Lior Charach

Low Levels of Low-Density Lipoprotein Cholesterol: A Negative Predictor of Survival in Elderly Patients with Advanced Heart Failure

Objectives: There are conflicting reports on the role of cholesterol as an adverse prognostic predictor in patients with heart failure (HF). This study aimed to examine the impact of low levels of low-density lipoprotein cholesterol (LDL-c) on cardiac mortality in a cohort of elderly patients with moderate and severe HF. Methods: Chronic HF patients from the HF Unit at the Tel-Aviv Medical Center (n = 212, 77% males) with an average NYHA classification of 2.8, a mean age of 76.9 ± 7.3 years (range 66-91) and a mean follow-up of 3.7 years were consecutively enrolled. The cohort was divided into tertiles according to LDL-c levels: LDL <90 mg/dl (group 1), LDL 90-115 mg/dl (group 2) and LDL >115 mg/dl (group 3). Results: The Cox regression analysis revealed that group 3 patients had the best outcome (p = 0.01 vs. groups 2 and 3), with 58% of them surviving longer than 50 months compared to 34% in group 1. The same trend was seen in the group of patients suffering from ischemic cardiomyopathy and in patients who were treated by statins (p = 0.04). Conclusion: Low LDL-c levels are associated with a reduced survival in elderly patients with clinically controlled moderate and severe HF.

Anti-oxidized low-density lipoprotein antibodies in chronic heart failure.

Oxidative stress may play a significant role in the pathogenesis of heart failure (HF). Antibodies to oxidized low-density lipoprotein (oxLDL Abs) reflect an immune response to LDL over a prolonged period and may represent long-term oxidative stress in HF. The oxLDL plasma level is a useful predictor of mortality in HF patients, and measurement of the oxLDL Abs level may allow better management of those patients. Antibodies to oxLDL also significantly correlate with the New York Heart Association score. Hypercholesterolemia, smoking, hypertension, and obesity are risk factors for atherosclerotic coronary heart disease (CHD) leading to HF, but these factors account for only one-half of all cases, and understanding of the pathologic process underlying HF remains incomplete. Nutrients with antioxidant properties can reduce the susceptibility of LDL to oxidation. Antioxidant therapy may be an adjunct to lipid-lowering, angiotensin converting enzyme inhibition and metformin (in diabetes) therapy for the greatest impact on CHD and HF. Observational data suggest a protective effect of antioxidant supplementation on the incidence of HD. This review summarizes the data on oxLDL Abs as a predictor of morbidity and mortality in HF patients.

Internal Thoracic Impedance - A Useful Method for Expedient Detection and Convenient Monitoring of Pleural Effusion

Measurement of internal thoracic impedance (ITI) is sensitive and accurate in detecting acute pulmonary edema even at its preclinical stage. We evaluated the suitability of the highly sensitive and noninvasive RS-207 monitor for detecting pleural effusion and for demonstrating increased ITI during its resolution. This prospective controlled study was performed in a single department of internal medicine of a university-affiliated hospital between 2012-2013. One-hundred patients aged 25–96 years were included, of whom 50 had bilateral or right pleural effusion of any etiology (study group) and 50 had no pleural effusion (controls). ITI, the main component of which is lung impedance, was continuously measured by the RS-207 monitor. The predictive value of ITI monitoring was determined by 8 measurements taken every 8 hours. Pleural effusion was diagnosed according to well-accepted clinical and roentgenological criteria. During treatment, the ITI of the study group increased from 32.9±4.2 ohm to 42.8±3.8 ohm (p<0.0001) compared to non-significant changes in the control group (59.6±6.6 ohm, p = 0.24). Prominent changes were observed in the respiratory rate of the study group: there was a decrease from 31.2±4.0 to 19.5±2.4 ohm (35.2%) compared to no change for the controls, and a mean increase from 83.6±5.3%-92.5±1.6% (13.2%) in O2 saturation compared to 94.2±1.7% for the controls. Determination of ITI for the detection and monitoring of treatment of patients with pleural effusion enables earlier diagnosis and more effective therapy, and can prevent hospitalization and serious complications, such as respiratory distress, and the need for mechanical ventilation. Trial Registration The study is registered at ClinicalTrials.gov NCT01601444

Diminished bile acids excretion is a risk factor for coronary artery disease: 20-year follow up and long-term outcome

Background: Patients with coronary artery disease (CAD) had significantly lower bile acid excretion (BAE) compared with non-CAD patients, leading to the hypothesis that the inability to efficiently excrete bile acids leads to coronary atherosclerosis development. We investigated the long-term role of BAE in CAD development and related mortality in 50 patients with proven CAD compared with that of 50 patients with chest pain and no CAD (controls) matched for clinical and laboratory characteristics. Methods: All subjects received a 4-day standard diet that included ~500 mg of cholesterol. Fecal bile acids from 24-h stool collections were measured by gas liquid chromatography. Results: CAD patients excreted lower amounts of total bile acids than controls (p < 0.001), less deoxycholic acid (p < 0.0001) and less lithocholic acid (p < 0.01). BAE was the best significant independent laboratory factor that predicted CAD (p < 0.05). Mortality and CAD development rates were significantly lower for the controls at the 20-year follow up. Conclusions: These results showed that CAD patients had markedly decreased BAE levels compared with non-CAD controls. BAE <415 mg/day was associated with increased CAD long-term mortality. Impaired ability to excrete cholesterol might be considered an additional independent risk factor for CAD development.

A longitudinal 20 years of follow up showed a decrease in the survival of heart failure patients who maintained low LDL cholesterol levels

Background Treatment by statins is well established for primary and secondary prevention of cardiac events but may be hazardous for patients with heart failure (HF). Aim We studied the long-term (20 years) association between baseline low-density lipoprotein cholesterol (LDL-c) levels and clinical outcome in patients with severe HF. Design Patients were divided into those with plasma LDL-c levels 110 mg/dl (Group 1) or >110 mg/dl (Group 2). Methods The mean follow-up of 305 study patients with advanced HF who had an average NYHA score of 2.7 was 11.3 years (range 15 months to 20 years). Mortality during follow-up was 43%. Results Patients with the highest baseline LDL-c levels had significantly improved outcome, whereas those with the lowest LDL-c levels had the highest mortality. This paradoxical effect was prominent in patients <70 years old. The negative association of LDL-c levels and mortality was most conspicuous among the HF patients who were treated with statins. Discussion and Conclusion Long-term follow-up findings showed that low LDL-c levels may predict a less favorable outcome in advanced HF, particularly in patients <70 years old and those taking statins. This negates the protocol of following an aggressive LDL-c-lowering strategy in younger patients with HF.

Cephalosporin-induced Neurological Toxicity in Elderly Patients with Preserved Renal Function

Cephalosporins are widely used in patients for the treatment of serious gram positive and gram-negative infections. Cephalosporins can induce some serious side effects, including neurotoxicity, mood disorder, hallucinations; however, non-convulsive status epilepticus has rarely been reported. We report three cases of acute reversible neurotoxicity associated with cephalosporins. Three patients without chronic kidney disease developed altered consciousness, hallucinations during ceftriaxone treatment for urinary tract infection and pneumonia and non-convulsive status epilepticus (NCSE) during cefazoline treatment for cellulitis-three days after initiation of the treatment. The electroencephalogram demonstrated continuous bursts of generalized, high-voltage, 1 Hz to 2 Hz sharp wave activity. Neurologic symptoms disappeared two days following withdrawal of ceftriaxone or cefazolin. The possibility of cephalosporin-induced neurotoxicity should be considered in patients developing neurological signs especially cognitive and seizures appearance during cephalosporin use and the discontinuation of the drug could lead to rapid complete neurological improvement.