Eytan Cohen

Predictors of long-term (4-year) mortality in elderly and young patients with acute heart failure.

The present study was designed to identify and compare predictors of short‐ and long‐term mortality in elderly and young patients hospitalized with acute heart failure (HF).

Use of intravenous morphine for acute decompensated heart failure in patients with and without acute coronary syndromes

Background: Current guidelines regarding the use of intravenous morphine (IM) in the management of patients with acute decompensated heart failure (ADHF) are discordant; whereas the American guidelines reserve IM for terminal patients, the European guidelines recommend its use in the early stage of treatment. Our aim was to determine the impact of IM on outcomes of ADHF patients. Methods: Stepwise logistic regression and propensity score analysis of ADHF patients with and without use of IM was performed in a national heart failure survey. Results: Of the 4102 enrolled patients, we identified 2336 ADHF patients, of whom 218 (9.3%) received IM. IM patients were more likely to have acute coronary syndromes, acute rather than exacerbation of chronic heart failure, and diabetes mellitus and dyslipidemia. They had higher heart rate, were less likely to receive diuretics and more likely to receive aspirin and statins. Unadjusted in-hospital mortality rates were 11.5% versus 5.0% for patients who did or did not receive IM, and the adjusted odds ratio (OR) for in-hospital death was: 2.0 (1.1–3.5, P = 0.02). Using propensity analysis, we identified 218 matched pairs of patients who did or did not receive IM. In multivariable analysis accounting for the propensity score (c-statistic 0.82), IM was not associated with increased in-hospital death (OR: 1.2 (0.6–2.4), P = 0.55). Conclusion: IM was used sparingly in our ADHF cohort, and was independently associated with increased in-hospital death in multivariable analysis, but not in propensity score analysis. Thus, IM may be used in ADHF, but with caution. Further randomized trials are warranted.

Elevated serum homocysteine is a predictor of accelerated decline in renal function and chronic kidney disease: A historical prospective study

OBJECTIVE To estimate the effect of elevated serum homocysteine level on renal function decline and on the incidence of chronic kidney disease (CKD) in the general population. METHODS A historical prospective study on 3602 subjects attending a screening center in Israel between the years 2000 and 2012. Only subjects with normal estimated glomerular filtration rate (eGFR) and without proteinuria were included. Subjects were divided to two groups according to mean total serum homocysteine level (≤ 15, >15μmol/l). Linear mixed effect model was used to estimate the annual eGRF decline in respect to homocysteine group. Cox proportional hazards models were used to estimate hazard ratios for CKD in the normal compared to the elevated homocysteine group. RESULTS Annual eGFR decline was 25% higher in subjects with elevated versus normal mean homocysteine level (0.90 ± 0.16 ml/min/1.37 m(2) vs. 0.72 ± 0.14 ml/min/1.37 m(2), p<0.001). In a median follow up of 7.75 years, 38 subjects developed CKD (1.05%). Elevated mean homocysteine level was highly associated with developing CKD (HR 4.85, 95% CI 2.48-9.49, p<0.001). In a multivariate analysis which adjusted for age, baseline kidney function, HDL cholesterol, BMI, vitamin B12 and folic acid levels, these relationships remained substantially unchanged. CONCLUSIONS Elevated mean serum homocysteine level is associated with an accelerated decline in renal function in both men and women, and is an independent risk factor for the development of CKD in the general population. Further prospective randomized clinical trials are needed to clarify whether the reduction in serum homocysteine concentrations will result in an improved renal prognosis.

Infective endocarditis due to Actinomyces neuii

Actinomyces endocarditis is very rare. At present the only Actinomyces species identified causing endocarditis are A. israelii, A. bovis, A. viscosus, A. pyogenes, A. meyeri and A. funkei. We here report the first case of endocarditis caused by Actinomyces neuii.

Blood transfusion for acute decompensated heart failure—friend or foe?

BACKGROUND In acute coronary syndromes (ACSs), blood transfusion (BT) has been associated with worse outcomes. The impact of BT among patients with acute decompensated heart failure (ADHF) remains unknown. METHODS Propensity score analysis of patients with ADHF with and without BT in a national heart failure (HF) survey was used in this study. RESULTS Of the 4,102 enrolled patients, 2,335 had ADHF, of whom 166 (7.1%) received BT. These patients were older (75.6% vs 73.6%, P = .04), more likely to be females (54.8% vs 43.9%, P = .007), more likely to have diabetes (59.0% vs 51.1%, P = .04) and renal dysfunction (59.0% vs 40.2%, P < .001), and more likely to receive inotropes (16.9% vs 8.0%, P < .001), but they had similar rates of ACS (41.0% vs 39.4%, P = .69) and prior HF (64.5% vs 70.0%, P = .23). Nadir hemoglobin levels were commonly <10 g/dL in BT patients (92.7% vs 8.0%); 15 BT patients had bleeding complications, of which 10 are major bleeding. Major predictors for BT were ACS (OR 1.85, 95% CI 1.15-2.96), inotropes use (OR 2.36, 95% CI 1.22-4.55), and nadir hemoglobin (OR 0.18 per 1 g/dL increase, 95% CI 0.14-0.22). In-hospital, 30-day, 1-year, and 4-year unadjusted mortality rates were higher for BT patients (10.8% vs 5.2%, P = .02; 11.0% vs 8.5%, P = .27; 39.6% vs 28.5%, P = .03; 69.5% vs 59.5%, P = .01, respectively). However, in 103 propensity-matched pairs (c-statistic 0.97), short-term mortality tended to be lower with BT (8.7% vs 14.6%, P = .20; 9.7% vs 18.4%, P = .08; 38.8% vs 42.7%, P = .59; and 72.8% vs 76.7%, P = .52, respectively). CONCLUSIONS Acute decompensated HF patients receiving BT had worse clinical features and unadjusted outcomes, but BT per se seemed to be safe and perhaps even beneficial.

Effect of nifedipine and theophylline in asthma

The effect of nifedipine, 10 mg po q.i.d. for 2 weeks, was studied in a randomized, double‐blind, crossover trial in nine patients with asthma receiving theophylline. Nifedipine did not significantly affect the mean (±SD) morning peak expiratory flow rate (PEFR; 336 ± 130 L/min for drug vs. 349 ± 92 L/min for placebo), evening PEFR (393 ± 69 L/min for drug vs. 367 ± 66 L/min for placebo), symptom score (27.4% ± 22.9% for drug vs. 33.8% ± 26.4% for placebo), or the number of albuterol inhalations per day (5.8 ± 3.5 for drug vs. 6.2 ± 4.1 for placebo). Furthermore, there was no change in PEFR 30, 60, or 120 minutes after nifedipine dosing. Nifedipine did not significantly affect the steady‐state serum theophylline trough levels (9.1 ± 2.2 mg/ml for drug vs. 10.2 ± 1.9 µg/ml for placebo) or the theophylline pharmacokinetic parameters, such as the elimination t1/2, peak serum concentration, time to peak, and AUC(0–24). We conclude that nifedipine has little, if any, effect on the clinical status, PEFR, or theophylline serum levels in patients with asthma who receive theophylline.

Acute hepatitis A: combination of the relapsing and the cholestatic forms, two rare variants.

Here we present an unusual case of a 23-year-old, otherwise healthy man who had a biphasic form of viral hepatitis A with a combination of two variants, the relapsing and cholestatic forms. One month after resolution of the first phase of acute hepatitis A, he was readmitted with jaundice and intense pruritus. During hospitalization, his serum bilirubin level increased to 50.2 mg/dL, with a slight increase in the other levels of liver enzymes. He was treated with ursodeoxycholic acid and later with corticosteroid therapy, resulting in resolution of symptoms and improvement of his liver function tests after 2 weeks. Medication therapy seems to be justified in markedly symptomatic patients with relapsing hepatitis.

Relationship Between Body Mass Index and Intraocular Pressure in Men and Women: A Population-based Study.

Purpose:To assess the possibility of a relationship between body mass index (BMI) and intraocular pressure (IOP) in both men and women. Materials and Methods:A retrospective cross-sectional analysis of a database from a screening center in Israel which assessed 18,575 subjects, within an age range 20 to 80 years. Results:The mean (±SD) age of the study sample was 46 (±10) years, 68% were men. A positive linear correlation was found between BMI and IOP for both men and women (r=0.166, P<0.0001 in men and r=0.202, P<0.0001 in women). Mean (95% confidence interval) IOP in subjects with BMI<25 kg/m2 was 12.8 mm Hg (range, 12.7 to 12.9 mm Hg) and increased significantly to 13.4 (range, 13.3 to 13.5 mm Hg); 13.9 mm Hg (range, 13.8 to14.0 mm Hg), and 14.3 mm Hg (range, 14.1 to 14.5 mm Hg) for BMI subcategories 25 to 29.9, 30 to 35, and >35 kg/m2, respectively (P<0.0001). These differences remained significant after multivariate adjustment for age, hypertension, and diabetes mellitus (P<0.0001). Similar multivariate adjustments showed that the coefficient factors for BMI (95% confidence interval) affecting IOP were 0.087 (range, 0.076 to 0.098) P<0.0001 and 0.070 (range, 0.058 to 0.082) P<0.0001 for men and women respectively, indicating that in men and women, the changes in IOP associated with a 10 kg/m2 increase in BMI were 0.9 and 0.7 mm Hg, respectively. Subjects with abnormal BMI compared with subjects with normal BMI had increased odds ratio of having IOP≥18 mm Hg after adjusting for confounding factors (P<0.001). Conclusions:This study shows that obesity is an independent risk factor for increasing IOP in both men and women. We consider this finding particularly pertinent in the context of the current obesity epidemic.

Assessment of orthostatic hypotension in the emergency room

The study sought to determine the duration of standing needed to detect most cases of orthostatic hypotension (OH) in the emergency room (ER) and to correlate OH with symptoms, hospitalization and survival. Patients attending a tertiary‐center ER within a 2‐month period underwent orthostatic tests after 1, 3 and 5 min of standing. OH was defined as a drop of ⩾20 mmHg in systolic pressure or ⩾10 mmHg in diastolic pressure on assuming an upright posture. Of the 814 patients tested (402 men, mean age 56.6±19.9 years), 206 (25.3%) had OH, detected in most cases (83.5%) after 3 min of standing. OH was associated with significantly higher supine systolic (p = 0.013) and diastolic (p = 0.004) blood pressure, symptoms of syncope (r = 0.11, p<0.001) or dizziness (r = 0.14, p<0.0001) and risk of hospitalization (50.9% vs 22.9%, p<0.0001). Crude mortality was similar between patients with and without OH (13.8% vs 8.7%, p = 0.06). However, on age‐adjusted analysis, patients older than 75 years with OH had significantly increased mortality (p = 0.04). In conclusion, 3 min of standing is apparently sufficient for the diagnosis of most cases of OH. Considering the high rate of OH and its predictive value for hospitalization, it should be routinely assessed in all ER patients.

Assessment of a Possible Link Between Hyperhomocysteinemia and Hyperuricemia

Background/Aim Hyperhomocysteinemia and hyperuricemia are both considered risk factors for coronary artery disease. However, the relationship between the 2 has not yet been thoroughly investigated. This study aimed to evaluate this relationship more closely. Material and Methods This study is a retrospective cross-sectional analysis of data from a screening center in Israel assessing 16,477 subjects, within an age range of 20 to 80 years. Results The mean age of the study sample was 46 years, and 68% were males. Hyperuricemia was found in 24.9% and 14.6% of subjects with elevated and normal homocysteine serum levels, respectively (P < 0.001). A positive association was found between homocysteine serum levels and uric acid serum levels. Compared with subjects with normal homocysteine serum levels, those with hyperhomocysteinemia had an odds ratio (OR) for hyperuricemia of 1.7 (95% confidence interval [CI], 1.5–1.9) and 1.6 (95% CI, 1.1–2.5) for males and females, respectively. After multivariate adjustment for age, hypertension, body mass index, estimated glomerular filtration rate, low-density lipoprotein cholesterol, high-density lipoprotein cholesterol, and thiazide use, the association remained significant in males (OR, 1.5; 95% CI, 1.3–1.7; P < 0.001) but not in females (OR, 0.9; 95% CI, 0.6–1.6; P = 0.82). Conclusions This large cohort showed a significant association between hyperhomocysteinemia and hyperuricemia. Sex differences were observed. This study suggests that accelerated atherosclerosis may be a consequence of the combined effect of these 2 factors.