Chaim Yosefy

Rosiglitazone improves, while Glibenclamide worsens blood pressure control in treated hypertensive diabetic and dyslipidemic subjects via modulation of insulin resistance and sympathetic activity.

Background: Type II diabetes is often associated with high blood pressure, elevated sympathetic activity, and high plasma insulin levels. Hypoglycemic agents may negatively interfere with blood pressure control, sympathetic activity, and plasma insulin level; therefore the choice of treatment in type II diabetes may be crucial. We aimed to compare the effects of two hypoglycemic drugs on blood glucose, blood pressure, sympathetic activity, and insulin levels in type II diabetic and hypertensive patients. Methods: Forty-eight (24M, 24F) type II diabetic, hypertensive, and hyperlipidemic subjects were enrolled and treated for 4 weeks with an ACE inhibitor (Cilazapril) and a statin (Simvastatin). They were then randomized into two groups to receive a thiazolidinedione (Rosiglitazone; ROS) or a sulfonylurea (Glibenclamide; GLB) for 8 weeks. Blood biochemistry, blood pressure, plasma insulin, endothelial function, and sympathetic skin activity were measured before and after treatment. Results: A significant drop in systolic and diastolic blood pressure by 6.1 ± 4.1mm Hg and 4.2 ± 1.9 mm Hg respectively; a reduction in plasma insulin concentration by 4.3 ± 1.9mU/L and a decline in skin sympathetic activity were observed in the group receiving ROS. The GLB group showed an increase in systolic blood pressure by 3.1 ± 2.5 mm Hg, no change in diastolic blood pressure, significant elevation in plasma insulin concentration by 2.3 ± 1.4 mu/L, and augmentation of sympathetic activity. No significant changes in endothelial function were observed in either group. Conclusions: Rosiglitazone improved both plasma glucose and blood pressure levels, probably by attenuation of hyperinsulinemia and sympathetic activity, while Glibenclamide worsened blood pressure control possibly by elevation of insulin levels and activation of the sympathetic system.

The Influence of Smoking Cessation on Hemodynamics and Arterial Compliance

Cigarette smoking is associated with consistent changes in small arteries and arterioles. Recently, arterial compliance was determined in smokers; however, the effect of smoking cessation on arterial compliance has not yet been investigated. The objective of the study was to assess how smoking cessation, achieved with use of behavioral and pharmacologic therapy, influences vascular compliance and arterial stiffness in smokers. In an open-label study, 60 habitual smokers were treated for 2 months with buproprion 300 mg per day and personal and group conversations in order to facilitate smoking cessation. Hemodynamic variables, including vascular compliance and augmentation index (AI), were measured twice, at the beginning of the study and after 6 months. Of the 60 smokers, 35 stopped smoking and 25 failed at the end of the 2-month treatment period. Of the 35 who were initially successful, 12 went back to smoking, and thus only 23 remained nonsmokers at the end of 6 months. Smoking cessation was accompanied by significantly lower arterial pressure and heart rate but by weight gain. Among the 23 subjects who stopped smoking for 6 months capacitive compliance (C1) did not change but oscillatory compliance (C2) rose significantly (from 5.1 ±2.3 to 6.3 ±3.0 p<0.01), and AI decreased significantly (from 63.1 ±22 to 50.6 ±17 p<0.05), whereas in smokers who still smoked after this period, both C1 and C2 and augmentation index did not change significantly from their basal values. The authors conclude that smoking cessation improves arterial stiffness as assessed by the augmentation index, owing mainly to increasing the small artery compliance, which is known to be an early index of endothelial damage.

Resistant Arterial Hypertension Is Associated With Higher Blood Levels of Complement C3 and C-Reactive Protein

Arterial hypertension is associated with increased plasma levels of complement C3, C4, and C‐reactive protein (CRP). The aim of the study was to compare these laboratory markers in patients with resistant arterial hypertension (RAH) and controlled arterial hypertension (CAH). Patients with RAH (n=34), those with CAH (n=34), and 26 normotensive controls were included. White blood cell count, erythrocyte sedimentation rates, and blood levels of complement components C3, C4, and high‐sensitivity C‐reactive protein (hs‐CRP) were compared among the study groups. In the RAH group, serum C3 (183.9±47.5 mg/dL) and hs‐CRP (6.9±5.8 mg/L) were higher than in the CAH group (C3, 123.1±42.3 mg/dL; P<.001, hs‐CRP, 4.2±4.8; P=.021, respectively). Significant positive correlations between systolic blood pressure and C3 (r=0.6481; P<.001) and hs‐CRP (r=0.3968; P=.02) were observed in the RAH group. RAH is associated with higher blood levels of C3 and CRP.

BiPAP Ventilation as Assistance for Patients Presenting with Respiratory Distress in the Department of Emergency Medicine

AbstractBackground: Noninvasive ventilatory support (NIVS) is intended to provide ventilatory assistance for a wide range of respiratory disturbances. The use of NIVS for treatment of respiratory distress may be applicable in the emergency department (ED). It may prevent endotracheal intubation and, likewise, may favorably influence the course of the patient’s hospitalization, depending on the primary disease or ventilatory disturbance. Objective: To evaluate the efficacy of bilevel positive airway pressure (BiPAP) ventilation in patients with acute respiratory distress presenting in the ED. Methods: A prospective, uncontrolled, nonrandomized, nonblind study enrolled 30 patients. They were cooperative and hemodynamically stable, aged over 18 years, and presented with acute respiratory distress as defined by predetermined criteria. They were connected to a BiPAP machine through a face mask, using an initial pressure of 8/3cm H2O, which was gradually raised to 12/7cm H2O inspiratory positive airway pressure/expiratory positive airway pressure. Standard drugs, inhalation and oxygen therapies were administered as needed. The BiPAP was disconnected either upon relief of respiratory distress or on deterioration of the patient’s condition. Results: Of the 30 patients in the study, 19 had cardiogenic pulmonary edema, four had acute asthma, three had exacerbation of COPD, three had pneumonia and one had malignant pleural effusion. BiPAP was instituted subsequent to failure of standard therapies. Twenty-six patients were classified as responders to the BiPAP ventilation and four as nonresponders (three patients were intubated after 1 hour and one patient 24 hours, post BiPAP). The total length of stay (LOS) in the ED was 3–5 hours and the mean LOS in hospital was 4.1 ± 1.5 days, versus 6.5 ± 1.2 days in LOS reports of similar patients in the same hospital during 1999, who did not undergo BiPAP ventilation. No other complications were observed. Conclusions: We found BiPAP ventilation simple, safe, effective and well tolerated by patients in respiratory distress. The rate of endotracheal intubation after successful BiPAP ventilation was low. In carefully selected patients with respiratory distress, BiPAP ventilation may successfully replace endotracheal intubation.

Impaired nitric oxide production, brachial artery reactivity and fish oil in offspring of ischaemic heart disease patients.

Abstract The offspring of coronary heart disease (CHD) patients are at particularly high risk for developing CHD. Endothelial dysfunction is present in the majority of CHD and atherosclerosis patients. Fish oil, rich in n-3 fatty acids has been shown to augment endothelium-dependent vasodilatation in human peripheral and coronary arteries. The aims of this study are to investigate presence of endothelial dysfunction determined by the brachial flow-mediated diameter, nitric oxide, plasma lipids and fibrinogen, and the effect of high doses of fish oil on these parameters. Twenty-four healthy offspring of CHD patients (study group) were supplemented with 9 g/day Alsepa fish oil (each gram containing 180mg EPA and 120mg DHA), for a period of two weeks. Plasma nitric oxide, urine nitric oxide, fibrinogens and flow-mediated vasodilatation (FMD) were determined prior to fish oil therapy, two weeks into therapy and four weeks after the end of therapy with fish oil. Twelve healthy subjects (control group) with no family history of heart disease were studied as controls (day one only). The offspring had a lower increase in FMD and lower nitric oxide production, compared with the control group. No other parameters varied between the two groups. The administration of fish oil did not result in any changes in the studied parameters. In healthy offspring of CHD patients, early endothelial dysfunction was documented before evidence of atherosclerosis. Ingestion of fish oil over a 13-day period did not improve endothelial dysfunction.

The diagnostic value of QRS changes for prediction of coronary artery disease during exercise testing in women: false-positive rates.

ObjectivesThe false positive rate of electrocardiographic exercise testing (ET) for coronary artery disease (CAD) in women ranges from 38 to 67%, using the ST-T changes (ST-T) criteria. The aim of this study was to compare the diagnostic accuracy of QRS duration change criteria with ST-T change criteria during ET. MethodsWe studied 234 women (mean age 58±17 years, range 27–83 years), of whom 160 were pre-menopausal (PrMW; mean age 41±9, range 27–56) and 74 were post-menopausal (PoMW; mean age 65±7, range 57–83). All participants underwent ET to rule out CAD, followed by thallium stress testing (TL). QRS duration, measured with a computerized optical scanner and ST-T changes at peak ET were compared with TL. An ischemic QRS response was defined as an exercise-induced prolongation of QRS duration >3 ms. ResultsThe sensitivities of QRS duration changes for the entire study group, the PrMW group and the PoMW group in comparison with TL, were 93, 88 and 92%, respectively, while the corresponding rates of specificity were 91, 85 and 91%, respectively. The sensitivities of ET ST-T changes for the entire study group, for the PrMW group and for the PoMW group were 48, 46 and 54%, respectively, while the corresponding rates of specificity were 62, 75 and 79%, respectively. The false-positive rate was 20% for ischemic ST-T and 4% for ischemic QRS duration for the entire study population. ConclusionsComputer-measured QRS duration changes during ET are more sensitive and specific than ST-T changes for the detection of ischemia in women.

Risk factor profile and achievement of treatment goals among hypertensive patients from the Israeli Blood Pressure Control (IBPC) program--initial cost utility analysis.

Aims: Blood pressure (BP) reduction is crucial in reducing cardiovascular morbidity and mortality. The IBPC (Israeli Blood Pressure Control) program was initiated in order to enhance the control of modifiable risk factors among high-risk hypertensive patients under follow-up by general practitioners in Israel. The cost effectiveness of an intervention program is an important factor in the decision-making process of its implementation and therefore was evaluated here. The objective of this evaluation is to estimate the costs, monetary savings and benefits in terms of QALYs (quality-adjusted life years) that would be expected if the program were to be expanded to 100 clinics nationwide, enabling around 14 800 persons to be treated. Methods: Hypertensive patients were screened in 30 general practice clinics, supervised by specialists in family medicine, each seeing 1000-5000 patients; 50-250 hypertensive patients were diagnosed at each participating clinic. BP levels, body mass index (BMI), lipid and glucose levels, as well as target organ damage and medications were recorded for all patients. Results: A total of 4948 (2079, 42% males) were registered. Mean age was 64.8 ± 12 years. After 1 year of follow-up versus baseline, the various parameters were as follows: BP control was achieved in 46.4% vs 29% of all hypertensive patients. LDL control (JNC VI criteria) was achieved in 41.7% vs 31.2% of all patients. Fasting plasma glucose control (glucose <126 mg/dl) was achieved in 22% vs 19% of diabetic patients and 5.2% vs 3.1% of the diabetics had fasting plasma glucose levels >200 mg/dl. Obesity (BMI >30 kg/m[Formula: See Text]) was noted in 36.7% vs 43.8% at baseline. The cost utility analysis of the reduction in risk factors was calculated based on the international dicta applied to the reduction in risk factors as a result of treatment. For 100 clinics nationwide and 14 800 persons to be treated the net saving to health services would be

Cost-utility analysis of a national project to reduce hypertension in Israel

977 993 and the increase in QALYs would be 602 years. Conclusions: Better risk factor control in hypertensive patients by general practitioners could reduce morbidity and mortality as well as be cost effective.

Circadian Variation of the Efficacy of Thrombolytic Therapy in Acute Myocardial Infarction—Isn’t the Time Ripe for Cardiovascular Chronotherapy?:

BackgroundThis study aims to calculate the health effects and costs of a proposed national hypertension prevention and control program.MethodsInterventions are based on experience from our two programs: 10-year period of Ashkelon Hypertension Detection and Control Program (AHDC Program) and the Israel Blood Pressure Control (IBPC) program. The costs of a nationwide program were calculated based on economic data, training staff levels, course frequency and unit costs.ResultsOver the next 20 years, the program should decrease the risk in one-half of the treated hypertensive cases of the following ailments: cardiovascular events such as Acute Myocardial Infarction (AMI) and Unstable Angina Pectoris (UAP) by 16.0%, stroke by 41.2%, End stage renal disease (ESRD) by 50.0% and peripheral vascular disease (PVD) by 42.6%. In total, around 2,242 lives, 35,117 years of life or 24,433 disability adjusted life years will be saved due to decreased mortality.Program costs amount to

Safety of nifedipine in threatened preterm labor: Investigation by three-dimensional echocardiography

352.7 million. However savings (