Yaacov Drory

Sudden unexpected death in persons <40 years of age

Abstract This study retrospectively assesses the underlying causes of sudden unexpected death and the occurrence of prodromal symptoms in 162 subjects (aged 9 to 39 years) over a 10-year period (1976 to 1985). Underlying cardiac diseases accounted for sudden death in 73% and noncardiac causes in 15% of subjects. In 12% of subjects, the causes were unidentifiable. Myocarditis (22%), hypertrophic cardiomyopathy (22%) and conduction system abnormalities (13%) were the major causes in 32 subjects aged

The effects of hormone replacement therapy in normal postmenopausal women: Measurements of Doppler-derived parameters of aortic flow

In this study the effects of hormone replacement therapy on cardiac function in healthy postmenopausal women were evaluated by Doppler echocardiography that was performed before (T1) and 2.5 months after the initiation of hormone replacement therapy (T2) in the peak estrogenic phase. The following parameters of aortic flow were measured: peak flow velocity, acceleration time, and ejection time. Additional parameters were calculated: flow velocity integral and mean acceleration. The study group included 24 postmenopausal women aged 43 to 60 years (mean 51.6 years). The control group consisted of 19 postmenopausal women aged 46 to 60 years (mean 53.5 years) who were not receiving hormone replacement therapy and who underwent the same evaluation. There were no changes in all Doppler parameters between T1 and T2 in the control group. However, in the study group there were significant increases in peak flow velocity (108.3 +/- 16.7 cm/sec at T1 vs 123 +/- 20.7 cm/sec at T2; p = 0.002), flow velocity integral (17.7 +/- 3.9 vs 21.5 +/- 4.7 cm; p = 0.0003), mean acceleration (11.5 +/- 1.9 vs 13.1 +/- 2.6 m/sec/sec; p = 0.001), and ejection time (324 +/- 37.6 vs 348.8 +/- 40.7 msec; p = 0.002). There was no change in acceleration time (94.8 +/- 6.6 vs 95 +/- 10.9 msec). These results demonstrate that estrogens increase both stroke volume and flow acceleration. The latter probably reflects a combination of enhanced inotropism and vasodilatation. We assume that the cardioprotective effect of hormone replacement therapy in postmenopausal women may be due not only to changes in lipid profile but also to direct effects of estrogens on central and peripheral hemodynamic parameters.

Smoking status and long-term survival after first acute myocardial infarction a population-based cohort study.

OBJECTIVES We compared long-term survival after acute myocardial infarction (AMI) of never-smokers, pre-AMI quitters, post-AMI quitters, and persistent smokers and assessed whether cigarette reduction among persistent smokers is associated with lower mortality. BACKGROUND Quitting smoking has been shown to improve outcome after AMI. However, longitudinal cohort data with repeated assessments of smoking and information on multiple confounders are lacking. Moreover, little is known about the importance, if any, of reductions in the amount smoked. METHODS Consecutive patients < or = 65 years of age, discharged from 8 hospitals in central Israel after first AMI in 1992 to 1993, were followed through 2005. Extensive data, including self-reported smoking habits, were obtained at baseline and 4 times during follow-up. Cox proportional hazards regressions were used to assess the hazard ratios (HRs) for death associated with smoking categories modeled as time-dependent variables. RESULTS At baseline, smokers were younger, more likely to be male, and had a lower prevalence of hypertension and diabetes than nonsmokers. Over a median follow-up of 13.2 years, 427 deaths occurred in 1,521 patients. The multivariable-adjusted HRs for mortality were 0.57 (95% confidence interval [CI]: 0.43 to 0.76) for never-smokers, 0.50 (95% CI: 0.36 to 0.68) for pre-AMI quitters, and 0.63 (95% CI: 0.48 to 0.82) for post-AMI quitters, compared with persistent smokers. Among persistent smokers, upon multivariable adjustment including pre-AMI intensity, each reduction of 5 cigarettes smoked daily after AMI was associated with an 18% decline in mortality risk (p < 0.001). CONCLUSIONS Smoking cessation either before or after AMI is associated with improved survival. Among persistent smokers, reducing intensity after AMI appears to be beneficial.

Myocardial ischemia during sexual activity in patients with coronary artery disease.

I t is generally agreed that oxygen requirements during sexual activity are moderate’.*; heart rate values during intercourse arc similar to those found in daily life’*; sexual activity in most patients with coronary artery disease (CAD) is associated with low risk of cardiac complications’; and coital death among patients with CAD is rare.’ There is, however, a paucity of relevant data on sexual activity in patients with CAD. The occurrence of silent ischemia during sexual intercourse in patients with coronary disease is among the issues that still require elucidation. This study utilized ambulatory elcctrocardiographic monitoring to detect the occurrence of ischemia during intercourse in patients with CAD. The relation between electrocardiographic findings on sexual activity and a near-maximal exercise test were compared. . . . The study group comprised 88 male CAD outpatients, mean age 52 years (range 36 to 66), who participated in our long-term cardiac rehabilitation program. Patients’ informed consent to undergo 24-hour ambulatory electrocardiographic monitoring, which included monitoring during sexual activity, was a prerequisite for admission into the study. The diagnosis of CAD was established by one or both of the following criteria: previous myocardial infarction (73 patients [83%]) and typical effort-induced angina (15 patients [17%]). Functional capacity (New York Heart Association classification) was established as class I for SO patients (57%), class II for 26 (30%), and class I11 for 12 (14%). All patients were in sinus rhythm and had been clinically stable for at least 4 months. None had anemia, respiratory disease, or chronic renal failure. Patients with cchocardiographic evidence of left ventricular hypertrophy or cardiomyopathy were excluded from the study, as were patients using digitalis, diuretics, or antiarrhythmic medication. Beta-blocking agents were discontinued 24 days before examination, and nitrates and calcium channel blockers were discontinued 224 hours before examination. Detailed individual case histories were recorded. All patients underwent thorough physical examination, a resting 12-lead electrocardiogram, a cycloergometric test: and 24-hour ambulatory electrocardiographic monitoring. The ergometric test was performed on a mcchanitally braked Monark bicycle ergometer, following our protocol described elsewhere.* All patients underwent a near-maximal test (85% of predicted maximal heart rate according to age) based on progressively increasing intermittent workloads at 5-minute intervals. The initial

Hyperinsulinemia, sex, and risk of atherosclerotic cardiovascular disease.

BackgroundThe possibility that hyperinsulinemia may be involved in the etiology of atherosclerotic cardiovascular disease (CVID) was first suggested 20 years ago. During the last decade, this possibility has received support from three large prospective studies. Methods and ResultsIn the present study, the association between CVID, glucose intolerance, obesity, and hypertension (the GOH conditions) and hyperinsulinemia was examined crosssectionally in a representative sample (n = 1,263) of the adult Jewish population aged 40–70 years in Israel. Previously known diabetics were excluded. CVID comprising clinical or ECG evidence of ischemic heart disease, as well as clinical evidence of cerebrovascular or peripheral vascular disease, was identified in 97 men and 39 women. A significant (p < 0.01) hyperinsulinemia- sex interaction was found for CVD rate, with the adjusted risk ratios (followed by 95% confidence limits), relative to the rate in 298 normoinsulinemic women, being 1.15 (0.68–1.95) in 328 normoinsulinemic men, 0.85 (0.48–1.49) in 277 hyperinsulinemic women, and 2.27 (1.33–3.08) in 360 hyperinsulinemic men. Age-adjusted CVD rates in men versus women were: a) similar and low among all normoinsulinemic normotensives and hyperinsulinemics free of any of the GOH conditions (all rates .6.5%); b) similar and high among normoinsulinemic hypertensives (13.4% versus 10.4%); c) significantly higher in men among hyperinsulinemic normotensives with glucose intolerance and/or obesity (15.2% versus 3.3%; p = 0.02) and all hyperinsulinemic hypertensives (21.5% versus 12.8%; p = 0.04). These trends remained significant after adjusting for age, ethnic group, and blood lipids. ConclusionsTherefore, hyperinsulinemia was associated with excess CVII risk in men but not in women, and all excess CVD risk in men was confined to hyperinsulinemic individuals in the presence of glucose intolerance, obesity, or hypertension.

Neighborhood Socioeconomic Context and Long-Term Survival After Myocardial Infarction

Background— Neighborhood of residence has been suggested to affect cardiovascular risk above and beyond personal socioeconomic status (SES). However, such data are currently lacking for patients with myocardial infarction (MI). We examined all-cause and cardiac mortality according to neighborhood SES in a cohort of MI patients. Methods and Results— Consecutive patients ≤65 years of age discharged from 8 hospitals in central Israel after incident MI in 1992 to 1993 were followed up through 2005. Individual data were obtained at study entry, including education, income, and employment. Neighborhood SES was estimated through a composite census-derived index developed by the Israel Central Bureau of Statistics. During follow-up, 326 deaths occurred in 1179 patients. Patients residing in disadvantaged neighborhoods had higher mortality rates, with 13-year survival estimates of 61%, 74%, and 82% in increasing tertiles (Ptrend<0.001). After adjustment for sociodemographic variables, traditional risk factors, MI severity indexes, and individual SES measures, the hazard ratios for death associated with neighborhood SES were 1.47 (95% confidence interval, 1.05 to 2.06) in the lower and 1.19 (95% confidence interval, 0.86 to 1.63) in the middle tertiles compared with the upper tertile (Ptrend=0.02). The respective hazard ratios were even stronger for cardiac death (1.63; 95% confidence interval, 1.09 to 2.25; and 1.41; 95% confidence interval, 0.96 to 2.07). In the final models, neighborhood context and several individual SES measures were concurrently associated with all-cause and cardiac mortality. Conclusions— Neighborhood SES is strongly associated with long-term survival after MI. The association is partly, but not entirely, attributable to individual SES and clinical characteristics. These data support a multidimensional relationship between SES and MI outcome.

Hardiness and sense of coherence and their relation to negative affect

This study attempted to determine the degree to which measures of health proneness and measures of negative affect represent two distinct, although related, constructs. In addition, it examined the relation between Antonovskys salutogenic construct of sense of coherence (SOC) and Kobasas health proneness construct of hardiness. Five health proneness and three negative affect measures were filled out by 164 male patients with coronary heart disease. The pattern of correlations between these measures and confirmatory factor analysis indicated that although the measures of health proneness are negatively related to measures of negative affect, these two sets of measures and the constructs to which they are related can be differentiated from each other. However, SOC was found to be less independent of negative affect than was hardiness.

Menopause-induced changes in Doppler-derived parameters of aortic flow in healthy women

Currently, estrogen replacement therapy is widely used as a specific treatment for hypoestrogenic associated conditions such as vasomotor instability, genitourinary atrophy and osteoporosis. These conditions affect a substantial number of postmenopausal women.1 The favorable effects of estrogen replacement therapy on cardiac morbidity and mortality in postmenopausal women have usually been attributed to an improved lipid profile. 2–4 It is now accepted that other mechanisms, such as the direct effect of estrogens on coronary vasculature and atherosclerotic plaque, may also have an important role in cardioprotection.3–5 Using Doppler echocardiography we recently demonstrated a significant increase in aortic flow velocity and acceleration after 10 weeks of hormone replacement therapy.6 These findings led us to investigate whether menopause and the related decrease in estrogen levels were associated with changes in Doppler-derived parameters of aortic flow.

Common ECG changes in athletes.

The various ECG changes found in a group of 3,000 healthy athletes are discussed on the basis of eight representative ECG recordings. The common findings were sinus bradycardia, atrioventricular conduction disturbances, left and right ventricular hypertrophy according to the accepted voltage criteria, right axis deviation, intraventricular conduction disturbances (mainly in the right side of the heart), and various disturbances of the repolarization phase. The literature on this subject is reviewed, and the possible mechanisms involved in production of the various ECG changes are discussed. It is pointed out that in the absence of other evidence suggestive of cardiovascular disease, these changes should be considered as a normal variant and not lead to restriction of physical activity.

Prognostic Importance and Long-term Determinants of Self-rated Health After Initial Acute Myocardial Infarction

Background:Self-rated health (SRH) is a valid measure of health and its trajectories over time have been found to predict mortality. A better understanding of the determinants of changes in SRH is required, particularly post-myocardial infarction (MI), where rapid changes in health may occur. Objectives:To evaluate the prognostic importance of SRH and the determinants of its long-term trajectory in patients with MI. Patients and Methods:Between February 1992 and February 1993, 1521 consecutive patients aged ≤65 years (19% women) discharged from all hospitals in central Israel after initial acute MI were enrolled and followed-up for a mean of 12 years. Extensive data were obtained at study entry, with SRH measured at baseline (retrospective assessment of pre-MI health status) and at 5 and 10 years. Results:Baseline SRH showed a strong graded association with mortality post-MI. The association was further strengthened when changes in SRH over time were taken into account. Using generalized estimating equations, independent predictors of poor SRH at follow-up were Asian/African origin, low education, poor income, low baseline SRH, comorbidity, impaired ejection fraction, diabetes, dyslipidemia, obesity, and physical inactivity. In a subsample with available psychosocial measures (n = 668), low social support and sense of coherence and high anxiety and depression were also predictive of poor SRH. Conclusions:SRH is an important risk marker after MI and its long-term trajectory is accurately predicted by demographic, socioeconomic, clinical, and psychosocial measures. Monitoring of SRH post-MI is therefore warranted.