Ori Rogowski

Mandatory Electrocardiographic Screening of Athletes to Reduce Their Risk for Sudden Death Proven Fact or Wishful Thinking

OBJECTIVES The purpose of this study was to determine if pre-participation screening of athletes with a strategy including resting and exercise electrocardiography (ECG) reduces their risk for sudden death. BACKGROUND An increasing number of countries mandate pre-participation ECG screening of athletes for the prevention of sudden death. However, the evidence showing that such a strategy actually reduces the risk of sudden death in athletes is limited. We therefore analyzed the impact of the National Sport Law enacted in Israel in 1997-which mandates screening of all athletes with resting ECG and exercise testing-on the incidence of sudden death among competitive athletes. METHODS We conducted a systematic search of the 2 main newspapers in Israel to determine the yearly number of cardiac arrest events among competitive athletes. The size of the population at risk was retrieved from the Israel Sport Authority and was extrapolated to the changes in population size over time. RESULTS There were 24 documented events of sudden death or cardiac arrest events among competitive athletes during the years 1985 through 2009. Eleven occurred before the 1997 legislation and 13 occurred after it. The average yearly incidence of sudden death or cardiac arrest events was 2.6 events per 100,000 athlete-years. The respective averaged yearly incidence during the decade before and the decade after the 1997 legislation was 2.54 and 2.66 events per 100,000 person years, respectively (p = 0.88). CONCLUSIONS The incidence of sudden death of athletes in our study is within the range reported by others. However, mandatory ECG screening of athletes had no apparent effect on their risk for cardiac arrest.

The "Short-Coupled" Variant of Right Ventricular Outflow Ventricular Tachycardia: A Not-So-Benign Form of Benign Ventricular Tachycardia?

Idiopathic ventricular tachycardia (VT) originating from the right ventricular outflow tract (RVOT‐VT) and idiopathic RVOT‐extrasystoles are generally considered benign arrhythmias. We described three cases who originally presented with typical “benign looking” RVOT‐extrasystoles or RVOT‐VT but developed malignant polymorphic VT during follow‐up. The unusual aspect of their RVOT‐extrasystoles was their coupling interval, which appears to be intermediate between the ultra‐short coupling interval of idiopathic VF and the long coupling interval seen in the truly benign RVOT‐VT.

Leukocytosis in obese individuals: possible link in patients with unexplained persistent neutrophilia

Abstract:  Background: Recently, it was shown that fat tissue produces and releases inflammatory cytokines, and that obesity may be regarded as a state of low‐grade inflammation. In this regard, we aimed to establish an association between obesity and persistent leukocytosis. Patients and methods: We present clinical observations of obese subjects primarily referred for further evaluation of leukocytosis without a cause and validated the link between leukocytosis and elevated body mass index (BMI) in a cross‐sectional study. Results: During 1999–2005, 327 patients were referred for further investigation because of persistent leukocytosis. Of these, 15.3% were asymptomatic obese, mostly females, with mild persistent neutrophilia accompanied by elevated acute‐phase reactants. After careful evaluation, no recognized cause for leukocytosis was found other than the fact that the patients were obese. During a mean follow‐up of 45.6 months, the leukocytosis and the elevated acute‐phase reactants persisted and no new causes for leukocytosis were evident. Furthermore, in a cross‐sectional analysis of 3716 non‐smoker subjects, 62 were found to have leukocytosis. Compared with the population with a normal white blood count range, these subjects with leukocytosis had higher BMI, serum C‐reactive protein (CRP) levels, waist circumference, and neutrophil and platelet count (all P < 0.0005). After logistic regression analysis, only BMI was shown to be associated with leukocytosis (P < 0.0005). Conclusions: Obesity is recognized as a possible cause for reactive leukocytosis. Awareness of this ‘obesity‐associated leukocytosis’ may help the clinician to avoid more extensive and unnecessary diagnostic work‐up, particularly in similar obese subjects.

H1N1 Influenza: Initial Chest Radiographic Findings in Helping Predict Patient Outcome

PURPOSE To retrospectively evaluate whether findings on initial chest radiographs of influenza A (H1N1) patients can help predict clinical outcome. MATERIALS AND METHODS Institutional review board approval was obtained; informed consent was waived. All adult patients admitted to the emergency department (May to September 2009) with a confirmed diagnosis of H1N1 influenza who underwent frontal chest radiography within 24 hours were included. Radiologic findings were characterized by type and pattern of opacities and zonal distribution. Major adverse outcome measures were mechanical ventilation and death. RESULTS Of 179 H1N1 influenza patients, 97 (54%) underwent chest radiography at admission; 39 (40%) of these had abnormal radiologic findings likely related to influenza infection and five (13%) of these 39 had adverse outcomes. Fifty-eight (60%) of 97 patients had normal radiographs; two (3%) of these had adverse outcomes (P = .113). Characteristic imaging findings included the following: ground-glass (69%), consolidation (59%), frequently patchy (41%), and nodular (28%) opacities. Bilateral opacities were common (62%), with involvement of multiple lung zones (72%). Findings in four or more zones and bilateral peripheral distribution occurred with significantly higher frequency in patients with adverse outcomes compared with patients with good outcomes (multizonal opacities: 60% vs 6%, P = .01; bilateral peripheral opacities: 60% vs 15%, P = .049). CONCLUSION Extensive involvement of both lungs, evidenced by the presence of multizonal and bilateral peripheral opacities, is associated with adverse prognosis. Initial chest radiography may have significance in helping predict clinical outcome but normal initial radiographs cannot exclude adverse outcome.

Heart rate and microinflammation in men: a relevant atherothrombotic link

Objective and background: To explore the possibility that increased resting heart rate (HR) is associated with a microinflammatory response. Such an association could explain, at least in part, the recently described worse cardiovascular prognosis in individuals with increased HR. Methods: Concentrations of fibrinogen and high-sensitivity C-reactive protein, as well as the absolute number of polymorphonuclear leucocytes, were analysed in a cohort of 4553 apparently healthy men and in those with atherothrombotic risk factors. Results: Following adjustment for age and body mass index, lipid profile and cardiovascular risk factors, a significant (p<0.001) difference was noted between individuals in the first quintile of HR (⩽58 beats/min) and those in the fifth quintile (⩾79 beats/min) regarding all the above-mentioned inflammatory biomarkers, the respective mean values being 7.38 and 8.11 μmol/l, 1.12 and 1.61 mg/l, and 4.23 and 4.74×109/l. Conclusions: Resting HR is associated with a microinflammatory response in apparently healthy men and in those with atherothrombotic risk factors. Sympathetic activation might be a common factor explaining such an association. If confirmed in additional studies, this association might be a relevant target for therapeutic manipulations.

Platelet counts and platelet activation markers in obese subjects.

Objective. In this work we studied the correlation between platelet count, platelet activation, and systemic inflammation in overweight, obese, and morbidly obese individuals. Methods and subjects. A total of 6319 individuals participated in the study. Complete blood counts, high sensitivity C-reactive protein (hs-CRP) serum levels, and body mass index (BMI) were measured during routine checkups. Platelet activation markers were studied among 30 obese (BMI = 41 ± 8 kg/m2) and 35 nonobese (BMI = 24 ± 3 kg/m2) individuals. Platelet activation status was evaluated by flow cytometry using specific antibodies against the activated platelet membrane glycoprotein IIb/IIIa, p-selectin (CD-62 p), and binding of Annexin-V to platelet anionic phospholipids. Results. Overweight, obese, and morbidly obese females had significantly elevated platelet counts ( P < .0001) compared with normal-weight females. No significant elevation of platelet counts was observed in the male subgroups. A significant age adjusted correlation between BMI and platelet counts ( P < .0001) was found among females. This correlation was attenuated (P = .001) after adjustment for hs-CRP concentrations. The flow cytometry analysis of platelets showed no significant differences in activation marker expression between nonobese and obese individuals. Discussion. Obesity may be associated with elevated platelet counts in females with chronic inflammation. Obesity is not associated with increased platelet activation.

Elevated resting heart rate is associated with the metabolic syndrome

BackgroundIncreased resting heart rate (RHR) may be associated with increased cardiovascular morbidity. Our aim was to explore the possibility that increased RHR is associated with the prevalence of the metabolic syndrome (MetS) in a sample of apparently healthy individuals and those with cardiovascular risk factors.MethodsWe performed a cross-sectional analysis in a large sample of apparently healthy individuals who attended a general health screening program and agreed to participate in our survey. We analyzed a sample of 7706 individuals (5106 men and 2600 women) with 13.2% of men and 8.9% of the women fulfilling the criteria for the MetS. The participants were divided into quintiles of resting heart rate. Multiple adjusted odds ratio was calculated for having the MetS in each quintile compared to the first.ResultsThe multi-adjusted odds for the presence of the MetS increased gradually from an arbitrarily defined figure of 1.0 in the lowest RHR quintile (<60 beats per minute (BPM) in men and <64 BPM in women) to 4.1 and 4.2 in men and women respectively in the highest one (≥80 BPM in men and ≥82 BPM in women).ConclusionRaised resting heart rate is significantly associated with the presence of MetS in a group of apparently healthy individuals and those with an atherothrombotic risk. The strength of this association supports the potential presence of one or more shared pathophysiological mechanisms for both RHR and the MetS.

Inflammatory Bowel Disease Is Not Associated With Increased Intimal Media Thickening

OBJECTIVES:Several studies have suggested that chronic inflammatory diseases might be associated with an acceleration of the atherosclerotic process. There is little information on the effect of chronic inflammation in patients with inflammatory bowel disease (IBD) on the presence of increased intimal media thickening (IMT), a surrogate marker for atherosclerotic diseases. In this work our aim was to determine whether IBD is a risk factor for increased IMT.METHODS:IMT was measured by ultrasound of the carotid arteries; a computer software program was used to analyze 80–100 independent IMT samples from each carotid artery segment in 61 patients with IBD (45 with Crohns disease and 16 with ulcerative colitis) and in 61 controls matched for age (±2 yr), sex, body mass index (BMI, ±2 kg/m2), and smoking status.RESULTS:Inflammatory markers (erythrocyte sedimentation rate, fibrinogen, high−sensitive C-reactive protein) were significantly (P < 0.001) elevated in IBD patients compared with controls. Even though there was a disease duration of 8.7 ± 8.5 yr, the mean IMT of IBD patients was similar to that of the control group (0.66 ± 0.09 vs 0.64 ± 0.07 mm; P > 0.05).CONCLUSIONS:Despite chronic inflammation, IBD patients had IMT values similar to those of the controls. Thus, unlike other inflammatory diseases, IBD appears not to be a risk factor for accelerated atherosclerosis.

Real-time risk stratification of patients with acute pulmonary embolism by grading the reflux of contrast into the inferior vena cava on computerized tomographic pulmonary angiography

Summary.  Objective: To investigate whether fast grading of reflux of contrast to the inferior vena cava (IVC) on computerized tomographic pulmonary angiography (CTPA) is a potential biomarker for real‐time risk stratification. Methods: We retrospectively identified 343 patients investigated for possible pulmonary embolism (PE) by CTPA at our medical center between September 2004 and March 2006. A total of 145 consecutive patients with PE (age 67 ± 19 years) and 168 consecutive ones with negative CTPAs (age 64 ± 20 years) fulfilled entry criteria. CTPAs were evaluated for retrograde reflux of contrast to the IVC by fast visual grading from 1 to 6 using the original axial images. Pulmonary obstruction index, the diameters of right and left ventricles and pulmonary artery, and patient survival data were recorded as well. Results: Twenty‐nine (20.0%) patients with positive CTs and 23 (13.7%) patients with negative CTs had substantial degrees (≥4) of reflux of contrast to the IVC (P = 0.14). The Kaplan–Meier 30‐day survival curves demonstrated significant reduction in survival in individuals with PE and grade ≥4 reflux of contrast to the IVC compared with lower grades (P = 0.008), but not in patients with grade ≥4 and no PE on CTPA (P = 0.26). The other cardiovascular parameters showed no significant correlation with survival in patients with and without PE. Conclusion: Substantial grades of reflux of contrast to the IVC during CTPA could predict early mortality in patients with acute PE. Rapid grading of reflux of contrast from the original axial CTPA images can be used for real‐time risk stratification in patients with acute PE.

Activated polymorphonuclear leukocytes and monocytes in the peripheral blood of patients with ischemic heart and brain conditions correspond to the presence of multiple risk factors for atherothrombosis.

Objective: Risk factors like hypertension, diabetes mellitus, dyslipidemia and smoking contribute to the pathogenesis of atherothrombosis. We investigated whether the multiplicity of risk factors for atherothrombosis is associated with leukocyte activation. Methods: We examined the availability of CD11b/CD18 antigen on the surface of peripheral blood polymorphonuclear leukocytes and monocytes in patients with acute ischemic heart and brain conditions. Results: There was a highly significant (p < 0.00001) increment in the availability of the CD11b/CD18 antigen on the surface of the polymorphonuclear leukocytes in patients with multiple (2 or more) vascular risk factors [mean fluorescence intensity (MFI) ± SD, 210 ± 102] as opposed to individuals with none or 1 risk factor for atherothrombosis (MFI 159 ± 73). Similar results were observed on the monocytes: 309 ± 151 and 235 ± 97, respectively (p < 0.00001). Conclusion: The multiplicity of risk factors for atherothrombosis is associated with the up-regulation of CD11b/CD18 antigen on the surface of peripheral blood polymorphonuclear leukocytes and monocytes, suggesting the presence of an increased inflammatory response and leukocyte activation in these individuals.