, MD, Shulamit Botvin, MD, Avraham Zilberman, MD, Teddy A. Weiss ... 18. Levy RD, Shapiro LM, Wright C, Mockus L, Fox K. The haemodynamic significance of asymptomatic ST... more
... Exercise and During Daily Activity Dan Tzivoni, MD, Shmuel Banai, MD, Shulamit Botvin, MD, Avraham Zilberman, MD, Teddy A. Weiss ... 18. Levy RD, Shapiro LM, Wright C, Mockus L, Fox K. The haemodynamic significance of asymptomatic ST segment depression assessed by ...
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Background One of the most daunting complications of cardiac catheterization is a cerebrovascular event ( CVE ). We aimed to assess the real‐life incidence, etiology, and risk factors of cardiac catheterization‐related acute CVE s in a... more
Background One of the most daunting complications of cardiac catheterization is a cerebrovascular event ( CVE ). We aimed to assess the real‐life incidence, etiology, and risk factors of cardiac catheterization‐related acute CVE s in a large cohort of patients treated in a single center. Methods and Results We undertook a retrospective analysis of 43 350 coronary procedures performed on 30 907 procedure days over the period 1992‐2011 and compared patient and procedural characteristics of procedures complicated by CVE s with the remaining cohort. CVE s occurred in 47 cases: 43 were ischemic, 3 intracerebral hemorrhages, and 1 undetermined. The overall CVE rate was 0.15%, with percutaneous coronary intervention ( PCI ) and diagnostic coronary angiography rates 0.23% and 0.09%, respectively. Using a forward stepwise multivariate logistic regression model including patient demographic and procedural characteristics, a total of 5 significant predictors were defined: prior stroke ( OR =15...
Research Interests: Israel, Multivariate Analysis, Humans, Female, Male, and 14 moreIncidence, Risk factors, Aged, Cardiac Catheterization, Middle Aged, Percutaneous Coronary Intervention, Coronary Angiography, Time Factors, Odds ratio, Retrospective Studies, Chi Square Distribution, Risk Factors, Cerebrovascular Disorders, and Logistic Models
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Predicting Major Adverse Cardiac Events and Infarct Size Using ST-Segment Resolution as a Continuous Rather Than a Dichotomous Variable in Patients Achieving Thrombolysis in Myocardial Infarction Flow Grade III After Primary Percutaneous Coronary Intervention for ST-Segment Elevation Myocardial I...more
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Research Interests: Cardiology, Methodology, Prediction, Treatment Outcome, Primary, and 15 moreElectrocardiography, Humans, Female, Male, Lead, Middle Aged, Cardiac Arrhythmias, Coronary Angiography, Myocardial Infarction, Size, Infarct Size, Beat, Ventricular Arrhythmia, Severity of Illness Index, and Cardiovascular medicine and haematology
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We sought to define reperfusion-induced ventricular arrhythmias (VAs) more precisely through simultaneous angiography, continuous ST-segment recovery, and beat-to-beat Holter analyses in subjects with anterior ST-elevation myocardial... more
We sought to define reperfusion-induced ventricular arrhythmias (VAs) more precisely through simultaneous angiography, continuous ST-segment recovery, and beat-to-beat Holter analyses in subjects with anterior ST-elevation myocardial infarction (STEMI) undergoing primary angioplasty [percutaneous coronary intervention (PCI)]. All 157 subjects with final TIMI 3 flow had continuous 12-lead electrocardiography with simultaneous Holter recording initiated prior to PCI for continuous ST-segment recovery and quantitative VA analyses. Ventricular arrhythmia bursts were detected against subject-specific background VA rates using a statistical outlier method. For temporal correlations, timing and quality of reperfusion were defined as first angiographic TIMI 3 flow with &amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;gt;or=50% stable ST-segment recovery. Almost all subjects had VAs [156/157 (99%)], whereas VA bursts during or subsequent to reperfusion occurred in 97/157 (62%). The majority of VA bursts (72%) arose within 20 min of reperfusion (95% CI: 26.7, 72), with onset at a median of 4 min post-reperfusion (IQR: 0-43) Bursts comprised a median of 1290 ventricular premature complexes (VPCs) (IQR: 415-4632) and persisted for a median of 105 min (IQR: 35-250). Most background VAs occurred as single VPCs; bursts typically comprised runs of three or more VPCs. Subjects with bursts had higher absolute peak ST segments and more frequent worsening of ST elevation immediately after reperfusion. Ventricular arrhythmia bursts temporally associated with TIMI 3 flow restoration and stable ST-segment recovery (reperfusion VA bursts) can be precisely defined in subjects with anterior STEMI and may constitute a unique electric biosignal of myocellular response to reperfusion.
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Silent myocardial ischaemia (significant ST depression without chest pain) is a common occurrence in most forms of coronary heart disease and can be associated with permanent changes in myocardial structure. The haemodynamic and ECG... more
Silent myocardial ischaemia (significant ST depression without chest pain) is a common occurrence in most forms of coronary heart disease and can be associated with permanent changes in myocardial structure. The haemodynamic and ECG manifestations of silent episodes are similar to those observed in painful ischaemia. Exercise testing is the most appropriate method for assessing the severity of coronary artery disease; increased sensitivity can be obtained by combining it with radionuclide scintigraphy or ventriculography. Ambulatory ECG monitoring may fail to detect ischaemic changes revealed by exercise provocation. The treatment approach should depend on the degree of ischaemia. Numerous clinical investigations in stable and unstable angina and in patients with a previous myocardial infarction indicate that the prognosis of patients with myocardial ischaemia does not depend on whether the ischaemia is silent or symptomatic. Silent and symptomatic episodes alone represent the same degree of coronary disease. Moreover, it appears that ischaemic episodes are a more powerful adverse prognostic influence than left ventricular function or the extent of coronary artery disease. All anti-ischaemic agents, such as beta-blockers, calcium antagonists and nitrates, and interventions such as coronary balloon angioplasty or coronary bypass surgery, are very effective treatments for myocardial ischaemia. All efforts should be made to prevent ischaemic episodes, whether silent or symptomatic, since the severity of disease rather than the presence or absence of symptoms more accurately reflects the need for intervention.
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In recent years, much attention has been given to end organ protection by antihypertensive, anti-heart failure, and anti-ischemic medications. This review describes the available information on end organ protection by calcium-channel... more
In recent years, much attention has been given to end organ protection by antihypertensive, anti-heart failure, and anti-ischemic medications. This review describes the available information on end organ protection by calcium-channel blockers (CCBs). In normotensive patients and patients with hypertension treated with long-acting dihydropyridines, medial thickness was thinner than in patients treated with atenolol or in untreated hypertensive patients. Long-term treatment was associated with significant reduction in left ventricular mass. Calcium-channel blockers also improved endothelial-dependent relaxation and reversed the vasoconstrictive response to nitric oxide inhibitors. In diabetic patients, CCBs were effective in preserving kidney function and microalbuminurea. The combination of angiotensin-converting enzyme (ACE) inhibitors and CCBs was more effective than ACE inhibitors alone in preserving kidney function. In animal experiments, CCBs prevented development of coronary atheroschlerosis; however, in humans only limited data are available on their antiatherogenic effect. Some studies suggest that CCBs exert antiplatelets properties and may therefore be beneficial in patients with coronary artery disease.
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Angina pectoris usually occurs in patients with significant coronary artery disease during periods of increased coronary demand such as increased heart rate. Bradycardia is a rare and unusal cause of angina pectoris that should be... more
Angina pectoris usually occurs in patients with significant coronary artery disease during periods of increased coronary demand such as increased heart rate. Bradycardia is a rare and unusal cause of angina pectoris that should be considered during the evaluation of patients with agnia. This paper reports three cases of bradycardia-induced angina.
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Background— Clinical trials have demonstrated that, compared with placebo, intensive statin therapy reduces ischemia in patients with acute coronary syndromes and in patients with stable coronary artery disease. However, no studies to... more
Background— Clinical trials have demonstrated that, compared with placebo, intensive statin therapy reduces ischemia in patients with acute coronary syndromes and in patients with stable coronary artery disease. However, no studies to date have assessed intensive versus moderate statin therapy in older patients with stable coronary syndromes. Methods and Results— A total of 893 ambulatory coronary artery disease patients (30% women) 65 to 85 years of age with ≥1 episode of myocardial ischemia that lasted ≥3 minutes during 48-hour ambulatory ECG at screening were randomized to atorvastatin 80 mg/d or pravastatin 40 mg/d and followed up for 12 months. The primary efficacy parameter (absolute change from baseline in total duration of ischemia at month 12) was significantly reduced in both groups at month 3 and month 12 (both P <0.001 for each treatment group) with no significant difference between the treatment groups. Atorvastatin-treated patients experienced greater low-density li...
Research Interests: Clinical Trial, Electrocardiography, Humans, Female, LDL-cholesterol, and 15 moreClinical Sciences, Aged, Acute Coronary Syndrome, Coronary heart disease, Public health systems and services research, Circulation, Coronary Artery Disease, Confidence Interval, Coronary artery, Myocardial Ischemia, Low density lipoprotein cholesterol, Sex Characteristics, Pravastatin, Cardiovascular Events, and Cardiovascular medicine and haematology
... To be eligible for randomization, patients were required to have at least two positive exercise tests (Bruce protocol) with exercise duration within ... Frishman W, Charlap S, Kimmel B. Effects of diltiazem, nifedipine, and their... more
... To be eligible for randomization, patients were required to have at least two positive exercise tests (Bruce protocol) with exercise duration within ... Frishman W, Charlap S, Kimmel B. Effects of diltiazem, nifedipine, and their combination in transient ST-segment deviations on the ...
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A 60-year-old man had recurrent episodes of spontaneously occurring pain in the chest which were associated with ST-segment elevation consistent with Prinzmetal&amp;amp;#39;s angina. The simultaneous elevation of the S-T segment in... more
A 60-year-old man had recurrent episodes of spontaneously occurring pain in the chest which were associated with ST-segment elevation consistent with Prinzmetal&amp;amp;#39;s angina. The simultaneous elevation of the S-T segment in anterior and inferior electrocardiographic leads with initial ST-segment depression followed by elevation in high lateral leads suggested that heightened vascular reactivity in variant angina may involve multiple coronary vessels during the same episode of vasospasm.
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The familial long QT syndrome is a rare condition that may occur with or without deafness. Dextrocardia with complete situs inversus is a familial syndrome generally found in normal subjects with a high incidence of consanguinity among... more
The familial long QT syndrome is a rare condition that may occur with or without deafness. Dextrocardia with complete situs inversus is a familial syndrome generally found in normal subjects with a high incidence of consanguinity among the parents. In this report we describe a Jerbian family with both disorders and with several cases of sudden death. Of 27 members
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Sinus node and atriventricular (A-V) nodal functions were evaluated by right atrial pacing in 220 consecutive patients recovering from acute myocardial infarction (AMI), 10-28 days after the infarct (mean = 14 days). In the 188 patients... more
Sinus node and atriventricular (A-V) nodal functions were evaluated by right atrial pacing in 220 consecutive patients recovering from acute myocardial infarction (AMI), 10-28 days after the infarct (mean = 14 days). In the 188 patients in whom a pacing rate of 120 beats/min could be achieved, sinus node recovery time, corrected sinus node recovery time (CSNRT) and total recovery time were correlated to infarct site and the presence or absence of myocardial ischemia. Sinus node recovery time and total recovery time were significantly longer in patients with inferior (1,153 + 28 and 3,129 + 179 ms, respectively) or non-Q-wave infarct (1,112 + 28 and 3,730 + 266 ms, respectively), than in patients with anterior infarct (1,044 + 20 and 1,153 + 28 ms, respectively). The parameters were within the reported normal range. When corrected for heart rate (CSNRT), these differences were no longer present. The presence or site of residual ischemia during right atrial pacing did not affect the sinus nodes parameters. A-V nodal function, studied in all 220 patients, was assessed by the appearance of second-degree A-V block at pacing rates below 120 beats/min and by measuring the shortest atrially paced cycle length with 1:1 A-V conduction. Second-degree A-V block appeared at a similar frequency in different AMI locations. Thus, sinus and A-V node functional status in patients recovering from AMI are not affected by infarct site or by the presence or absence of residual myocardial ischemia.
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Recurrent ventricular tachycardia (torsade de pointes) is a serious and sometimes fatal arrhythmia occurring usually with quinidine therapy. Four patients experienced ventricular tachycardia after receiving conventional doses of... more
Recurrent ventricular tachycardia (torsade de pointes) is a serious and sometimes fatal arrhythmia occurring usually with quinidine therapy. Four patients experienced ventricular tachycardia after receiving conventional doses of disopyramide phosphate (600 mg/day) for recurrent atrial fibrillation-two of them in combination with amiodarone hydrochloride. Isoproterenol hydrochloride infusion was effective in three patients, while ventricular pacing promptly abolished ventricular ectopic beats and the ventricular tachycardia in the fourth patient. Torsade de pointes is more likely to occur in patients with severe repolarization delay and sinus bradycardia or atrioventricular block, and its appearance in four patients within a period of nine months after the introduction of disopyramide treatment in our service raises the possibility that this is not a rare complication of this drug, especially if used in combination with other QT interval-prolonging agents.
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Bioprosthetic valve thrombosis is uncommon and the diagnosis is often elusive and may be confused with valve degeneration. We report our experience with mitral bioprosthetic valve thrombosis and suggest a therapeutic approach. From 2002... more
Bioprosthetic valve thrombosis is uncommon and the diagnosis is often elusive and may be confused with valve degeneration. We report our experience with mitral bioprosthetic valve thrombosis and suggest a therapeutic approach. From 2002 to 2011, 149 consecutive patients who underwent mitral valve replacement with a bioprosthesis at a single center were retrospectively screened for clinical or echocardiographic evidence of valve malfunction. Nine were found to have valve thrombus. All 9 patients had their native valve preserved, representing 24% of those with preserved native valves. Five patients (group 1) presented with symptoms of congestive heart failure at 16.4 ± 12.4 months after surgery. Echocardiogram revealed homogenous echo-dense film on the ventricular surface of the bioprosthesis with elevated transvalvular gradient, resembling early degeneration. The first 2 patients underwent reoperation: valve thrombus was found and confirmed by histologic examination. Based on these, the subsequent 3 patients received anticoagulation treatment with complete thrombus resolution: mean mitral gradient decreased from 23 ± 4 to 6 ± 1 mm Hg and tricuspid regurgitation gradient decreased from 83 ± 20 to 49 ± 5 mm Hg. Four patients (group 2) were asymptomatic, but routine echocardiogram showed a discrete mass on the ventricular aspect of the valve: 1 underwent reoperation to replace the valve and 3 received anticoagulation with complete resolution of the echocardiographic findings. In conclusion, bioprosthetic mitral thrombosis occurs in about 6% of cases. In our experience, onset is early, before anticipated valve degeneration. Clinical awareness followed by an initial trial with anticoagulation is warranted. Surgery should be reserved for those who are not responsive or patients in whom the hemodynamic status does not allow delay. Nonresection of the native valve at the initial operation may play a role in the origin of this entity.
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The ability of mibefradil, a new T-channel-selective calcium antagonist, to improve exercise tolerance and silent ischemic parameters in patients with chronic stable angina was compared in 3 separate trials with 2 other commonly used... more
The ability of mibefradil, a new T-channel-selective calcium antagonist, to improve exercise tolerance and silent ischemic parameters in patients with chronic stable angina was compared in 3 separate trials with 2 other commonly used calcium antagonists: diltiazem SR (120 mg/twice daily) and amlodipine (10 mg/day). Compared with amlodipine, mibefradil 100 mg given once daily over a 3-week period resulted in a statistically significantly larger increase from baseline in total exercise tolerance test (ETT) duration (treatment difference of 40.9 sec, p = 0.04), time to onset of angina (treatment difference 61.2 sec, p &lt; 0.001), and time to onset of ischemia (treatment difference of 54.4 sec, p = 0.004). The decrease in weekly anginal episodes was 58% with mibefradil versus 19% with amlodipine, and the reduction in nitroglycerin consumption was 58% with mibefradil versus a 10% increase with amlodipine. The decrease in the number of silent ischemic episodes detected by a 48-hour Holter recording was significantly larger (p = 0.03) with mibefradil 100 mg (88%) compared with amlodipine 10 mg (38%). Similarly, a larger decrease in the duration of silent ischemia was observed with mibefradil (69%) compared with that seen with amlodipine (38%). The preliminary results of a second trial comparing mibefradil with amlodipine were consistent with the first demonstrating that the improvement for all 3 ETT parameters was larger for mibefradil (ETT duration: 55.2 sec; delay in onset angina: 74.2 sec; time to onset of ischemia: 63.6 sec), but in this trial the treatment differences did not reach statistical significance. In the trial comparing mibefradil (100 mg once daily) with diltiazem SR (120 mg twice daily), both compounds had equivalent effects on all ETT parameters tested. Mibefradil produced a 21% increase in exercise duration compared with a 20% increase with diltiazem. Although mibefradil yielded larger increases in the time to onset of angina and the time to onset of 1-mm ST-segment depression (42% and 38%, respectively) than did diltiazem (34% and 25%, respectively), the treatment differences did not reach statistical significance. Both mibefradil and diltiazem SR were associated with at least a 70% reduction from baseline in anginal frequency and nitroglycerin consumption. Mibefradil-treated patients showed greater decreases in heart rate and the rate-pressure product at each stage of the ETT than patients treated with amlodipine or diltiazem SR. All 3 drugs were well tolerated. However, compared with mibefradil, amlodipine and diltiazem SR produced a higher incidence of leg edema. In conclusion, the effectiveness of mibefradil in improving all 3 ETT parameters was greater than that of amlodipine and equivalent to that of diltiazem SR. Moreover, mibefradil provided greater reductions in the heart rate and cardiac workload than did the other 2 drugs.
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Five placebo-controlled, double-blind, multicenter, parallel-design studies were performed to evaluate the antianginal and anti-ischemic characteristics of the novel T-channel-selective calcium antagonist, mibefradil, in the treatment of... more
Five placebo-controlled, double-blind, multicenter, parallel-design studies were performed to evaluate the antianginal and anti-ischemic characteristics of the novel T-channel-selective calcium antagonist, mibefradil, in the treatment of patients with chronic stable angina pectoris. Of the 5 studies, 2 were monotherapy dose-finding trials and 3 were conducted in patients receiving background antianginal therapy: either beta blockers (2 studies) or long-acting nitrates (1 study). A total of 865 patients were randomized to 1 of 4 mibefradil dose groups (25, 50, 100, and 150 mg; n = 565) and placebo (n = 300). The antianginal and anti-ischemic effects of mibefradil were assessed across all 5 studies by evaluating exercise tolerance test variables, weekly number of anginal attacks and short-acting nitroglycerin consumption, and in both dose-finding studies, the number and total duration of silent ischemic episodes (48-hour Holter monitoring). A statistically significant increase in exercise duration was achieved in 3 of 5 studies with the 50-mg dose of mibefradil and in 3 of 3 studies with the 100-mg dose of the compound over the effects observed in the placebo groups. A significant delay in time to onset of ischemia during exercise was induced in all studies with the 50- and 100-mg doses of mibefradil. The 25-mg dose of mibefradil was not significantly better than placebo, and the effects of the 150-mg dose of the compound were similar to those observed with the 100-mg dose. Across all studies, a dose-related decrease was observed in the number of weekly anginal attacks and in weekly nitroglycerin consumption. Similarly, a significant dose-related decrease in the number and duration of silent ischemic episodes was observed during Holter monitoring for 48 hours in the 2 dose-finding studies. The antianginal and anti-ischemic effects were associated with a dose-related decrease in heart rate and double product both at rest and at exercise termination. Treatment with the 50- and 100-mg doses of mibefradil was found to be well tolerated and safe compared with placebo, a finding that held true for patients on chronic beta-blocker or long-acting nitrate therapy. Taken together, these studies indicate that mibefradil is an effective and well-tolerated once-daily treatment for chronic stable angina pectoris at doses of 50 and 100 mg, which are the lowest and highest effective doses of the compound, respectively.
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Research Interests: Nonparametric Statistics, Echocardiography, Humans, Left Ventricular Assist Device, Female, and 12 moreMale, Regression Analysis, Confidence intervals, Adult, Cardiac Output Monitoring, Retrospective Studies, Heart Ventricles, Atrial Septal Defect, Cardiac output, Left Ventricular, Surgical Repair, and Cardiovascular medicine and haematology
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One hundred forty-four patients underwent a Bruce protocol treadmill exercise test during which an electrocardiogram (ECG) was recorded simultaneously with a 2-channel Holter recorder with bipolar V3- and V5-like leads and by a... more
One hundred forty-four patients underwent a Bruce protocol treadmill exercise test during which an electrocardiogram (ECG) was recorded simultaneously with a 2-channel Holter recorder with bipolar V3- and V5-like leads and by a conventional 12-lead system. Sixty-eight patients had no ST depression on either the Holter or on the 12-lead ECG during the exercise test, whereas in 70 patients ischemic changes were recorded by both methods; thus, in 138 of the 144 patients (96%), the results of the 2 tests were concordant. The severity of ST depression, as judged by the heart rate at which ischemic changes were first noted and the maximal ST depression observed, were similar on both recording systems. The Holter system identified 6 of the 7 patients whose ischemic changes were confined to the inferior wall on the 12-lead ECG. The addition of the V3 lead as a second ischemic lead increased the ischemia detection by 10%. Ninety-five patients also underwent coronary arteriography. In these patients the sensitivity of the Holter system during exercise in detecting significant coronary artery disease was 81% and that of 12-lead ECG was 84%, the specificity was 85% and 85%, respectively, and the positive predictive value 91% and 91%, respectively. Thus, the 2-channel Holter recording system with bipolar V3- and V5-like leads was as accurate as the 12-lead system in detecting ischemic changes during exercise and proved that ambulatory monitoring system can reliably reproduce ST segment.
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... Dynamic Changes in the ST-T Segment During Sleep in Ischemic Heart Disease SHLOMO STERN, MD, FACC DAN TZIVONI, MD Jerusalem, Israel ... The deterioration of ST-T changes in the lattergroup lasted for several hours and only rarely was... more
... Dynamic Changes in the ST-T Segment During Sleep in Ischemic Heart Disease SHLOMO STERN, MD, FACC DAN TZIVONI, MD Jerusalem, Israel ... The deterioration of ST-T changes in the lattergroup lasted for several hours and only rarely was accompanied by chest pain that ...
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The diagnostic value of 12-lead electrocardiography during dobutamine stress echocardiography (DSE) is not well documented. We reviewed the records of 116 patients referred for DSE and coronary angiography, 52 of whom were excluded... more
The diagnostic value of 12-lead electrocardiography during dobutamine stress echocardiography (DSE) is not well documented. We reviewed the records of 116 patients referred for DSE and coronary angiography, 52 of whom were excluded because of abnormal ST segment or inadequate DSE. Of the analyzed 65 patients, 42 had angiographic evidence of significant coronary disease, 41 had evidence of ischemia according to the echocardiographic criteria, and 30 had ST changes during the study. DSE had sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV) of 88%, 81%, 90%, and 78%, respectively. Twelve-lead electrocardiography had sensitivity, specificity, PPV, and NPV of 52%, 64%, 72%, and 41%, respectively. NPV increased to 92% in patients with negative DSE and negative ST changes. PPV increased to 95% if both DSE and 12-lead electrocardiographic ischemic changes were observed. Twelve-lead electrocardiography has an incremental diagnostic value when used during DSE.
Research Interests: Stress, Electrocardiography, Humans, Technique, Number, and 13 moreElectrocardiogram, Coronary Angiography, Coronary heart disease, Public health systems and services research, Retrospective Studies, Electrodes, Sensitivity and Specificity, Electrode, Predictive value of tests, Positive predictive value, Negative predictive value, Cardiovascular medicine and haematology, and Numero
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Background: Previous studies have suggested that women with myocardial infarction are treated less aggressively and have worse outcomes compared with men. The objective of this study was to evaluate sex dif-... more
Background: Previous studies have suggested that women with myocardial infarction are treated less aggressively and have worse outcomes compared with men. The objective of this study was to evaluate sex dif- ferencesinthemanagementandoutcomesofelderly(age 70 years) women and men with acute coronary syn- dromes (ACSs) in the new millennium. Methods: This study includes 1331 consecutive el- derly patients with ACSs admitted to
Research Interests: Treatment Outcome, Israel, Prospective studies, Humans, Hospitalization, and 19 moreFemale, Male, Patient Compliance, Follow-up studies, Aged, Acute Coronary Syndrome, Coronary Angiography, Myocardial Infarction, Coronary heart disease, Sex Factors, Survival Rate, Odds ratio, Age Factors, Elderly Women, Indexation, Hospital Mortality, Syndrome, Mortality rate, and Medical Treatment
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The aim of this study was to examine the dependence of the ischemic threshold during exercise testing on the exercise protocol employed and to determine the relation between the ischemic thresholds observed during exercise and during... more
The aim of this study was to examine the dependence of the ischemic threshold during exercise testing on the exercise protocol employed and to determine the relation between the ischemic thresholds observed during exercise and during daily activity. The ischemic threshold (heart rate at 1-mm ST segment depression) during daily activity has been reported to be lower than that observed during exercise testing. Recent reports have hypothesized that this difference is probably dependent on the exercise protocol employed. Twenty-two patients with known coronary artery disease, not receiving antianginal medications, were evaluated by repeated exercise testing according to the Bruce and the modified Davidson protocols and by 48-h ambulatory electrocardiographic monitoring. Although the heart rate at 1-mm ST segment depression was somewhat lower with the Davidson than with the Bruce protocol (112 +/- 14 vs. 115 +/- 14 beats/min), the rate-pressure product at 1-mm ST segment depression was similar during the two protocols (16,900 +/- 4,000 vs. 17,700 +/- 3,600). The mean heart rate (100 + 12 beats/min) at 1-mm ST segment depression during ambulatory ischemic episodes (n = 137) was significantly lower than that observed during both exercise protocols (p &lt; 0.001 for both comparisons). Exercise-induced ischemia occurs at a relatively fixed threshold that is mainly dependent on myocardial oxygen demand and is independent of the exercise protocol employed. Ischemia on ambulatory monitoring, however, occurs at a much more variable threshold that is commonly lower than that observed during exercise and is therefore dependent on other factors in addition to increased demand.
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Spontaneous coronary artery dissection is an extremely rare cause of myocardial infarction. It has been reported mainly in young women during or after pregnancy. The prognosis and treatment of coronary dissection are not clear. We report... more
Spontaneous coronary artery dissection is an extremely rare cause of myocardial infarction. It has been reported mainly in young women during or after pregnancy. The prognosis and treatment of coronary dissection are not clear. We report three cases of spontaneous coronary artery dissection in young women. One of them was pregnant and one was 2 weeks after delivery. The dissection involved the left anterior descending artery (LAD) in two cases and the left main coronary artery in one case. There was no evidence of atherosclerosis on angiography or intracoronary ultrasound in any of the patients. Two of the women were treated by stent implantation with excellent results. This is the first known report of successful coronary stenting of spontaneous coronary artery dissection. The pregnant woman was not a candidate for stent implantation and underwent implantation of the left internal mammary to the LAD without cardiopulmonary bypass. She completed her pregnancy uneventfully.
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Nicotine patches are commonly used by people who try to quit smoking. Because high doses of nicotine may increase heart rate and potentiate cardiac arrhythmia or ischemia, its use in patients with coronary artery disease was investigated.... more
Nicotine patches are commonly used by people who try to quit smoking. Because high doses of nicotine may increase heart rate and potentiate cardiac arrhythmia or ischemia, its use in patients with coronary artery disease was investigated. The objective was to assess the cardiovascular safety of nicotine patches in patients with coronary artery disease (CAD) who try to quit smoking.
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Summary: The effect of supine physical exercise on cerebral blood flow (CBF) was measured in 30 normal subjects with the 133Xe inhalation technique. The CBF measurements were correlated to changes in Pco2, heart rate, and blood pressure,... more
Summary: The effect of supine physical exercise on cerebral blood flow (CBF) was measured in 30 normal subjects with the 133Xe inhalation technique. The CBF measurements were correlated to changes in Pco2, heart rate, and blood pressure, and to cardiac output and right atrial pressure in 10 of the subjects who underwent Swan-Ganz catheterization. No significant change was found in CBF during physical exercise, although a marked increase in cardiac output, blood pressure, and right atrial pressure and a mild decrease in Pco2 were found. Cerebrovascular resistance increased by 38%, in contrast to a decrease of 33% in the peripheral vascular resistance. The factors that affect the mechanism of cerebrovascular autoregu-lation during exercise are discussed.
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Research Interests: Natural History, Echocardiography, Prospective studies, Humans, Left Ventricular Assist Device, and 15 moreHospitalization, Female, Male, Follow-up studies, Acute Myocardial Infarction, Middle Aged, Myocardial Infarction, Public health systems and services research, Time Factors, Thrombosis, Streptokinase, Embolism, Thrombolytic Therapy, The American, and Heart Diseases
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Ischaemic hepatitis, although infrequent, should be considered as a cause of fulminant hepatitis in patients with congestive heart failure. Ischaemic hepatitis is characterized by a marked rise in transaminases occurring within 24-48 h of... more
Ischaemic hepatitis, although infrequent, should be considered as a cause of fulminant hepatitis in patients with congestive heart failure. Ischaemic hepatitis is characterized by a marked rise in transaminases occurring within 24-48 h of circulatory failure. Cardioversion of atrial fibrillation to sinus rhythm is associated with an increase in cardiac output in most patients; however, a transient reduction in cardiac output may occur in more than one-third of patients, and may therefore induce ischaemic hepatitis. This is the first report of fulminant ischaemic hepatitis as a complication of cardioversion of atrial fibrillation.
Research Interests: Heart Failure, Humans, Liver, Ischemia, Male, and 4 moreAtrial Fibrillation, Clinical Sciences, Aged, and Liver Failure
The use of a mobile gamma camera with thallium 201 myocardial imaging is described to exclude myocardial infarction in a patient admitted to the coronary care unit in shock and with clinical, enzyme, and ECG changes consistent with... more
The use of a mobile gamma camera with thallium 201 myocardial imaging is described to exclude myocardial infarction in a patient admitted to the coronary care unit in shock and with clinical, enzyme, and ECG changes consistent with infarction. The patient suffered from acute aortic dissection associated with congenital coarctation of the aorta. The myocardial scan excluded transmural myocardial injury.
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The cardiovascular effects and safety of transdermal nicotine patches were assessed in 50 healthy smokers using repeated 48 hour ambulatory electrocardiographic monitoring as a part of a smoking cessation program. Following baseline... more
The cardiovascular effects and safety of transdermal nicotine patches were assessed in 50 healthy smokers using repeated 48 hour ambulatory electrocardiographic monitoring as a part of a smoking cessation program. Following baseline measurements, subjects were randomized to active (n = 25) or placebo (n = 25) treatment groups for a period of 2 weeks. Twenty-two patients in each group completed the trial. During the treatment period, subjects also received behavioral supportive therapy. Heart rate and blood pressure were significantly reduced relative to baseline both groups. In the active treatment group, mean values at baseline and after 2 weeks of double-blind treatments were as follows: heart rates, 74.0 and 71.3 beats/min, respectively; systolic blood pressure, 108.9 and 106.9 mmHg; and diastolic blood pressure, 69.7 and 68.2 mmHg, respectively. Values for the placebo group were as follows: heart rate, 73.2 and 69.6 beats/min; systolic blood pressure, 110.6 and 105.3 mmHg; diastolic blood pressure, 71.4 and 70.5 mmHg. The confidence intervals of the mean for the differences between the groups are as follows: heart rate, -4.0 +8.2; systolic blood pressure, -6.7, +10.1; diastolic blood pressure, -7.9, +3.9. There were no changes in the frequency of atrial or ventricular arrhythmia as documented by repeated 48 hour ambulatory ECG recordings from baseline period before stopping smoking compared with the treatment period in the active as well as in the placebo groups. No ischemic events were detected in any of the volunteers during either the baseline or treatment periods. As a measure of smoking abstinence, we assessed the level of carbon monoxide in expired air; in the active group, the mean levels fell from 14.2 to 4.4 ppm after smoking cessation and in the placebo group from 13.2 to 4.2 ppm. The mean urine cotinine level fell from 8.18 mmol/l at baseline to 5.74 mmol/l after 2 weeks of treatment in the active group and from 8.78 to 3.93 mmol/l in the placebo group. The number of cigarettes smoked per week in both treatment groups was significantly reduced: from 175.2 to 8.4 for the active group and from 136 to 8.6 for the placebo group. Eleven out of 22 subjects in each group quit smoking completely. Smoking withdrawal symptoms during the first week of treatment were more severe in the placebo group than in those on active treatment. There were no significant side effects in either the placebo or the active treatment groups. These results indicate that nicotine delivered by transdermal system is free of cardiac adverse effects in healthy volunteers.
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Torsades de pointes (TdP) is a life-threatening ventricular tachycardia that occurs in the setting of a prolonged QT interval and is most frequently related to administration of antiarrhythmic drugs. Patients with organic heart disease,... more
Torsades de pointes (TdP) is a life-threatening ventricular tachycardia that occurs in the setting of a prolonged QT interval and is most frequently related to administration of antiarrhythmic drugs. Patients with organic heart disease, with low serum electrolyte levels, with a previous episode of TdP and with bradycardia or baseline QT prolongation may be at increased risk of developing TdP. After initiation of a QT prolonging therapy, the dosage should be modified if the QT interval reaches 560-600 ms. Cessation of medication and immediate hospitalization are indicated in the presence of lightheadedness, syncope, or increased frequency and complexity of ventricular premature beats. The conventional therapy of TdP with isoproterenol or cardiac pacing, although usually effective, has certain disadvantages. Isoproterenol is contraindicated in patients with hypertension or ischemic heart disease, whereas institution of cardiac pacing requires skilled personnel and fluoroscopy. Recently, infusion of magnesium sulfate has been shown to abolish TdP both in the clinical and experimental setting. Compared with conventional therapy, magnesium sulfate has the advantage of safety and simplicity of its administration. In doubtful cases, if does not aggravate a ventricular tachycardia that is not TdP, as may occur with isoproterenol. This advantage and the prompt effectiveness of the drug in four clinical series, including 31 patients, support the use of magnesium sulfate as the first line of therapy for TdP.
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One-third of patients with acute anterior wall infarction develop left ventricular apical thrombi. Mobile thrombi carry the highest risk of systemic embolization, particularly in the early phase after the acute infarction. We report here... more
One-third of patients with acute anterior wall infarction develop left ventricular apical thrombi. Mobile thrombi carry the highest risk of systemic embolization, particularly in the early phase after the acute infarction. We report here on a young patient in whom a protruding and mobile left ventricular thrombus was detected on two-dimensional echocardiogram 1 week after an acute antero-septal infarction. Intravenous administration of relatively low doses of streptokinase was followed within 14 h by complication-free resolution and disappearance of the thrombus.
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During the years 1971-1974, ambulatory ECG monitoring (AEM) during everyday activities was done in 888 consecutive subjects. Half of them were patients who suffered from chronic ischemic heart disease (IHD), while in the others no... more
During the years 1971-1974, ambulatory ECG monitoring (AEM) during everyday activities was done in 888 consecutive subjects. Half of them were patients who suffered from chronic ischemic heart disease (IHD), while in the others no symptoms or signs of this disease were found. Ventricular arrhythmias (VA) were detected in 196 subjects of the former and in 190 of the latter group. The Bureau of Statistics provided information concerning the individuals who died before December 31, 1976, the cause of their death and whether or not the death occurred in hospital or was &#39;sudden&#39;. We found that during the follow-up period, the rate of sudden cardiac death among the patients with IHD in whom AEM detected VA was higher than in subjects without VA. In the former group, there were 12 sudden cardiac deaths among 196 patients, while in the latter there were only 4 out of 248, a statistically significant difference. Sudden cardiac death was more frequent in individuals without IHD if AEM disclosed VA (4 sudden cardiac deaths among 190 subjects), as compared to individuals without VA (no sudden cardiac deaths among 254 subjects).
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In 103 patients who recovered from an acute myocardial infarction (AMI) we evaluated the usefulness of predischarge clinical, routine laboratory and M-mode echocardiographic (echo) criteria in predicting cardiac complications during a... more
In 103 patients who recovered from an acute myocardial infarction (AMI) we evaluated the usefulness of predischarge clinical, routine laboratory and M-mode echocardiographic (echo) criteria in predicting cardiac complications during a period of 12-41 months (25.0 +/- 10.7 months) follow-up. The echo parameters evaluated were: left ventricular diastolic diameter, left ventricular percent fractional shortening and the mitral valve E point septal separation. The combination of these three echo criteria was defined as an echo-index, which was considered abnormal if at least two of the three single parameters were pathological. Congestive heart failure occurred in 35 (34%) patients, with significantly higher prevalence among those older than 65 years, with previous AMI and with predischarge findings of heart failure. However, the sensitivity of these clinical parameters was unsatisfactory (34-69%). The sensitivity, specificity and positive predictive value of the echo-index for future heart failure were 89, 88 and 80%, respectively. Chest pain prior to hospital discharge was the only criteria predicting high risk of reinfarction (p = 0.001). The risk of cardiac death was related to age older than 65 years (p = 0.03) and an abnormal echo-index (p = 0.01). The overall mortality rate was 13%, but only 6% among those with normal and 26% among those with pathologic echo-index. In conclusion, in patients who recovered from an AMI, a simple and easily measured echo-index was superior to most clinical and routine laboratory criteria in predicting future heart failure and cardiac death.
Research Interests: Cardiology, Echocardiography, Heart Failure, Humans, Left Ventricular Assist Device, and 12 moreCongestive Heart Failure, Acute Myocardial Infarction, Mitral Valve Repair, Myocardial Infarction, Angina pectoris, Prognosis, Sudden Cardiac Death, Ischemic Heart Disease, Indexation, Chest Pain, Positive predictive value, and Mortality rate
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Metoprolol is a widely used anti-ischemic drug with a relatively short half-life. To improve patient&amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;#39; compliance and to provide 24-hour coverage, its once daily ORally OSmotic (OROS)... more
Metoprolol is a widely used anti-ischemic drug with a relatively short half-life. To improve patient&amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;#39; compliance and to provide 24-hour coverage, its once daily ORally OSmotic (OROS) formulation was developed. In this multicenter double-blind study, the anti-ischemic effects of metoprolol OROS given once daily at doses of 190 and 285 mg were compared to the regular metoprolol formulation of 100 mg 2 or 3 times daily. Sixty-five patients with stable coronary artery disease, positive exercise tests, and ischemic episodes during daily activity as recorded by ambulatory electrocardiographic monitoring (AEM) were included. In the OROS group, 23 patients completed all 3 treatment periods. In these patients, the number of myocardial ischemic episodes decreased from 239 on placebo to 128 during the 190 mg/day dose (p &amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;lt; 0.0001) and to 86 during the 285 mg/day treatment period (p &amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;lt; 0.0001). In the metoprolol group, there were 204 episodes at baseline and 142 and 140 during the 100 mg 2 or 3 times daily treatment periods (p &amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;lt; 0.0001 for both). During exercise testing, time to 1-mm ST depression increased significantly in the OROS group from 6.3 minutes at baseline to 7.1 and 9.6 minutes during 190- and 285-mg treatment periods. In the metoprolol group, it increased from 5.8 to 7.2 and 8.2 minutes, respectively. Both formulations of metoprolol were well tolerated. The OROS formulation was highly effective in suppressing daily and exercise-induced ischemia and exerted its effect throughout the 24-hour period.
Research Interests: Humans, Female, Male, Aged, Middle Aged, and 3 moreAdult, Coronary Artery Disease, and Exercise Test
Research Interests: Electrocardiography, Sudden Death, Humans, Congestive Heart Failure, Female, and 18 moreMale, Follow-up studies, Creatine Kinase, Recurrence, Clinical Sciences, Aged, Middle Aged, Myocardial Infarction, Adult, Coronary heart disease, Public health systems and services research, Isoenzymes, Angina pectoris, Prognosis, Circulation, Exercise Test, Tachycardia, and The American
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To assess the presence of residual myocardial ischemia, right atrial pacing was performed in 30 patients with 31 episodes of acute myocardial infarction (AMI) on the day before their discharge from the hospital. Ten patients had anterior,... more
To assess the presence of residual myocardial ischemia, right atrial pacing was performed in 30 patients with 31 episodes of acute myocardial infarction (AMI) on the day before their discharge from the hospital. Ten patients had anterior, 11 inferior, and 10 subendocardial AMI. The atrial pacing was performed in the intensive care unit. The electrode was introduced by direct puncture of the antecubital vein and positioned under intracavitary ECG control. No complications occurred in any of the patients. Ischemic ST depression was observed in 14 patients. Only 1 of 10 with anterior AMI had a positive test, compared with 7 of 11 with inferior AMI and 6 of 10 with subendocardial AMI. It is concluded that right atrial pacing can be performed safely in patients soon after AMI, and that the procedure is sensitive in detecting residual myocardial ischemia. It is expected that this method will provide a tool for identifying high-risk patients, thus enabling better treatment and possibly a r...