Zwi Schlesinger

Calcium antagonists and mortality in patients with coronary artery disease: A Cohort study of 11,575 patients☆

OBJECTIVES This study sought to establish the risk ratio for mortality associated with calcium antagonists in a large population of patients with chronic coronary artery disease. BACKGROUND Recent reports have suggested that the use of short-acting nifedipine may cause an increase in overall mortality in patients with coronary artery disease and that a similar effect may be produced by other calcium antagonists, in particular those of the dihydropyridine type. METHODS Mortality data were obtained for 11,575 patients screened for the Bezafibrate Infarction Prevention study (5,843 with and 5,732 without calcium antagonists) after a mean follow-up period of 3.2 years. RESULTS There were 495 deaths (8.5%) in the calcium antagonist group compared with 410 in the control group (7.2%). The age-adjusted risk ratio for mortality was 1.08 (95% confidence interval [CI] 0.95 to 1.24). After adjustment for the differences between the groups in age and gender and the prevalence of previous myocardial infarction, angina pectoris, hypertension, New York Heart Association functional class, peripheral vascular disease, chronic obstructive pulmonary disease, diabetes and current smoking, the adjusted risk ratio declined to 0.97 (95% CI 0.84 to 1.11). After further adjustment for concomitant medication, the risk ratio was estimated at 0.94 (95% CI 0.82 to 1.08). CONCLUSIONS The current analysis does not support the claim that calcium antagonist therapy in patients with chronic coronary artery disease, whether myocardial infarction survivors or others harbors an increased risk of mortality.

Cerebrovascular accident complicating acute myocardial infarction: Incidence, clinical significance, and short-long-term mortality rates

Abstract purpose: The purpose of this study was to report the incidence, the antecedents, and the clinical significance of clinically recognized cerebrovascular accidents or transient ischemic attacks (CVA-TIA) complicating acute myocardial infarction. patients and methods: During 1981 to 1983, a secondary prevention study with nifedipine (SPRINT) was conducted in 14 hospitals in Israel among 2,276 survivors of acute myocardial infarction. During the study, demographic, historical, and medical data were collected on special forms for all patients with diagnosed acute myocardial infarction in 13 of these 14 hospitals (the SPRINT registry, n=5,839). Mortality followup was completed for 99% of hospital survivors for a mean follow-up of 5.5 years (range: 4.5 to 7 years). results: The incidence of CVA-TIA was 0.9% (54 of 5,839). The latter rate increased significantly only with age, from 0.4% among patients up to 59 years old to 1.6% among those aged greater than or equal to 70 years. Multivariate analysis identified age, congestive heart failure, and history of stroke as predictors of CVA-TIA during the acute phase of myocardial infarction. Patients with CVA-TIA exhibited a complicated hospital course, with a 15-day mortality rate of 41%. Subsequent mortality rates in survivors at 1 and 5 years were 34% and 59%, respectively. Rates at the same time points in patients without CVA-TIA were 16%,11%, and 29% (p conclusion: In this large cohort of consecutive patients with myocardial infarction, CVATIA was a relatively infrequent complication of acute myocardial infarction. Factors independently favoring the occurrence of CVA-TIA were old age, previous CVA, and congestive heart failure. CVA-TIA occurring during acute myocardial infarction independently increased the risk of early death threefold as well as the risk of long-term mortality in early-phase survivors (2.5-fold).

Repeat infusions of recombinant tissue-type plasminogen activator in patients with acute myocardial infarction and early recurrent myocardial ischemia

When conventional treatment of patients with early clinical reinfarction after thrombolytic therapy fails, mechanical revascularization may be attempted. An alternative strategy, repeat thrombolytic infusions, is reported. Fifty-two patients with acute myocardial infarction were treated with one or two additional thrombolytic infusions of recombinant tissue-type plasminogen activator (rt-PA) because of nonsustained ischemia after initial treatment with rt-PA or streptokinase. Thirty-five patients received the second infusion within 1 h of the first; 13 patients received the second infusion 1 to 72 h after the first and 4 patients received it later during their hospitalization. Bleeding complications occurred in 10 patients (19%); however, most of these were minor (no intracranial bleeding) and only 2 patients required blood transfusion. In 14 patients in whom the decrease in fibrinogen and plasminogen levels was measured after the first and second infusions, this decrease was only 25% and 63%, respectively--only slightly higher than the 22% and 53% decreases measured in 63 patients who had only one rt-PA infusion. In 44 patients (85%), the acute ischemia resolved completely within 1 h after initiation of the second infusion. In 23 patients (44%), pain and ST segment elevation did not recur and invasive coronary intervention was avoided. Thus, repeat rt-PA infusions can stabilize a substantial number of patients with acute reinfarction and, even when relief is temporary, repeat rt-PA infusions can minimize myocardial damage while patients await mechanical revascularization.

Malignant arrhythmias in relation to values of serum potassium in patients with acute myocardial infarction

The relationship between levels of potassium in the serum and the development of malignant arrhythmias was examined in a retrospective study involving 1011 patients presenting with acute myocardial infarction. Thirteen percent of the overall patients studied had significant hypokalemia (k less than 3.5 mmol/liter). The average initial level of potassium in patients who developed malignant arrhythmias was (4.10 mmol/liter) significantly lower (P less than 0.01) than those patients who did not develop such arrhythmias (4.19 mmol/liter). To determine whether the level of potassium was, in itself, the primary cause of malignant arrhythmias following myocardial infarction, a subgroup analysis of factors influencing these levels was performed. It was determined that diabetics have a higher level of potassium than nondiabetics (4.2 mmol/liter versus 4.11 mmol/liter - P = 0.01) and a lower incidence of malignant arrhythmias (50.5% versus 63.5% - P = 0.002). No correlation was found between treatment with either digitalis or diuretics and malignant arrhythmias. Size and location of infarcted areas was found to have a direct relationship with development of arrhythmias. Size and location of infarctions, however, were not found to be related to levels of potassium in the serum. Our findings support and clarify earlier suggestions establishing the levels of potassium in the serum as an important causative factor, together with size and location of infarctions, in the development of malignant arrhythmias.

Exit Block in Myxedema, Treated Effectively by Thyroid Hormone Therapy

A case of a 71‐year‐old female who developed exit block one year after implantation of a pervenous pacemaker is reported. The pacemaker had been implanted for sick sinus syndrome; the exit block was probably due to the development of severe myxedema which caused high pacing threshold. Normal pacing threshold was obtained on the seventh day of adequate thyroid hormone therapy and a follow‐up one year later revealed effective control of the myxedema and no abnormalities in the function of the pacemaker system.

The CB-12L: A New Device for Transtelephonic Transmission of a 12-Lead Electrocardiogram

The value of transtelephonic transmission of ECG information is well established, and technological advances have continuously provided improved state‐of‐the‐art equipment. Shahal Medical Services provides professional care to subscribers who call the medical center and describe their symptoms, whereupon therapeutic measures are decided upon. A new 12‐lead patient controlled device for telephonically transmitting an ECG (CB‐12L) has become available; the aim of this study was to evaluate its accuracy and practicability. Forty tracings (20 standard ECG tracings obtained under medical supervision in the physicians office and 20 by the patient in his home using the new CB‐12L ECG device and transmitted by telephone to the center) from 20 subjects with various electrocardiographic pathologies were reviewed by 19 experienced physicians who were asked to interpret the results and identify the recording device. In 82% of the possibilities, the interpretation of the tracings was identical for both those recorded by the standard ECG recorder and the CB‐12L ECG. An equal number of physicians could not identify the means by which device the tracings were taken. Proper placement of the electrodes did not prove to be a problem for the patient. Thus, the CB‐12L ECG was found to be an easily operable and reliable tool which may be of value for early and prompt diagnosis of threatening cardiac situations in the prehospital setting.

Effect of isosorbide-5-mononitrate on exercise performance and clinical status in patients with congestive heart failure: Results of the nitrates in congestive heart failure (NICE) study

Background and Aims: Nitrate therapy improves hemodynamics in patients with heart failure, but the chronic effects of oral nitrates on exercise performance and clinical status have not been well studied. Methods: Oral isosorbide-5-mononitrate (ISMN) (50 mg once daily) or placebo was administered to 136 patients (NYHA Class 2–3) treated for heart failure, all receiving captopril and most also furosemide. Endpoints were treadmill exercise time at 12 weeks by modified Naughton protocol (primary), with an additional 12-week follow-up period. Secondary endpoints included left ventricular dimensions, ejection fraction, cardiothoracic ratio, functional class, quality of life, hospitalizations and plasma norepinephrine and atrial natriuretic peptide in a four-center substudy. Results: Intention-to-treat analysis showed that mean change in treadmill exercise duration tended to be greater in patients receiving ISMN than placebo (treatment difference +42 s, 95% CI –5, +90 s at 12 weeks and +21 s, 95% CI –25, +74 s after 24 weeks) (NS). Treatment difference was greater in the prespecified subgroup with ejection fraction 31–40% (+55 s, 95% CI –11, +136 s at 12 weeks and +65 s, 95% CI +3, +147 s) (p = 0.035) at 24 weeks. No deleterious effects (i.e. hypotension) were observed with ISMN, although headache was reported in 19% of the active treatment group (p = 0.0001). Conclusions: ISMN added to captopril increased treadmill exercise time in patients with heart failure and a lesser reduction in baseline ejection fraction, although for the group as a whole, the increase in treadmill time was not significant.

Serial Changes in Left Ventricular Diastolic Indexes Derived from Doppler Echocardiography After Anterior Wall Acute Myocardial Infarction

Restrictive ventricular filling pattern derived from Doppler echocardiography after anterior wall AMI may serve as an indicator of diastolic dysfunction due to initial myocardial stiffness and complications such as extension of the infarction, Dressler syndrome, septal rupture, or myocardial failure. Later changes, such as prolongation of deceleration time, may indicate remodeling process, healing of the complications of AMI, or improved revascularization.

Randomized double-blind comparison of the effects of isosorbide dinitrate retard, verapamil sustained-release, and their combination on myocardial ischemic episodes.

The antianginal and anti-ischemic efficacy of isosorbide dinitrate (ISDN) retard 120, verapamil 120 sustained-release (s.r.) and their combination was evaluated in 30 patients with chronic angina pectoris. The study was a randomized, double-blind crossover comparison. The evaluation was determined by exercise testing and 24-hour electrocardiographic ambulatory monitoring. The sum of ST-segment depression at comparable exercise levels was reduced by 37% (p less than 0.001) after verapamil 120 s.r. and by 45% (p less than 0.001) after combination therapy. After ISDN retard 120 the sum of ST-segment depression was also slightly reduced by 18% without attaining statistical significance. Total walking time and time to angina pectoris during treadmill exercise were significantly prolonged after all treatments. The sum of ST-segment depression in the 24-hour Holter ECG was reduced by 46% (p less than 0.001) after verapamil and by 39% (p less than 0.01) after combined therapy. After ISDN retard 120 the mean reduction was 34% (p less than 0.01). In conclusion, the result of the study indicated that ISDN retard 120, verapamil 120 s.r. and a combination of both drugs are effective in reducing the frequency and duration of ischemic episodes in patients with ischemic heart disease.

A Right Atrial Mass in the Presence of a Permanent Pacemaker Electrode in a Patient with Polycythemia Vera

A case of a huge right atrial mass that developed 2 years after a permanent pacemaker implantation is described. The patient had a history of polycythemia vera, which is known to present a high tendency towards the development of thrombosis. In light of this fact, we suggest that in similar cases a full echocardiography follow‐up should be performed, and long‐term anticoagulant therapy should be considered in selected cases.