Noa Mashav

Takotsubo cardiomyopathy and QT interval prolongation: who are the patients at risk for torsades de pointes? ☆

OBJECTIVES QT interval prolongation is prevalent among patients with Takotsubo cardiomyopathy (TC), whereas torsades de pointes (TdP) has rarely been reported in these patients. We studied all peer-reviewed reports on TC-associated QT interval prolongation and all peer-reviewed reports on TC-associated TdP to characterize the clinical circumstances leading to TdP in patients with TC. METHODS The literature search yielded 14 reports on TC-associated TdP and 26 reports on TC-associated QT interval prolongation. Overall, 15 patients with TC-associated TdP and 86 patients with TC-associated QT interval prolongation were reported. We systematically reviewed each report and recorded the risk factors for TdP as well as the clinical circumstances of TC. RESULTS The prevalence of the male sex was higher among patients with TC-associated TdP relative to patients with TC-associated QT interval prolongation (26.7% vs 5.8%; P = .01). There was a trend in the mean maximal corrected QT interval being longer among patients with TC-associated TdP relative to patients with TC-associated QT interval prolongation (679.9 +/- 230.6 vs 555.9 +/- 63.8 milliseconds; P = .06). There were no differences between patients with TC-associated TdP and patients with TC-associated QT interval prolongation in mean age, maximal troponin levels, and lowest ejection fraction. Overall, 12 (80.0%) patients with TC-associated TdP had risk factors for TdP other than the female sex and systolic dysfunction, including suspicion of congenital long QT syndrome, bradycardia, hypokalemia, recent conversion from atrial fibrillation to sinus rhythm, and using QT prolonging agents. CONCLUSIONS Men with TC-associated QT interval prolongation are at risk for TdP. Most patients with TC-associated TdP have risk factors for TdP other than the female sex and systolic dysfunction.

C-reactive protein velocity following antibiotics in patients with chronic obstructive pulmonary disease exacerbation and community acquired pneumonia

INTRODUCTION Distinguishing community acquired pneumonia (CAP) from chronic obstructive pulmonary disease (COPD) exacerbation is a challenging task, since fever, productive cough, dyspnea, and leukocytosis are all common features of both conditions. Moreover, chest X-ray might not be sensitive enough. It is therefore quite common for physicians to prescribe unnecessary antibiotics for COPD exacerbation, leading to resistant bacteria and other related adverse affects. AIM To study whether CRP levels upon admission and the delta in CRP levels following initiation of antibacterial treatment, could provide an efficient tool for distinguishing CAP from COPD exacerbation. METHODS The study group included 36 COPD exacerbation and 49 CAP patients, admitted to a single Internal Medicine department during the years 2004-2006. All patients were treated with cephalosporins and macrolides upon admission. RESULTS CRP levels upon admission were significantly higher among CAP patients than among COPD exacerbation patients (111.5+/-104.4 vs. 34.9+/-28.6 mg/l, p<0.0001). CRP levels on the second day of hospitalization, following antibiotic administration to all patients, made a sharp incline in 36.7% of CAP patients compared to only 5.9% of COPD exacerbation patients (p=0.005), and remained unchanged in 61.8% of COPD patients compared to 16.3% of CAP patients (p=0.0006). CONCLUSIONS CRP levels upon admission and the delta in CRP levels following initiation of antibacterial treatment could provide an efficient tool for distinguishing CAP from COPD exacerbation.

Prevalence and predictors of slow flow in angiographically normal coronary arteries.

BACKGROUND One out of 5 patients undergoing coronary angiography has angiographically normal coronary arteries (ANCA). Some of them have abnormally slow coronary flow (SCF). The prevalence and causes of SCF in these patients are not clear. METHODS We studied 114 consecutive patients with ANCA. Each angiogram was independently evaluated by 2 physicians unaware of all other clinical features of the case. Coronary flow (CF) was graded using the corrected TIMI Frame Count (cTFC) and Coronary Clearance Frame Count (CCFC) methodologies. SCF was defined as a cTFC exceeding the reported normal (mean cTFC + 2 SD) in each of the three major coronary arteries. The association between SCF and various clinical, inflammatory, and metabolic variables was tested using a multivariable analysis model. RESULTS Thirty-nine (34%) patients had SCF. Inter-individual CF varied substantially among them (range 10-143 frames/sec, mean: 37 ± 22 frames/sec). The intra-individual CF did not vary: CF correlated well in the three major epicardial coronary arteries of a given individual (r = 0.7, p = 0.0001). Multivariable analysis revealed that current smoking was the most significant variable related to SCF (odds ratio = 4.7, p = 0.006, CI 95% 1.6-13.3). The SCF group included significantly more smokers (41% versus 15%, p = 0.002). CONCLUSIONS SCF is a common finding (34%) among patients with angiographically normal coronary arteries. In these patients, slow flow is a systemic phenomenon that involves all three coronary arteries rather than a local event and is associated with current smoking.

Depressive symptoms and erectile dysfunction in men with coronary artery disease.

OBJECTIVES To study the association between erectile dysfunction (ED) and depressive symptoms in men with coronary artery disease (CAD). A cross-sectional analysis of data obtained during a prospective study was carried out. METHODS A cohort of men undergoing coronary angiography filled-out the sexual health inventory for males (SHIM) and the mental health inventory 5 (MHI5) questionnaires for detection and severity assessment of both ED and depressive symptoms. CAD documented by coronary angiography was defined as > or = 50% stenosis in at least one of the major epicardial coronary arteries. RESULTS Overall, 242 men, with a mean age of 63.7 +/- 12.0 years, were included in the study. ED and depressive symptoms were found in 76% and 47.9% of men, respectively, whereas 94 (38.8%) men suffered from both. The prevalence of diabetes mellitus and the mean age were significantly higher, whereas the mean MHI5 scores were significantly lower, in the group with ED than that without. ED was associated independently with age (P <.0001) and depressive symptoms (P = .007), but not with the number of obstructed coronary arteries, history of diabetes mellitus, hypertension, or smoking. After controlling for age and diabetes mellitus, the scores of SHIM were positively correlated with MHI5 scores (r = .14; P = .03). CONCLUSIONS These results validate the high prevalence of both ED and depressive symptoms in men with CAD. ED in men with CAD might be associated with age and depressive symptoms.

Sexual activity and erectile dysfunction in elderly men with angiographically documented coronary artery disease

We studied the prevalence of erectile dysfunction (ED) in elderly men, aged 65 years or above, with coronary artery disease (CAD) documented by coronary angiography. A total of 123 men (112 men with CAD and 11 men without CAD), mean age 74.6±5.9 years, was included. To detect ED and assess its severity, all participants were asked to complete the Sexual Health Inventory for Males (SHIM) questionnaire. Lack of sexual activity was more prevalent among men with CAD relative to men without CAD (31.3 vs 0.0%). Among the sexually active men, ED was more prevalent among men with CAD relative to men without CAD (85.7 vs 72.7%). A general linear model showed that age was the only factor associated with SHIM scores among the sexually active men with CAD (P=0.001). Other factors, such as the number of occluded coronary arteries, diabetes mellitus, hypertension, smoking, various medications and marital status, were not associated with SHIM scores in elderly men with CAD. We conclude that lack of sexual activity and ED are very common in elderly men with CAD. Among the sexually active men with CAD, ED severity is associated only with age.

Increased erythrocyte aggregation in men with coronary artery disease and erectile dysfunction

We studied the association between erythrocyte aggregation (EA) and erectile dysfunction (ED) in men with coronary artery disease (CAD). Men with CAD documented by coronary angiography filled the Sexual Health Inventory for Males questionnaire to detect ED and assess its severity. EA was evaluated by filming slides of blood smear. Low percentage of slide field covered by erythrocytes represented increased EA. Overall, 133 men with CAD, mean ages 62.4±12.2 years, were included: 100 (75.2%) with ED and 33 (24.8%) without ED. EA was increased among men with ED compared with men without ED (percentage of slide field covered by erythrocytes 66.7±14.7 vs 73.1±14.5%; P=0.03). After adjustment for age, diabetes mellitus, hemoglobin and hematocrit levels, EA was associated with ED severity (r=0.18; P=0.038). We conclude that EA is increased in men with CAD and ED. This finding may be relevant to the pathophysiology of ED in men with CAD.

Anemia and inflammation have an additive value in risk stratification of patients undergoing coronary interventions.

Aims Anemia and inflammation are both associated with unfavorable outcomes in patients with ischemic heart disease and might be pathophysiologically linked. We aimed to analyze the additive value of anemia and inflammation on the outcomes of patients undergoing percutaneous coronary intervention. Methods Cox regression models were fitted for hemoglobin and C-reactive protein (CRP) cut-offs and performed separately for myocardial infarction (MI) and angina pectoris patients undergoing catheterization at a tertiary hospital between 2006 and 2011. Major adverse cardiovascular events (MACEs) were defined as all-cause mortality, MI and stroke. Results Included were 1976 patients (825 with angina pectoris and 1151 with MI). The median follow-up in the MI and the angina pectoris groups was 14 and 13 months, respectively (maximal follow-up of 4 years). In the MI group, the risk of MACE during follow-up was increased with the presence of either anemia (hazard ratio 2.1, P = 0.07) or of elevated CRP (hazard ratio 1.9, P = 0.04), whereas the presence of both increased the risk even further (hazard ratio 3.4, P < 0.01). In the angina pectoris group, the risk of MACE was increased only in patients who had both anemia and elevated CRP (hazard ratio 2.9, P < 0.01). Conclusion Inflammation and anemia are independently and additively associated with MACE in MI patients.