Itzhak Shapira

Myocardial ischemia during sexual activity in patients with coronary artery disease.

I t is generally agreed that oxygen requirements during sexual activity are moderate’.*; heart rate values during intercourse arc similar to those found in daily life’*; sexual activity in most patients with coronary artery disease (CAD) is associated with low risk of cardiac complications’; and coital death among patients with CAD is rare.’ There is, however, a paucity of relevant data on sexual activity in patients with CAD. The occurrence of silent ischemia during sexual intercourse in patients with coronary disease is among the issues that still require elucidation. This study utilized ambulatory elcctrocardiographic monitoring to detect the occurrence of ischemia during intercourse in patients with CAD. The relation between electrocardiographic findings on sexual activity and a near-maximal exercise test were compared. . . . The study group comprised 88 male CAD outpatients, mean age 52 years (range 36 to 66), who participated in our long-term cardiac rehabilitation program. Patients’ informed consent to undergo 24-hour ambulatory electrocardiographic monitoring, which included monitoring during sexual activity, was a prerequisite for admission into the study. The diagnosis of CAD was established by one or both of the following criteria: previous myocardial infarction (73 patients [83%]) and typical effort-induced angina (15 patients [17%]). Functional capacity (New York Heart Association classification) was established as class I for SO patients (57%), class II for 26 (30%), and class I11 for 12 (14%). All patients were in sinus rhythm and had been clinically stable for at least 4 months. None had anemia, respiratory disease, or chronic renal failure. Patients with cchocardiographic evidence of left ventricular hypertrophy or cardiomyopathy were excluded from the study, as were patients using digitalis, diuretics, or antiarrhythmic medication. Beta-blocking agents were discontinued 24 days before examination, and nitrates and calcium channel blockers were discontinued 224 hours before examination. Detailed individual case histories were recorded. All patients underwent thorough physical examination, a resting 12-lead electrocardiogram, a cycloergometric test: and 24-hour ambulatory electrocardiographic monitoring. The ergometric test was performed on a mcchanitally braked Monark bicycle ergometer, following our protocol described elsewhere.* All patients underwent a near-maximal test (85% of predicted maximal heart rate according to age) based on progressively increasing intermittent workloads at 5-minute intervals. The initial

Elevated resting heart rate is associated with the metabolic syndrome

BackgroundIncreased resting heart rate (RHR) may be associated with increased cardiovascular morbidity. Our aim was to explore the possibility that increased RHR is associated with the prevalence of the metabolic syndrome (MetS) in a sample of apparently healthy individuals and those with cardiovascular risk factors.MethodsWe performed a cross-sectional analysis in a large sample of apparently healthy individuals who attended a general health screening program and agreed to participate in our survey. We analyzed a sample of 7706 individuals (5106 men and 2600 women) with 13.2% of men and 8.9% of the women fulfilling the criteria for the MetS. The participants were divided into quintiles of resting heart rate. Multiple adjusted odds ratio was calculated for having the MetS in each quintile compared to the first.ResultsThe multi-adjusted odds for the presence of the MetS increased gradually from an arbitrarily defined figure of 1.0 in the lowest RHR quintile (<60 beats per minute (BPM) in men and <64 BPM in women) to 4.1 and 4.2 in men and women respectively in the highest one (≥80 BPM in men and ≥82 BPM in women).ConclusionRaised resting heart rate is significantly associated with the presence of MetS in a group of apparently healthy individuals and those with an atherothrombotic risk. The strength of this association supports the potential presence of one or more shared pathophysiological mechanisms for both RHR and the MetS.

Effect of tumor necrosis Factor-Alphaon endothelial and inducible nitric oxidesynthase messenger ribonucleic acidexpression and nitric oxide synthesisin ischemic and nonischemic isolated rat heart

Abstract Objectives The present study aimed to investigate the influence of endogenous tumor necrosis factor-alpha (TNF-α) that was synthesized during ischemia and exogenous TNF-α on endothelial and inducible nitric oxide synthase (eNOS and iNOS) messenger ribonucleic acid (mRNA) expression and nitric oxide (NO) production in the isolated rat heart. Background Tumor necrosis factor-α is recognized as being a proinflammatory cytokine with a significant cardiodepressant effect. One of the proposed mechanisms for TNF-α-induced cardiac contractile dysfunction is increased NO production via iNOS mRNA upregulation, but the role of NO in TNF-α-induced myocardial dysfunction is highly controversial. Methods Isolated rat hearts studied by a modified Langendorff model were randomly divided into subgroups to investigate the effect of 1-h global cardioplegic ischemia or the effect of 1-h perfusion with exogenous TNF-α on the expression of eNOS mRNA and iNOS mRNA and on NO production. Results After 1 h of ischemia, there were significant increases in TNF levels in the effluent (from hearts), and eNOS mRNA expression had declined (from 0.91 ± 0.08 to 0.68 ± 0.19, p Conclusions We believe this is the first study to directly show that TNF-α does not increase NO synthesis and release but does downregulate eNOS mRNA in the ischemic and nonischemic isolated rat heart.

Comparison of Left Ventricular Function Using Isometric Exercise Doppler Echocardiography in Competitive Runners and Weightlifters Versus Sedentary Individuals

It is unclear whether cardiovascular responses to heavy isometric exercise are changed by intensive training. We evaluated the effects of this type of exercise on left ventricular (LV) function in athletes engaged in static and dynamic sport, compared with sedentary persons, and looked for peculiarities in static athletes responses that might reflect adaptive mechanisms to their specific activity. The study population comprised 45 men (age 24 +/- 5 years): 29 dynamic and 16 static athletes (runners and weightlifters, respectively). The control group consisted of 20 age and gender-matched healthy sedentary persons. All performed 50% of maximal voluntary contraction on a whole-body isometric exercise device for 2 minutes. Echocardiographic calculations were determined at rest and exercise. Upon exercise, stroke volume, cardiac output, end-diastolic volume, and ejection fraction increased significantly in athletes, while end-systolic volume and systemic vascular resistance decreased. In sedentary persons, stroke volume and resistance remained unchanged, cardiac output and LV volumes increased, and ejection fraction decreased from 67 +/- 5% to 60 +/- 5% (p <0.01 compared with rest; p <0.0001 compared with athletes). Whereas peak flow velocity decreased from 103 +/- 10 to 81 +/- 6 cm/s in sedentary persons, it increased from 112 +/- 9 to 126 +/- 8 cm/s in the static group and from 120 +/-3 to 126 +/- 9 cm/s in the dynamic athletes (p <0.0001 compared with the sedentary group). Mean acceleration decreased in the sedentary group, remained unchanged among the dynamic athletes, and increased among the static athletes. We conclude that cardiovascular responses to heavy isometric exercise are modified by intensive training. Athletes, taken as a group, react differently and adapt better than sedentary individuals. Moreover, among them, those involved in static sport show an improved cardiovascular adaptation to this type of exercise.

High-Dose Isosorbide Dinitrate for Myocardial Revascularization With Composite Arterial Grafts

BACKGROUNDnComposite arterial grafting for myocardial revascularization is a surgical technique in which free arterial conduits are proximally attached to an in situ internal mammary artery.nnnMETHODSnComposite arterial grafting was performed in 78 patients with internal mammary artery (n = 24), inferior epigastric artery (n = 21), or radial artery (n = 33) connected to the internal mammary artery. Overall, 254 distal anastomoses were performed (average number, 3.3 per patient), 225 of which were arterial. All patients were treated postoperatively with high-dose isosorbide dinitrate (4 to 20 mg/h for 24 hours).nnnRESULTSnThe in-hospital mortality rate was 2.6% (2 patients). Early recatheterization studies performed 3 weeks (range, 1 to 20 weeks) after operation in 30 patients demonstrated patency rates of 100%, 93%, and 100% for the composite internal mammary artery, inferior epigastric artery, and radial artery groups, respectively. In addition, two inferior epigastric artery conduits had major intraluminal constriction. At a mean follow-up of 20 months (range, 1 to 42 months) all patients are alive, and all but 2 in the inferior epigastric group (97%) are angina free.nnnCONCLUSIONSnThis surgical technique can be safely used. On the basis of our experience, the right internal mammary artery and the radial artery are the most suitable conduits for this procedure. High-dose nitrates given perioperatively prevent spasm and ensure early patency rates.

Programmed ventricular stimulation using up to two extrastimuli and repetition of double extrastimulation for induction of ventricular tachycardia: A new highly sensitive and specific protocol

The sensitivity and specificity of a new protocol of programmed ventricular stimulation were evaluated in 71 consecutive patients who were divided into 2 groups: group 1 included 41 patients, of whom 25 had sustained ventricular tachycardia (VT) not associated with cardiac arrest and 16 had ventricular fibrillation (VF) not precipitated by any obvious factor; group 2 included 30 patients without demonstrable heart disease and no suspected or documented sustained ventricular tachyarrhythmias. The study consisted of a standard protocol (up to 2 extrastimuli given only once for each extrastimulus prematurity, 2 right ventricular sites and 3 basic pacing cycle lengths, as well as rapid ventricular pacing) in which double extrastimulation at the shortest coupling intervals that allowed ventricular capture was repeated 10 times. A stimulus current of 3 mA was used. Sustained ventricular tachyarrhythmias were induced in 23 of 25 (92%) patients who presented with sustained VT, 14 of 16 (88%) patients who presented with VF and 2 of 30 (7%) group 2 patients. Eighteen of 25 (72%) patients with sustained VT but only 4 of 16 (25%) with VF had arrhythmias inducible at immediate trials of single or double extrastimulation (p less than 0.01). Repetition of double extrastimulation increased the yield of inducible sustained ventricular tachyarrhythmia to 92% in patients with sustained VT (+20%, p = 0.14) and 75% (+50%, p = 0.013) in patients with VF. Rapid right ventricular pacing added a 13% increase in the overall yield in patients with VF. This new protocol of programmed ventricular stimulation has both high sensitivity (90%) and specificity (93%) for induction of sustained VT.(ABSTRACT TRUNCATED AT 250 WORDS)

Predictors for poststroke outcomes: the Tel Aviv Brain Acute Stroke Cohort (TABASCO) study protocol.

Background Recent studies have demonstrated that even survivors of mild stroke experience residual damage, which persists and in fact increases in subsequent years. About 45% of stroke victims remain with different levels of disability. Identifying factors associated with poststroke cognitive and neurological decline could potentially yield more effective therapeutic opportunities. Aims and hypothesis We hypothesize that data based on biochemical, neuroimaging, genetic and psychological measures can, in aggregate, serve as better predictors for subsequent disability, cognitive and neurological deterioration, and suggest possible interventions. Design The Tel-Aviv Brain Acute Stroke Cohort (TABASCO) study is an ongoing, prospective cohort study that will recruit approximately 1125 consecutive first-ever mild–moderate stroke patients. It is designed to evaluate the association between predefined demographic, psychological, inflammatory, biochemical, neuroimaging and genetic markers, measured during the acute phase, and long-term outcome: subsequent cognitive deterioration, vascular events (including recurrent strokes), falls, affect changes, functional everyday difficulties and mortality. Discussion This study is an attempt to comprehensively investigate the long-term outcome of mild–moderate strokes. Its prospective design will provide quantitative data on stroke recurrence, the incidence of other vascular events and the evaluation of cognitive, affective and functional decline. Identifying the factors associated with poststroke cognitive and functional decline could potentially yield more effective therapeutic approaches.

Waist circumference as the predominant contributor to the micro-inflammatory response in the metabolic syndrome: a cross sectional study

BackgroundThe metabolic syndrome (MetS) is associated with the presence of low grade inflammation. Our aim was to analyze the inter-relations between each of the components of the metabolic syndrome (MetS) and four inflammatory markers, namely high sensitivity C-reactive protein (hs-CRP), the erythrocyte sedimentation rate, the concentration of fibrinogen and the white blood cell count.MethodsWe have analyzed data collected between September 2002 and June 2009 in the Tel-Aviv medical center inflammation survey (TAMCIS). We recruited both apparently healthy individuals and individuals presenting with atherothrombotic risk factors. All participants were enrolled during their routine annual health check-up and gave their written informed consent. This is a cross sectional study in which we have fitted linear regression models using inflammatory markers as the dependant variables and adjust them according to the different components of the MetS and multiple other confounders.ResultsIncluded were 12,072 individuals of whom there were 7,760 men at a mean (S.D.) age of 44 (11) years, and 4,312 women aged 44 (11) years. A significant correlation was noted between most components of the MetS and all inflammatory markers, the most significant one being with hs-CRP. In the multi-adjusted regression analysis, waist was the factor that best explained the variability of hs-CRP, in both women and men. It also remained a significant variable for the other inflammatory markers.ConclusionsFrom amongst the various components of the MetS, waist circumference appears to exert the most influence upon the presence and intensity of the micro-inflammatory response.

Triggered C-reactive protein (CRP) concentrations and the CRP gene −717A>G polymorphism in acute stroke or transient ischemic attack

C‐reactive protein (CRP) increases following an acute stroke/transient ischemic attack (TIA), but the increment level varies among patients. We analyzed CRP concentrations during an acute stroke/TIA in relation to the CRP gene −717A>G polymorphism. Six months following an acute ischemic stroke/TIA, basal concentrations of CRP were measured in 507 controls and 219 patients and were found to be unassociated with the CRP −717A>G polymorphism. However, during the acute phase of stroke/TIA, individuals with the AG/GG genotype had significantly elevated CRP concentrations as opposed to those with the AA genotype (2.02u2003±u20031.59 vs. 1.73u2003±u20031.69u2003mg/l, Pu2003=u20030.027). In addition, significant 3.22‐fold increments in CRP concentrations was noted in individuals carrying the −717G allele when comparing the acute phase with the basal state of each patient and averaging the results. CRP −717A>G polymorphism is associated with triggered CRP concentrations during acute stroke/TIA. These findings might shed more light on the mechanisms of CRP elevation in acute ischemic stroke/TIA.

Low-grade inflammation in individuals with the hypertriglyceridemic waist phenotype: Another feature of the atherogenic dysmetabolism

The purpose of this study was to explore the possibility that the recently described hypertriglyceridemic waist (HTGW) phenotype, a risk for future coronary artery disease, is associated with the presence of low-grade inflammation. This is a cross-sectional study in a cohort of apparently healthy nondiabetic employed individuals in whom the presence of low-grade inflammation was determined by using the Dade Behring high-sensitivity C-reactive protein (hs-CRP) assay. We have presently analyzed the results obtained in 9842 apparently healthy individuals, at a mean (SD) age of 44 (11) years. We identified 1249 individuals (70.0% men) with HTGW phenotype according to the cutoff points of waist girth of at least 90 cm for men and at least 85 cm for women and triglycerides levels of at least 177 mg/dL for men and at least 133 mg/dL for women. In addition, we identified 1164 individuals (69.3% men) with the metabolic syndrome (MetS) according to the updated Adult Treatment Panel III criteria. The mean (SD) of hs-CRP was 1.3 (2.9) mg/L for the 8055 individuals who had neither the HTGW phenotype nor the MetS, 2.1 (2.7) mg/L for those who had the HTGW phenotype and no MetS, and 2.5 (2.7) for 538 individuals with the MetS and no HTGW phenotype, whereas those who had both atherogenic disorders presented an hs-CRP concentration of 2.9 (2.3) mg/L. In this cohort of apparently healthy nondiabetic employed individuals, the HTGW phenotype had a similar prevalence as the MetS and was associated with the presence of low-grade inflammation. This inflammation could be a pathophysiologic link between this dysmetabolism and atherothrombosis. In addition, the HTGW phenotype is relatively prevalent and could be a simple and inexpensive way to single out individuals at risk for future coronary artery disease.