Miriam Shteinshnaider

Warfarin for Stroke Prevention Still Underused in Atrial Fibrillation: Patterns of Omission

BACKGROUND AND PURPOSE The value of warfarin in preventing stroke in patients with chronic atrial fibrillation is well established. However, the prevalence of such treatment generally lags behind actual requirements. The aim of this study was to evaluate doctor- and/or patient-related demographic, clinical, and echocardiographic factors that influence decision for warfarin treatment. METHODS Between 1990 and 1998, 1027 patients were discharged with chronic or persistent atrial fibrillation. This population was composed of (1) patients with cardiac prosthetic valves (n=48), (2) those with increased bleeding risks (n=152), (3) physically or mentally handicapped patients (n=317), and (4) the remaining 510 patients, the main study group who were subjected to thorough statistical analysis for determining factors influencing warfarin use. RESULTS The respective rates of warfarin use on discharge in the 4 groups were 93.7%, 30.9%, 17.03%, and 59.4% (P=0.001); of the latter, an additional 28.7% were discharged on aspirin. In the main study group, warfarin treatment rates increased with each consecutive triennial period (29.7%, 53.6%, and 77.1%, respectively; P=0.001). Age >80 years, poor command of Hebrew, and being hospitalized in a given medical department emerged as independent variables negatively influencing warfarin use: P=0.0001, OR 0.30 (95% CI 0.17 to 0.55); P=0.02, OR 0.59 (95% CI 0.36 to 0.94); and P=0.0002, OR 0.26 (95% CI 0.12 to 0.52), respectively. In contrast, past history of stroke and availability of echocardiographic information, regardless of the findings, each increased warfarin use (P=0.03, OR 1.95 [95% CI 1.04 to 3.68], and P=0.0001, OR 3.52 [95% CI 2.16 to 5.72], respectively). CONCLUSIONS Old age, language difficulties, insufficient doctor alertness to warfarin benefit, and patient disability produced reluctance to treat. Warfarin use still lags behind requirements.

Seating-Induced Postural Hypotension Is Common in Older Patients with Decompensated Heart Failure and May Be Prevented by Lower Limb Compression Bandaging

Background: Postural hypotension induced by transition from supine to sitting position and measures for its prevention in heart failure has not been investigated. Objective: Our purpose was to evaluate the prevalence of postural hypotension and associated clinical manifestations as well as the contribution of various risk factors for postural hypotension on transition from lying to sitting in older patients with decompensated heart failure, and to study the eventual preventive effect of leg bandaging. Methods: Seating-induced postural hypotension (≥20 mm Hg systolic and/or ≥10 mm Hg diastolic blood pressure fall) was assessed on the first study day in 108 patients aged ≥60 years, hospitalized for acutely decompensated heart failure. On the next day, in patients manifesting postural hypotension, compression bandages were applied along both legs before seating. Blood pressure, heart rate, O2 saturation, and the occurrence of dizziness or palpitations were recorded prior to and 1, 3 and 5 min following seating. Results: Postural hypotension occurred in 49.1% of patients. Dizziness and/or palpitations manifested in 25%. Diastolic (36.1%) versus systolic (23.1%) postural hypotension prevailed (p = 0.05). On univariate analysis, postural hypotension was associated with female sex (p = 0.03), more severe heart failure (p = 0.05), longer bedrest (p = 0.04), higher supine systolic (p = 0.01) or diastolic (p = 0.002) blood pressure, nonischemic heart failure (p = 0.002), and not using nitrates (p = 0.01). On multivariate analysis, longer bedrest (OR = 1.58, 95% CI = 1.13–2.2, p < 0.001), higher supine diastolic blood pressure (OR = 1.33, 95% CI = 1.1–1.61, p = 0.001), and nonischemic heart failure (OR = 3.48, 95% CI = 1.4–8.63, p = 0.009) were the most predictive of postural hypotension. Compression bandages prevented postural hypotension in 21 of 49 patients and decreased the degree of postural blood pressure fall (p < 0.001). Conclusion: Seating-induced postural hypotension is common among older inpatients with decompensated heart failure, especially with longer bedrest, higher supine diastolic blood pressure and non-ischemic etiology. Leg compression bandaging may be useful for the prevention of postural hypotension in these patients.

Clinical characteristics and prognostic significance of serum albumin changes in an internal medicine ward

BACKGROUND The prognostic significance of hypoalbuminemia and the dynamic changes in serum albumin during hospitalization in internal medicine wards has not been sufficiently investigated. METHODS Demographic, clinical and laboratory data were collected from 276 patients admitted to our internal medicine ward for a variety of acute disorders. Following discharge, all-cause mortality was recorded. These data were compared between patient groups, according to levels of albumin: hypoalbuminemia or normoalbuminemia (serum albumin <34 g/l and ≥ 34 g/l, respectively), on admission and discharge. RESULTS Hypoalbuminemia on admission and on discharge was found in 46% and 54% of patients, respectively. Anemia, renal dysfunction, malignant disease, hypocholesterolemia, lymphopenia and albuminuria were more prevalent in patients with hypoalbuminemia, compared to those with normoalbuminemia (p ≤ 0.03). During a median follow-up period of 23 months, 107 of 276 patients died. Mortality was significantly higher (p<0.001) in patients with hypoalbuminemia than normoalbuminemia on admission (52.0% vs. 27.5%) and on discharge (53.7% vs. 21.2%), including those admitted with normoalbuminemia and discharged with hypoalbuminemia (43.6%). Survival rate was higher for patients admitted with hypoalbuminemia and discharged with normoalbuminemia than for those remaining with hypoalbuminemia (82.4% vs. 42.8%, p=0.004). The level of albumin on discharge (each 10 g/l decrement) was the most powerful predictor of shortened survival (relative risk 2.79, 95% confidence interval 2.04-3.70). CONCLUSIONS Hypoalbuminemia on admission, as well as persistence or development of hypoalbuminemia throughout hospitalization, was associated with poor prognosis. Treatment aimed at increasing low albumin or maintaining its normal level may improve survival.

First morning standing up may be risky in acutely ill older inpatients

Information about orthostatic hypotension (OH) among elderly patients hospitalized for acute conditions in short‐term facilities is scarce. Many older inpatients carry various predisposing factors for OH. However, its existence goes frequently unrecognized. In this context, first morning standing up following admission for an acute disease may be dangerous. The aim of this study was to investigate OH and associated manifestations in this situation. OH (⩾20 mmHg systolic and/or ⩾10 mmHg diastolic blood pressure fall), heart rate, arrhythmias and appearance of dizziness or palpitations were recorded in 121 sequential inpatients aged >65 years, prior to and 1, 3 and 5 min following first morning standing. OH occurred in 64.5% of patients, while dizziness and/or palpitations appeared in 76%. Severe adverse effects were registered in 11.5% of OH patients. Significantly associated with OH were: bed rest lasting 9–24 h (vs ⩽8 h, p<0.001), appearance of dizziness or palpitations (p<0.001 and p = 0.005, respectively), heart failure (p = 0.02) and renal dysfunction (p = 0.04). OH and/or associated symptoms are frequent in acutely ill older inpatients on first morning standing up following nocturnal bed rest. The ominous potential consequences call for alertness to this phenomenon and application of appropriate preventive measures.

Lower Limb Compression Bandaging Is Effective in Preventing Signs and Symptoms of Seating-Induced Postural Hypotension

Background and Aims: Data concerning postural hypotension (PH) induced by transition from supine to sitting position are scarce and measures for its prevention have not been investigated. Our objective was to assess the preventive role of lower limb compression bandaging on PH and associated manifestations in older inpatients when seated from lying position. Methods: In a randomized crossover study, 61 patients aged >65 years were enrolled. Following bed rest lasting >36 h, each patient was seated and studied for 2 consecutive days, unbandaged or bandaged. PH was defined as a fall of ≧20 mm Hg and/or ≧10 mm Hg in systolic/diastolic blood pressure, respectively. Compression bandages were applied along both legs before seating; the pressure was approximately 30 mm Hg. Blood pressure, heart rate, O2 saturation, dizziness and palpitations were recorded prior to and 1, 3, and 5 min following seating. Results: Prevalence of PH was identical in the unbandaged versus bandaged state (55.7%). However, dizziness, palpitations, accelerated heart rate and decreased O2 saturation over 5 min were more prevalent in the unbandaged versus bandaged state (p < 0.01, <0.001, <0.05, <0.001, respectively). In the unbandaged state, presence versus absence of PH was associated with significantly greater incidence of palpitations, tachycardia and decline of O2 saturation over time (p < 0.04, <0.03, <0.03, respectively). In the bandaged state, O2 saturation over 5 min tended to rise irrespective of PH, but mean values were higher in patients without PH (p < 0.02). Conclusions: Lower limb compression bandaging does not reduce the incidence of PH. However, associated manifestations are largely prevented.

Magnesium administration may improve heart rate variability in patients with heart failure

BACKGROUND AND AIM Intracellular magnesium (icMg) depletion may coexist with normomagnesemia. Mg deficiency (serum and/or intracellular) and decreased heart rate variability (HRV) are common in heart failure (HF). Since both are predictors of poor prognosis, it was of interest to evaluate the effect of Mg supplementation on HRV in patients with HF. METHODS AND RESULTS We investigated the effect of Mg administration on HRV in normomagnesemic patients with systolic HF. HRV, serum Mg and icMg were determined before and after 5-week 300 mg/day Mg citrate treatment in 16 patients (group 1). The control group included 16 Mg-non-treated HF patients (group 2). HRV was determined by a non-linear dynamics analysis, derived from the chaos theory, which calculates HRV-correlation dimension (HRV-CD). After 5 weeks, serum Mg (mmol/l) increased more significantly in group 1 (from 0.78+/-0.04 to 0.89+/-0.06, p<0.001), than in group 2 (from 0.79+/-0.07 to 0.84+/-0.06, p=0.042). IcMg and HRV-CD increased significantly only in group 1 (from 59+/-7 to 66+/-9 mmol/g cell protein, p=0.025, and from 3.47+/-0.42 to 3.94+/-0.36, p<0.001, respectively). In group 2, the differences in the respective parameters were 63+/-12 to 66+/-9 mmol/g cell protein (p=0.7) and 3.59+/-0.42 to 3.55+/-0.4 (p=0.8). CONCLUSION Mg administration to normomagnesemic patients with systolic HF increases serum Mg, icMg and HRV-CD. Increasing of HRV by Mg supplementation may prove beneficial to HF patients.

Anemia in diabetic patients at an internal medicine ward: Clinical correlates and prognostic significance

BACKGROUND Characteristics and prognostic significance of anemia in hospitalized diabetic patients are unknown. METHODS We studied 3145 unselected patients admitted to two Internal Medicine Departments, 872 (27.7%) of whom were diabetic. Forty diabetic patients died during the first hospitalization period. Out of the remaining 832 patients, 334 (40.2%) were anemic and evaluated for survival. In 87 diabetic patients, the cause of anemia was evident on admission, whereas the other 247 had to be further investigated for etiology of anemia. RESULTS Compared to non-anemic diabetic patients, the diabetic anemic patients were older (mean age 71.4 vs. 64.4 years, P<.001) and predominantly females (52.4% vs. 44.4%, P<.02). Of the 247 evaluated patients, 38% were deficient in iron, 12% in vitamin B(12) and/or folate, 54% had anemia of chronic disease, 47% suffered from heart failure, 39% had renal dysfunction and 22% were complex nursing care patients and/or had diabetic foot. On median follow-up of 19.2 months, mortality rate was higher in anemic compared to non-anemic diabetic patients (17.3% vs. 4%, P<.001), the main cause of death being infection. Male sex (P=.03), albuminuria (P=.01) and heart failure (P=.06) were associated with shorter survival, male sex being the most significant (OR 2.02, 95% CI 1.04-4.00). CONCLUSION Frequency of anemia was increased in diabetic patients admitted to the Internal Medicine Departments, compared to the studies performed on ambulatory patient populations. Anemia was multifactorial and associated with higher mortality, predominantly from infections. Males with albuminuria and heart failure were at higher risk of death.

Application of HRV-CD for estimation of life expectancy in various clinical disorders

BACKGROUND Low heart rate variability (HRV) was found in various medical conditions including heart failure and acute myocardial infarction. Decreased HRV in these conditions predicted poor prognosis. METHODS HRV was estimated in 133 unselected inpatients with relevant clinical bedside conditions by non-linear analysis derived from chaos theory, which calculates the correlation dimension (CD) of the cardiac electrophysiologic system (HRV-CD). RESULTS Mean HRV-CD in the entire group was 3.75+/-0.45. Heart failure, coronary artery disease, cardiac arrhythmia, low serum potassium, renal dysfunction, and diabetes mellitus were significantly associated with reduced HRV-CD compared to their counterparts [3.6 vs. 3.9 (P<.001), 3.65 vs. 3.87 (P=.005), 3.58 vs. 3.8 (P=.01), 3.38 vs. 3.81 (P=.02), 3.59 vs. 3.8 (P=.04), and 3.66 vs. 3.82 (P=.04), respectively]. Stepwise logistic regression showed heart failure to be the condition most significantly associated with low HRV-CD (odds ratio 4.2, 95% confidence interval 1.90-9.28, P<.001). In the entire group, decreased HRV-CD (< or =3.75 vs. >3.75) was associated with lower survival (P=.01). Mortality of diabetic patients with HRV-CD < or =3.75 exceeded the mortality in patients with HRV-CD >3.75 (P=.02). Heart failure, renal dysfunction or age over 70 combined with HRV-CD < or =3.75 also appeared to be associated with augmented mortality. CONCLUSIONS Diminished HRV-CD is associated with heart failure, coronary artery disease, cardiac arrhythmia, renal dysfunction, diabetes mellitus and low serum potassium. Among the latter, heart failure is most significantly associated with decreased HRV-CD. Decreased HRV-CD values, especially in diabetics, are also associated with lower survival.

Effect of Various Clinical Variables on Total Intracellular Magnesium in Hospitalized Normomagnesemic Diabetic Patients before Discharge

Deficiency of intracellular magnesium (icMg) may coexist with normal serum Mg levels. Little is known about clinical and pharmacological factors affecting icMg in normomagnesemic patients with diabetes mellitus (DM). Moreover, no information exists regarding the icMg state in diabetic patients after acute illness and before hospital discharge. We have evaluated the effect of antihyperglycemic medications and other relevant clinical variables on icMg in 119 such patients. Total icMg was measured in peripheral blood mononuclear cells. Twenty healthy volunteers served as controls. IcMg content (µg/mg cell protein) was lower in DM compared to controls (1.74 ± 0.44 vs 2.4 ± 0.39, p < 0.001). It was also significantly lower in patients treated with insulin (1.57 ± 0.31 vs 1.8 ± 0.46, p = 0.01), while metformin treatment was associated with higher icMg (1.86 ± 0.49 vs 1.63 ± 0.35, p = 0.003). After adjustment for age, gender, and concomitant use of other hypoglycemic drugs, only treatment with metformin was independently associated with increased icMg (p = 0.03). No statistically significant association or correlation was found between icMg content and age, causes of hospitalization, comorbid conditions, treatment with other drugs, concentrations of HbA1c, serum glucose, Mg, or creatinine. In conclusion, icMg is depleted in normomagnesemic DM patients. Insulin treatment is associated with worsening of icMg status, while metformin treatment may confer protective effect.

Seated postural hypotension is common among older inpatients.

Abstract.Bed-rest > 12 hours produced postural hypotension (PH) in 54% of seated older inpatients. PH was multifactorial, equally initiated throughout 5 minutes and symptoms arised frequently following small blood pressure drops. In this context PH should be anticipated and prevented.