Shmuel Gottlieb

Prognostic significance of ischemic episodes in patients with previous myocardial infarction.

This study assessed the prognostic significance of ischemic changes during daily activity as recorded by ambulatory electrocardiographic monitoring in a group of 224 low-risk postinfarction patients. Of the 224 patients studied, 74 (33%) had transient ischemic episodes on Holter monitoring. During the 28 months of follow-up the frequency of cardiac events (cardiac death, reinfarction, hospitalization for unstable angina, balloon angioplasty or coronary bypass surgery) was 51% among those with ischemic episodes on Holter monitoring, compared with 12% in those without such changes (p less than 0.0001). The 74 patients with positive results in their exercise tests and Holter monitoring had a 51% event rate, compared with 20% among the 44 patients with a positive exercise test result but negative Holter results (p less than 0.001). The event rate in those without ischemic changes either on the exercise test or on Holter was only 8.5%. Among patients with good (greater than 40%) or reduced (less than 40%) left ventricular ejection fraction, those with transient ST depression on Holter had a significantly higher cardiac event rate compared with those without it. A similar event rate was found in patients with only silent, only symptomatic and with silent and symptomatic ischemic episodes.

Relation of coronary artery disease to atherosclerotic disease in the aorta, carotid, and femoral arteries evaluated by ultrasound

This prospective study was conducted to correlate the presence of angiographically significant coronary artery disease (CAD) and atherosclerotic disease in the aorta, carotid, and femoral arteries as measured by ultrasound. One hundred two consecutive patients admitted for coronary angiography for suspected CAD participated in the study. All patients underwent transesophageal echocardiography for the evaluation of thoracic aortic atherosclerosis and B-mode ultrasound for evaluation of carotid and femoral atherosclerosis. Intimal-medial thickness > 1 mm in the thoracic aorta or peripheral vessels was considered as evidence of atherosclerosis. Patients with CAD (n = 64) had a significantly higher incidence of atherosclerotic plaques in the thoracic aorta, carotid, and femoral arteries than subjects with normal coronary arteries: 91%, 72%, 77% vs 31%, 47% and 42%, respectively. Extracoronary plaque was a stronger predictor of CAD than conventional risk factors. Evidence of plaque in patients younger than median age (64 years) had a higher specificity than in patients above median age (77% vs 40%, respectively, p <0.0001). Plaque score of the extracardiac vessels was significantly higher in patients with multivessel CAD than in patients with 1-vessel CAD disease and in subjects with normal coronary arteries (p <0.001). Thus, atherosclerotic plaques in the aortic and femoral arteries and, to a lesser extent, in the carotid arteries are strong predictors of CAD.

Prazosin therapy for refractory variant angina

The selective alpha, blocker prazosin was used to abolish Prinzmetals variant angina in six patients. All had had an acute transmural myocardial infarction, after which the anginal attacks with transient ST segment elevation developed, and three of them had already suffered from variant angina prior to the infarction. Therapeutic trials with high doses of nifedipine, verapamil, nitrates, beta blockers, and (in one case) phenoxybenzamine were ineffective in all six patients. Prazosin, 8 to 30 mg/day combined with low-dose nitrates or nifedipine completely abolished the attacks in four patients, markedly reduced their frequency and intensity in one patient, and had to be stopped in the sixth one because of hypotension and dizziness. Except for this last patient, the drug was well tolerated by all the others, and no changes in blood pressure were observed. In four patients discontinuation or reduction of prazosin resulted in exacerbation of symptoms, but its renewal was followed by disappearance of the attacks. Since the mean follow-up period in this study was 4 to 6 months, further evaluation appears necessary concerning the long-term effects of this drug in Prinzmetals variant angina.

Findings of automatic border detection in subjects with left ventricular diastolic dysfunction by Doppler echocardiography

Left ventricular automatic border detection (ABD) patterns were defined in the parasternal short-axis and the apical four-chamber views and were compared with pulsed-wave diastolic Doppler flow-velocity patterns of the mitral valve in 49 subjects (aged 39 to 87 years), 10 selected normal individuals, and 39 consecutive patients with high-quality echocardiographic Doppler studies and relaxation abnormalities (Doppler peak early diastolic velocity/peak late velocity ratio < 1). Both short-axis and apical four-chamber views were useful in the assessment of diastolic function by ABD. However, in subjects with high-quality two-dimensional echocardiographic Doppler studies, ABD was technically more feasible in the apical four-chamber view (97%; 38/39 subjects) than in the short-axis view (64%; 25/39 subjects) and correlated better with Doppler parameters. Compared with normal subjects, patients with abnormal Doppler relaxation patterns showed significant differences in diastolic filling indexes obtained by the ABD technique. The ratio of peak rapid filling rate/peak atrial filling rate (PRFR/PAFR) obtained from the dA/dt waveform in the apical four-chamber view had the highest correlation with Doppler indexes (r = 0.79). A PRFR/PAFR ratio of 1.5 best discriminated between normal individuals and subjects with relaxation abnormalities, with high sensitivity and specificity (95% and 100%, respectively). The PRFR/PAFR ratio obtained from the dA/dt waveform seemed to be a simple and useful method to distinguish between normal and abnormal left ventricular diastolic filling, as defined by Doppler echocardiography.

Early right atrial pacing after myocardial infarction

Right atrial (RA) pacing and modified treadmill testing (TT) were performed in 111 patients recovering from acute myocardial infarction (MI) before hospital discharge to determine whether ischemic responses are more common with RA pacing than with TT and whether the prognosis could be better determined by the results of 1 test compared with the other. Patients with predischarge congestive heart failure, chest pain, physical disability or age older than 70 years were excluded. Ischemic responses were significantly more frequent during RA pacing than during TT (41% vs 34%, p = 0.02). The results of the 2 tests were concordant in 102 patients (92%): Both were positive in 37 and both negative in 65. In 8 patients, results of RA pacing were positive and results of TT were negative; only 1 patient had positive TT and negative RA pacing responses. The higher percentage of positive responses during RA pacing than during TT can be attributed to the significantly higher pressure-rate product achieved during pacing (18,773 vs 16,831 mm Hg/min, p less than 0.001). The ischemic threshold, defined as the pressure-rate product at which an ischemic change was first noted in a particular patient, was almost identical in both tests. During a mean follow-up period of 16 months, 10 patients had recurrent MI; 8 had positive predischarge RA pacing but only 5 had positive TT responses (p = 0.008). Six patients died; in 3 RA pacing responses were positive and in 2 TT responses were positive.(ABSTRACT TRUNCATED AT 250 WORDS)

Early right atrial pacing after myocardial infarction: II. Results in 77 patients with predischarge angina pectoris, congestive heart failure, or age older than 70 years☆

Seventy-seven consecutive postinfarction patients who had either predischarge angina pectoris or congestive heart failure, or who were older than 70 years of age, underwent right atrial (RA) pacing before hospital discharge. In 60% of these patients, ischemic changes developed during RA pacing; this high yield of positive response indicates advanced coronary arterial disease. During a mean follow-up of 15 months, these patients had a high mortality rate (18%) and a reinfarction rate of 9%. RA pacing separated this a priori high-risk group into lower- and higher-risk subsets. Of the 46 patients with a positive RA pacing response, 6 had reinfarction, while none of the 31 patients with a negative RA pacing response had reinfarction (p = 0.04); 10 of the 14 cardiac deaths were among the patients who had positive RA pacing responses at discharge (p = not significant). Thus, of the 20 major cardiac events, 16 occurred among those with positive RA pacing responses (p less than 0.05). Predischarge clinical symptoms, however, were not good predictors of subsequent major cardiac events. We conclude that RA pacing can be safely performed even in high-risk and elderly patients and a positive response can identify those who have a poorer prognosis. Therefore, for postinfarction patients who, according to the prevailing criteria, are excluded from treadmill testing, we advocate the use of RA pacing.

Contemporary use and outcome of percutaneous coronary interventions in patients with acute coronary syndromes: insights from the 2010 ACSIS and ACSIS-PCI surveys

AIMSnIn patients with acute coronary syndromes (ACS), percutaneous coronary intervention (PCI) is the mainstay of treatment based on current guidelines. In this paper we describe contemporary management and outcomes of patients with ACS treated by PCI in the national ACS Israeli survey (ACSIS) performed in March and April 2010.nnnMETHODS AND RESULTSnThe ACSIS 2010 registry was conducted in all 25 hospitals in Israel and included all comers admitted with ACS. In-hospital and 30-day outcome was assessed. The registry included 2,193 patients with ACS. Coronary angiography was performed in 86.1% and PCI in 75.1% of cases. The mean age was 62.5 years, the transradial approach was used in 32% of patients and overall use of drug-eluting stents was 34%. Procedural complications were extremely low at less than 1%. The thirty-day mortality rate was 2.1% and the repeated myocardial infarction (MI) rate was 2.5%. The major adverse cardiac and cerebral events (MACCE) rate was 5.6%. Multivariable analysis identified age, chronic renal failure, and hyperglycaemia on admission as independent predictors of 30-day mortality for all subsets of ACS, and Killip class >I on admission and prior MI for patients with ST-elevation ACS only.nnnCONCLUSIONSnWhen evidence-based medicine is applied in the treatment of patients with ACS, clinical outcome is favourable. Several clinical predictors identify high-risk patients who require special attention.

Residual left ventricular function and prognosis of patients with asymmetric septal hypertrophy recovering from acute myocardial infarction.

The prognosis of patients recovering from acute myocardial infarction (MI) depends mainly on their residual left ventricular (LV) function. In patients with asymmetric septal hypertrophy (ASH) who are recovering from MI, a larger functioning myocardial mass may remain. However, the frequency of ASH in these patients has not yet been described. Predischarge echocardiography, radionuclide ventriculography, and treadmill stress tests were performed in 403 consecutive patients who had recovered from acute MI. Eighty-eight patients (22%) had ASH with septal thickness greater than or equal to 1.3, and 32 (8%) had septal thickness greater than or equal to 1.5 cm. One hundred thirty-six patients who had recovered from a first MI and had no ASH served as control subjects. Left ventricular ejection fraction (LVEF) in the group with ASH was significantly higher than in control subjects (61% vs 50%; p = 0.0001). LV end-diastolic diameter (LVD(d] and E point septal separation (EPSS) were smaller in the group with ASH (4.9 cm and 5.4 mm) than in the control group (5.5 cm and 10.5 mm). The frequency of positive treadmill test results, angina pectoris, recurrent MI, heart failure, and death during a 22-month follow-up period was similar in both groups. Fifty subjects in the control group were matched with 50 patients from the group with ASH on the basis of maximal level of creatine phosphokinase, location of infarct, and presence or absence of hypertension, and the difference between the two groups was even more marked (LVEF 48% vs 61%, respectively; p = 0.0004).(ABSTRACT TRUNCATED AT 250 WORDS)