Leonardo Reisin

Cerebrovascular accident complicating acute myocardial infarction: Incidence, clinical significance, and short-long-term mortality rates

Abstract purpose: The purpose of this study was to report the incidence, the antecedents, and the clinical significance of clinically recognized cerebrovascular accidents or transient ischemic attacks (CVA-TIA) complicating acute myocardial infarction. patients and methods: During 1981 to 1983, a secondary prevention study with nifedipine (SPRINT) was conducted in 14 hospitals in Israel among 2,276 survivors of acute myocardial infarction. During the study, demographic, historical, and medical data were collected on special forms for all patients with diagnosed acute myocardial infarction in 13 of these 14 hospitals (the SPRINT registry, n=5,839). Mortality followup was completed for 99% of hospital survivors for a mean follow-up of 5.5 years (range: 4.5 to 7 years). results: The incidence of CVA-TIA was 0.9% (54 of 5,839). The latter rate increased significantly only with age, from 0.4% among patients up to 59 years old to 1.6% among those aged greater than or equal to 70 years. Multivariate analysis identified age, congestive heart failure, and history of stroke as predictors of CVA-TIA during the acute phase of myocardial infarction. Patients with CVA-TIA exhibited a complicated hospital course, with a 15-day mortality rate of 41%. Subsequent mortality rates in survivors at 1 and 5 years were 34% and 59%, respectively. Rates at the same time points in patients without CVA-TIA were 16%,11%, and 29% (p conclusion: In this large cohort of consecutive patients with myocardial infarction, CVATIA was a relatively infrequent complication of acute myocardial infarction. Factors independently favoring the occurrence of CVA-TIA were old age, previous CVA, and congestive heart failure. CVA-TIA occurring during acute myocardial infarction independently increased the risk of early death threefold as well as the risk of long-term mortality in early-phase survivors (2.5-fold).

Improvements in signs and symptoms during hospitalization for acute heart failure follow different patterns and depend on the measurement scales used: an international, prospective registry to evaluate the evolution of measures of disease severity in acute heart failure (MEASURE-AHF).

BACKGROUNDnThe natural evolution of signs and symptoms during acute heart failure (AHF) is poorly characterized.nnnMETHODS AND RESULTSnWe followed a prospective international cohort of 182 patients hospitalized with AHF. Patient-reported dyspnea and general well-being (GWB) were measured daily using 7-tier Likert (-3 to +3) and visual analog scales (VAS, 0-100). Physician assessments were also recorded daily. Mean age was 69 years and 68% had ejection fraction <40%. Likert measures of dyspnea initially improved rapidly (day 1, 0.22; day 2, 1.31; P <.001) with no significant improvement thereafter (day 7, 1.51; day 2 versus 7 P = .16). In contrast, VAS measure of dyspnea improved throughout hospitalization (day 1, 50.1; day 2, 64.7; day 7, 83.2; day 1 versus 2 P < .001, day 2 versus 7 P < .001). Symptoms of dyspnea and GWB tracked closely (correlation r = .813, P < .001). Physical signs resolved more completely than did symptoms (eg, from day 1 to discharge/day 7, absence of edema increased from 33% to 72% of patients, whereas significant improvements in dyspnea increased from 27% to 52% of patients; P < .001).nnnCONCLUSIONSnChanges in patient-reported symptoms and physician-assessed signs followed different patterns during an AHF episode and are influenced by the measurement scales used. Multiple clinical measures should be considered in discharge decisions and evaluation of AHF therapies.

More rapid relief of pain with isosorbide dinitrate oral spray than with sublingual tablets in elderly patients with angina pectoris

To evaluate the possibility of improving clinical practice in the treatment of angina pectoris, the duration of relief of pain with isosorbide dinitrate (ISDN) oral spray and sublingual tablets were compared in elderly patients with chronic stable angina pectoris. Nine patients (mean age 67 years) were studied in a randomized crossover trial. The patients underwent bicycle ergometry, which resulted in typical chest pain associated with electrocardiographic ST-segment depression in all 9. The patients received ISDN oral spray or sublingual tablets immediately on termination of exercise. At least 6 hours later another ergometry test was performed and the patients were crossed over to the other drug. ISDN spray relieved pain in all patients at a mean duration of 61.6 +/- 24.4 seconds after administration, whereas the duration of relief of pain by ISDN sublingual tablets was 112.4 +/- 70 seconds. The difference was highly significant (p less than 0.0005). It is concluded that clinical practice of treatment of angina pectoris in the elderly can be improved by using ISDN oral spray rather than sublingual tablets. The spray is effective at twice the rapidity of the sublingual tablet.

Spontaneous disappearance of cough induced by angiotensin-converting enzyme inhibitors (captopril or enalapril)

Abstract Cough is a disturbing adverse effect of angiotensin-converting enzyme (ACE) inhibitors. Its incidence was found to be very low in postmarketing surveillance studies, but much higher (up to 19%) in studies specifically designed to detect it. 1–4 Cough was reported to be the leading cause for discontinuation of ACE inhibitors. 1 It is usually persistent and dry, and occasionally may be cause vomiting. It is typically accompanied by a tickling sensation in the throat and rapidly disappears after discontinuation of ACE inhibitors. The exact mechanism of this adverse effect is unknown. The purpose of this report is to describe the patterns of cough induced by ACE inhibitors, emphasizing 3 new patterns in which cough spontaneously disappears permanently or intermittently.

Three-vessel coronary artery spasm in a patient with variant angina and normal coronary arteries

Variant angina with two or more electrocardiographic or angiographic localizations has seldom been reported [1-4]. We present a case of variant angina pectoris and normal coronary arteries with three different and independent electrocardiographic localizations.

Individualized antianginal therapy guided by systemic arterial pressure

All antianginal drugs except nitrates are also first-line antihypertensive drugs. Their antianginal efficacy has not been evaluated in relation to pretreatment blood pressure. They may aggravate ischemia due to excessive reduction in blood pressure. Until the results of direct comparative studies are available, it is advisable to start treatment of angina pectoris in normotensive and hypotensive patients with other drugs that do not primarily decrease blood pressure. Nitrates are a reasonable choice.