Michael Jonas

Hospital and 1-year outcome after acute myocardial infarction in patients with diabetes mellitus and hypertension.

Hypertension (HT) and diabetes mellitus (DM) lead to structural and functional cardiac impairment and worsen the prognosis after myocardial infarction (MI). However, the prognosis of male or female patients with the coexistence of HT and DM after MI has not been clearly demonstrated. The study sample comprised 4317 consecutive patients with an acute MI from a prospective nationwide survey conducted in 1992, 1994 and 1996 in all 25 coronary care units operating in Israel. The in-hospital, 30-day and 1-year outcome of diabetic hypertensive patients (n=546) was compared with that of diabetic normotensive patients (n=547) and with that of nondiabetic hypertensive patients (n=1192) and nondiabetic normotensive subjects (n=2032). The crude in-hospital, 30-day and 1-year mortality rates of diabetic hypertensive patients (11.7, 16.5 and 27.6%, respectively) were significantly higher than those of the diabetic normotensive patients (9.5, 15.4 and 22.9%, respectively) and nondiabetic hypertensive patients (7.1, 11.6 and 17.6%, respectively). Kaplan–Meier survival curves showed increased mortality rates during the 1-year follow-up in diabetic hypertensive patients. Adjusted risk for 1-year mortality was increased in diabetic patients. However, the risk was similar in diabetic hypertensive and normotensive patients (hazard ratio (HR) 1.55, 95% confidence interval (CI) 1.25–1.93, and 1.62, 95% CI 1.29–2.04, respectively). Adjusted Kaplan–Meier survival curves of diabetic hypertensive patients converged with those of the diabetic normotensives. The existence of DM increases the 1-year mortality after MI by about 60%. However, controlled hypertension did not worsen the outcome of diabetic male or female patients after MI.

Clinical profile and long-term prognosis of women ≤50 years of age referred for coronary angiography for evaluation of chest pain

A significant lack of information exists regarding risk factors, preventive strategies, diagnostic testing, and treatment of women with coronary artery disease (CAD), especially in the young age group. We studied the clinical profile, angiographic results, and long-term follow-up of 135 women aged < or =50 years referred for coronary angiography because of chest pain. The most prominent risk factor was hyperlipidemia (60%), followed by a family history of coronary disease (44%), systemic hypertension (40%), cigarette smoking (31%), postmenopausal state (23%), and diabetes mellitus (21%). Angiographically significant CAD was demonstrated in 79 of 135 patients (58%), most of whom (61%) had 1-vessel CAD. Women with compared to those without significant CAD had a higher prevalence of hyperlipidemia (71% vs 45%; p = 0.002) and of the post-menopausal state (30% vs 16%; p = 0.028). There was no difference in the incidence of positive noninvasive evaluation (ergometry or thallium scan) before catheterization between women with or without significant coronary lesions. At a follow-up period of 2 to 7 years, 3 women had acute myocardial infarction, all of whom demonstrated coronary lesions on prior angiography. No difference was found regarding the recurrence of chest pain on follow-up between women with or without significant CAD. Mortality and congestive heart failure were observed more frequently in women with CAD (6% vs 0%; p = 0.0516 and 12% vs 2%; p = 0.047, respectively).

Sulfonylureas are not associated with increased mortality in diabetics treated with thrombolysis for acute myocardial infarction.

Background: Sulfonylurea compounds may impair ischemic preconditioning and endogenous fibrinolysis. Increased mortality has been reported in diabetics receiving these drugs prior to admission for acute myocardial infarction when treated by direct angioplasty. Although thrombolytics are currently employed far more frequently than direct angioplasty the effect of sulfonylureas on mortality in the setting of thrombolysis has not been previously addressed. Methods: Two hundred forty five diabetics treated with either accelerated t-PA or streptokinase in a national, multi-center, randomized comparison of argatroban vs. heparin (n=1200) were grouped by anti-diabetic treatment prior to hospitalization, and their outcomes were compared by retrospective analysis. Results: Baseline characteristics were similar in all groups (sulfonylureas: n=121, oral medications other than sulfonylureas: n=17, insulin: n=28, diet alone: n=79). Sulfonylurea use was not associated with increased mortality or adverse event rates. By logistic regression analysis with diet treatment as reference, only prior insulin use was associated with higher risk for mortality at 30 days and 1 year (odds ratios 4.5 and 5.22, respectively, p<0.05). Conclusions: Sulfonylureas use prior to admission is not associated with adverse outcomes in diabetics treated with thrombolytics for myocardial infarction. Since direct angioplasty may increase mortality in patients taking these drugs, a randomized trial is needed to specifically compare different strategies of acute reperfusion in diabetics. Abbreviated abstract. Increased mortality has been reported in diabetics using sulfonylureas when treated for myocardial infarction by direct angioplasty. No study has specifically addressed the effect of these drugs on outcomes in the setting of thrombolysis. In a retrospective analysis of 245 diabetics treated with thrombolysis in a randomized comparison of argatroban vs. heparin, outcomes were compared in relation to anti-diabetic therapy prior to admission. Sulfonyl-urea use did not adversely affect prognosis, which was worst among diabetics previously treated with insulin. In conclusion, sulfonylureas do not worsen outcomes of diabetics treated with current thrombolytic regimens in comparison with other anti-diabetic treatments.AbstractBackground: Sulfonylurea compounds may impair ischemic preconditioning and endogenous fibrinolysis. Increased mortality has been reported in diabetics receiving these drugs prior to admission for acute myocardial infarction when treated by direct angioplasty. Although thrombolytics are currently employed far more frequently than direct angioplasty the effect of sulfonylureas on mortality in the setting of thrombolysis has not been previously addressed. Methods: Two hundred forty five diabetics treated with either accelerated t-PA or streptokinase in a national, multi-center, randomized comparison of argatroban vs. heparin (n=1200) were grouped by anti-diabetic treatment prior to hospitalization, and their outcomes were compared by retrospective analysis. Results: Baseline characteristics were similar in all groups (sulfonylureas: n=121, oral medications other than sulfonylureas: n=17, insulin: n=28, diet alone: n=79). Sulfonylurea use was not associated with increased mortality or adverse event rates. By logistic regression analysis with diet treatment as reference, only prior insulin use was associated with higher risk for mortality at 30 days and 1 year (odds ratios 4.5 and 5.22, respectively, p<0.05). Conclusions: Sulfonylureas use prior to admission is not associated with adverse outcomes in diabetics treated with thrombolytics for myocardial infarction. Since direct angioplasty may increase mortality in patients taking these drugs, a randomized trial is needed to specifically compare different strategies of acute reperfusion in diabetics. Abbreviated abstract. Increased mortality has been reported in diabetics using sulfonylureas when treated for myocardial infarction by direct angioplasty. No study has specifically addressed the effect of these drugs on outcomes in the setting of thrombolysis. In a retrospective analysis of 245 diabetics treated with thrombolysis in a randomized comparison of argatroban vs. heparin, outcomes were compared in relation to anti-diabetic therapy prior to admission. Sulfonyl-urea use did not adversely affect prognosis, which was worst among diabetics previously treated with insulin. In conclusion, sulfonylureas do not worsen outcomes of diabetics treated with current thrombolytic regimens in comparison with other anti-diabetic treatments.

Relation of early and one-year outcome after acute myocardial infarction to systemic arterial blood pressure on admission

We evaluated whether elevated blood pressure (BP) levels with an acute myocardial infarction (AMI) affect the in-hospital course, short-term, and 1-year outcome. Data were derived from a nationwide survey of 2,212 consecutive patients with AMI. Patients were stratified into 3 groups according to admission BP levels: 1,320 patients had normal BP, 840 patients had high BP, and 52 patients had excessive BP. In-hospital (7 days) course, short-term (30 days), and 1-year outcome was compared between the groups. The 3 groups were similar with respect to age, but patients with excessive BP were more likely to be women and have a history of systemic hypertension and diabetes mellitus. The rate of thrombolytic therapy was similar among the 3 groups, but patients with excessively elevated BP were treated during hospitalization much more often with beta blockers, angiotensin-converting enzyme inhibitors, and diuretics. The incidence of stroke, transient ischemic attack, and bleeding complications were comparable in the 3 groups. In-hospital mortality was 5.0% , 4.0%, and 1.9% in the normal, high, and excessively elevated BP groups, respectively (p = 0.19). The short-term rehospitalization or mortality rate was similar among the 3 groups. The 1-year mortality rate was 12.3%, 14.1%, and 10.2% in the normal, high, and excessively elevated BP groups, respectively (p = 0.61). A multivariate logistic regression analysis yielded age, women, and Killip class > or = 2 as the only significant predictors of mortality during follow-up. Thus, with the current medical therapy, excessively elevated BP levels with AMI is not associated with a worse short-term or 1-year outcome.

Prognostic significance of cerebrovascular disease in 11,526 chronic coronary artery disease patients

Patients with chronic CAD and a history of cerebrovascular events were compared with patients without prior cerebrovascular events to assess the effect of these events on 5-year prognosis. Despite adjustment for older age and higher comorbidity among patients who had experienced a cerebrovascular event, a history of such an event was associated with an increased risk of 1.86 for total mortality.

Long-term diuretic therapy in patients with coronary disease: increased colon cancer-related mortality over a 5-year follow-up

Objectives: Recent studies have suggested that long-term diuretic therapy may be associated with increased risk of renal cell carcinoma. This carcinoma is not a common malignancy, but it shares risk factors with the considerably more widespread colon cancer (CC). However, there are no data whether or not a relationship between long-term diuretic therapy and CC mortality exists. In this study we tested the hypothesis that long-term diuretic therapy may be associated with increased CC mortality over a 5.6-year follow-up period.Subjects and methods: The study sample comprised 14 166 patients aged 45 to 74 years with a previous myocardial infarction and/or stable anginal syndrome, screened for participation in the bezafibrate infarction prevention (BIP) study. There were 2153 patients receiving diuretics and 12 013 patients receiving no diuretics.Results: During the follow-up 139 (6.5%) new cases of cancer were diagnosed in the diuretic–treated group compared with 622 (5.2%) in the group receiving no diuretics (P = 0.02). Colon cancer mortality was significantly higher in the diuretic-treated patients (0.1 vs 0.5%, P = 0.001), whereas mortality differences for other cancer types were not documented. Multivariate analysis identified diuretics as an independent predictor of increased colon cancer incidence and colon cancer mortality with a hazard ratio (HR) of 2.0 (95% CI 1.2–3.2) for colon cancer incidence and 3.7 (95% CI 1.7–8.3) for mortality. However, the association between diuretic therapy and higher incidence of colon cancer was observed only among non-users of aspirin. A relatively lower colon cancer incidence was observed in the furosemide subgroup, and higher in the small combined amiloride/hydrochlorthiazide subgroup (HR 3.15, 95% CI 1.15–8.65).Conclusion: Long-term exposure to diuretic therapy may be associated with an increased colon cancer-related mortality.

Are coronary patients at higher risk with digoxin therapy? An ongoing controversy

Previous reports have yielded contradictory conclusions regarding the safety of digoxin therapy in patients with acute myocardial infarction. The purpose of our study was to determine whether digoxin therapy is associated with increased mortality in patients with chronic coronary artery disease. We analyzed data from 8173 patients who were screened for participation in the Bezafibrate Infarction Prevention (BIP) trial and who survived an acute myocardial infarction at least 6 months prior to the study. Three-year overall mortality of the 451 (15.5%) patients receiving digoxin (according to the judgement of their treating physician) at the time of screening for BIP participation, was 22.4% compared to 8.3% in the patients who did not receive digoxin. Cardiac mortality was 16.2% in the digoxin-treated group, compared to 4.9% in the non-treated patients. The increased risk associated with digoxin remained statistically significant when patients were stratified according to sex, age groups, functional capacity and the presence of hypertension, diabetes or angina. The administration of digoxin to survivors of an acute myocardial infarction in the chronic phase of their disease, is statistically associated with a 30-50% increase in the risk of overall and cardiac mortality during long-term follow-up. A propensity of increased risk of arrhythmias in ischemic coronary patients may explain this finding.

Assessment of Pseudohypertrophy as a Measure of Left-Ventricular Compression in Patients with Cardiac Tamponade

Background: Left-ventricular pseudohypertrophy reflecting left-ventricular compression was reported in a selected group of patients with cardiac tamponade. Hypothesis: Criteria for the presence of pseudohypertrophy can be established to guide its use as a sign of left-ventricular compression in patients with cardiac tamponade. Methods: Left-ventricular wall thickness, diameters, relative diastolic wall thickness (%) = (posterior wall thickness/end diastolic radius) x 100 and estimated left-ventricular mass were measured in patients with small, moderate and large pericardial effusion, in patients with cardiac tamponade before and after pericardiocentesis (16 patients in each group) and in 30 control subjects with normal echocardiograms. Results: Left-ventricular posterior wall thickness was increased (12 ± 2 vs. 9 ± 1 mm, p < 0.001), left-ventricular end-diastolic diameter was reduced (3.9 ± 0.5 vs. 4.6 ± 0.3 cm, p < 0.001) and relative left-ventricular diastolic wall thickness was increased (61 ± 13 vs. 41 ± 4.5%, p < 0.001) only in patients with cardiac tamponade compared to controls, but not in patients with small, moderate and large effusions, respectively (relative wall thickness: 42 ± 5, 41 ± 7 and 44 ± 7%, p = NS). Mean values of the estimated left-ventricular mass were similar in all groups. Following pericardiocentesis all parameters were normal. Conclusions: Despite normal left-ventricular mass, relative left-ventricular diastolic wall thickness is elevated in patients with cardiac tamponade. In contrast it is normal in patients with various degrees of pericardial effusion supporting its use as a quantitative measure of left-ventricular compression in patients with suspected cardiac tamponade.