Stamatis Stamatelopoulos

The Athens Stroke Registry: Results of a Five-Year Hospital-Based Study

The advent and wide application of new technology, especially noninvasive techniques, has enabled physicians to more completely investigate and clarify the etiopathogenic mechanisms of stroke. Such data have not been available until recently for Southeastern Europe. In addition, during the last decades, strategies for the modification of risk factors and primary prevention may have changed the prevalence of each subgroup of stroke as well. We investigated 1,042 consecutive patients who had first strokes, during a period of 5 years (from June 1992 to May 1997) and classified them prospectively based on etiopathogenic mechanisms. Patients with transient ischemic attacks and subarachnoid hemorrhage were excluded. There were 613 male and 429 female patients, with a mean age of 70.2 ± 11.9 years. Forty-six percent of the patients arrived within 3 h from stroke onset. The probable mechanisms were: large-artery atherosclerosis, 156 (15%); lacunes, 177 (17%); cardioembolic, 335 (32.1%); infarct of unknown cause, 182 (17.5%); miscellaneous causes, 35 (3.3%), and intracerebral hemorrhage (ICH), 157 (15.1%). In the cardioembolic group, nonvalvular atrial fibrillation (NVAF) was the probable cause in 225 patients, especially in patients older than 75 years (65%). The overall hospital mortality was 15.2% (from 0.6% for lacunar stroke to 34% for ICH). In our population, cardioembolism is the most frequent subtype of stroke. NVAF is the most likely source, especially in older patients.

Stroke Incidence and Case Fatality in Southern Greece The Arcadia Stroke Registry

BACKGROUND AND PURPOSE For Greece, information on incidence of stroke and distribution of type of stroke has not been reported. We determined the incidence of first-ever stroke in men and women, the incidence of stroke by type, and the associated case fatality. METHODS A population-based registry was established in the Arcadia province, located in eastern central Peloponessos, in the southern part of Greece. Between November 1, 1993, and October 31, 1995, all subjects with a first-ever stroke were identified. For case ascertainment, information from death certificates, hospital records, public health centers, and general practitioners was used. RESULTS During a 24-month period, 555 subjects with a first-ever stroke were registered. The incidence rates (per 100 000) by age group (18 to 34, 35 to 44, 45 to 54, 55 to 64, 65 to 74, 75 to 84, >/=85 years) for men were 5, 31, 113, 240, 662, 1275, and 3218, respectively. For women, the rates were 11, 18, 48, 196, 478, 1166, and 2137, respectively. Age- and sex-standardized to the European population, the annual incidence rate for subjects aged 45 to 84 years was 319.4/100 000 (95% CI, 283 to 356). In men, cerebral infarction was diagnosed in 81% of cases, intracerebral hemorrhage in 16%, and subarachnoid hemorrhage in 2%. For women, these figures were 85%, 12%, and 3%, respectively. The 28-day case fatality rate was 26.6% (95% CI, 22.9% to 30.2%), with no differences between men and women. Case-fatality increased with age and was higher for intracerebral hemorrhage than for cerebral infarction. CONCLUSIONS The incidence of stroke in our population-based study ranks low part compared with other European studies. The distribution of stroke types and case fatality rate appear to be similar to those of other industrialized countries.

Outcome of patients with congestive heart failure treated with standard versus high doses of enalapril: a multicenter study

OBJECTIVES We sought to prospectively and randomly compare survival with clinical and hemodynamic variables in patients with congestive heart failure (CHF) treated with standard versus high doses of enalapril. BACKGROUND Angiotensin-converting enzyme (ACE) inhibitors produce hemodynamic and symptomatic benefits in patients with CHF, but there is still controversy about the optimal dose in this clinical setting. METHODS Two hundred and forty-eight patients with advanced CHF (age 56.3+/-12 years) were randomized to receive a maximal tolerated dose of enalapril, up to 20 mg/day in group 1 (mean dose achieved 17.9+/-4.3 mg/day, n = 122) and 60 mg/day in group 2 (mean dose achieved 42+/-19.3 mg/day, n = 126). RESULTS At enrollment, patients in group 1 were in New York Heart Association (NYHA) functional class 2.6+/-0.7 and had a mean systolic blood pressure (SBP) of 117+/-18 mm Hg, a mean heart rate (HR) of 85+/-16 beats/min and a left ventricular ejection fraction (LVEF) of 20.0+/-9.8%. In group 2, patients were in NYHA class 2.6+/-0.7; their SBP was 118+/-17 mm Hg, HR 83+/-15 beats/min and LVEF 18.8+/-8.1%. There were no significant differences in these characteristics between the two groups of patients at enrollment. After 12 months of follow-up, 22 (18%) of 122 patients in group 1 and 23 (18%) of 126 patients in group 2 had died (p = 0.995, with 80% power of the study to detect a delta difference of 13%). The NYHA class was the same (1.9+/-0.7) in both groups; SBP was 111+/-16 and 111+/-17 mm Hg, HR 77+/-12 and 79+/-13 beats/min and LVEF 31+/-19% and 30+/-12% in groups 1 and 2, respectively. These differences were not statistically significant. The study had a power of 80% to detect (p = 0.05) the following changes: 13% in death rate, 0.25 units in NYHA class, 6 mm Hg in SBP, 5 beats/min in HR and 6% in LVEF. CONCLUSIONS No significant differences were found in survival and clinical and hemodynamic variables between patients receiving standard and those receiving high doses of enalapril.

Mechanical ventilation in conjunction with the intra-aortic balloon pump improves the outcome of patients in profound cardiogenic shock.

Objective: To examine the effects of mechanical ventilation with positive end-expiratory pressure (PEEP), in conjunction with the intra-aortic balloon pump (IABP), on the outcome of patients in profound cardiogenic shock. Patients: Twenty-eight consecutive patients presenting with myocardial infarction complicated by cardiogenic shock refractory to medical therapy, including dobutamine, dopamine and fluid administration. Eighteen patients were assisted by the IABP alone (IABP group), and ten patients by the IABP plus controlled mechanical ventilation with PEEP set at 10 cmH2O (IABP + CMV group). Results: Weaning from mechanical assistance was accomplished in 8 out of 18 patients in the IABP group versus 9 out of 10 patients in the IABP + CMV group (p = 0.04). Ultimately, 5 of 18 patients in the IABP group were discharged from the hospital versus 8 of 10 patients in the IABP + CMV group (p = 0.01). Conclusion: Mechanical ventilation with PEEP at 10 cmH2O supplements the IABP and may improve the survival rates of patients suffering from cardiogenic shock.

Transcatheter patch occlusion of experimental atrial septal defects.

The effectiveness and safety of transcatheter patch atrial septal defect (ASD) occlusion were studied in 20 piglets. Experimental atrial septal defects were created by foramen ovale dilation. ASDs were corrected by polyurethane patches of two types (flat and sleeve). Specially made balloon catheters supported the patches for periods varying from 1 to 6 days; after this period, the supporting catheters were withdrawn and the patches were released. All transcatheter patches were safely embedded in the atrial septum 48 hr or more after implantation. All defects were fully occluded. One patch became infected. The transcatheter patch experimental ASD occlusion method was found effective and safe, potentially applicable in the occlusion of human ASDs. Cathet Cardiovasc Intervent 2002;57:404–407.

Severe cardiogenic shock, after cardioversion, reversed by the intraaortic balloon pump

Sir: Electrical cardioversion is often followed by a transient decrease in cardiac output and, rarely, by acute pulmonary edema and death [1, 2, 3, 4, 5]. We report the case, to our knowledge the first, of a patient who, following cardioversion, developed cardiogenic shock refractory to medical therapy, which was promptly relieved by the addition of the intraaortic balloon pump (IABP). A 73-year-old man, who had a 2-year history of dyspnea on moderate exertion, was admitted to our hospital for elective cardioversion of atrial fibrillation of 5 months duration. He had a history of twovessel coronary artery disease, a left ventricular ejection fraction of 21% and the pulmonary capillary wedge pressure measured 1 year before was 15 mmHg. On admission his blood pressure was 110/ 70 mmHg and a 1±2/6 systolic murmur was heard at the apex. A chest roentgenogram revealed cardiomegaly. Five months before his admission amiodarone, 400 mg daily, was added to anticoagulants. The patient was sedated and given a single 100 J transthoracic DC shock, which restored normal sinus rhythm at a heart rate of 72 beats/min, associated with a blood pressure of 110/70 mmHg. Three hours after the procedure, the patient was alert, in stable clinical condition and had begun to eat when he complained of epigastric discomfort and became dyspneic. Over the next 15 min severe pulmonary edema developed, followed by a precipitous fall in blood pressure and, finally, electromechanical dissociation. Following cardiopulmonary resuscitation the patient remained in refractory cardiogenic shock, with an intraarterial pressure of 60/ 40 mmHg and sinus rhythm. Thirty minutes later mechanical assistance with an IABP was begun, which resulted in a gradual clinical improvement and, after 6 h, return of normal hemodynamics and diuresis, allowing the discontinuation of inotropic medications. Sixteen hours later the IABP was removed and the patient remained clinically and hemodynamically stable. The electrocardiogram showed sinus rhythm at a rate of 76 beats/min and was otherwise unchanged from before and immediately after cardioversion. CPK peaked at 982 U/l with an MB-CK fraction of 19% and a serum sample for measurement of troponin T obtained within 18 h was positive. An echocardiogram showed no return of left atrial mechanical activity and a radionuclide left ventriculography showed an ejection fraction of 19 %. Two years later, the patient remained clinically stable, in sinus rhythm and in NYHA functional class II, and a radionuclide left ventriculography showed an ejection fraction of 25 %. The incidence of acute pulmonary edema after cardioversion has been measured between 0.45% and 3.53% [2, 3]. A total of 29 episodes have been reported, with fatal outcomes in four cases [1, 2, 3, 4, 5]. The mechanism of pulmonary edema in these cases is uncertain. In our patient the development of cardiogenic shock 3 h after a single 100 J DC shock excludes its relation to anesthetic drugs or to myocardial injury from the shock. The complaint of epigastric pain shortly before hemodynamic collapse, the rise in enzymes and the positive troponin T are consistent with the occurrence of a myocardial ischemic event. In conclusion, in this particular patient with severely depressed left ventricular function, even a small amount of ischemic myocardial injury, combined with the absence of left atrial contraction after cardioversion, may have sufficed to cause lifethreatening hemodynamic deterioration, which was promptly alleviated by mechanical assistance with the IABP.

The application of educational objectives within a classical institutional framework

The aim of this study was to evaluate a learning system based on educational objectives as applied at departmental level in an institution structurally and functionally preset to conventional methods. The subject of Clinical Therapeutics was divided into 453 specific objectives. Classes A and B (457 and 345 students respectively) were divided into twelve and thirteen groups respectively. The groups which studied the objectives took an anonymous examination using multiple choice questionnaires before and at the end of the course. Class C (155 students, nine groups) was taught conventionally by teachers in the ward and by lectures.

Determinants of Coronary Flow Pattern

From the Department of Clinical Therapeutics, School of Medicine, University of Athens (Prof. B. Malamos). The coronary arterial flow (CAF) has the unique characteristic to occur mainly during ventricular diastole. There are conditions, however, in which it is mainly systolic as in severe aortic regurgitation (Green and Gregg, 1940b; W6gria, Muelheims, Golub, Jreissaty, and Nakano, 1958; Menno, and Schenk, 1961; Schenk, Menno, and Martin, 1961; Karp, and Roe, 1966), in coronary insufficiency (Hepps, Roe, and Rutkin, 1963), and following insertion into the ascending aorta of a specially designed catheter mounted valve (Anthopoulos, Stamatelopoulos, Sideris, and Moulopoulos, 1970a). CAF may also appear to be rel-