Sexual activity cardiological survey on members of the Israel Heart Society.

A nationwide telephone survey conducted under the auspices of the Israeli Heart Society examined cardiologists' knowledge of and attitudes towards sexual activity among cardiac patients with concomitant sexual dysfunction. The items covered demography, understanding of relevant mechanisms, drug effects and cardiovascular physiology during sexual activity, suitable interventions and sources of the cardiologists' knowledge. Compliance was excellent (364/379 [96%] responders). Attitudes and knowledge were similar among males and females: 74% underestimated the published frequency of erectile dysfunction in general and among cardiac patients specifically; 90% knew that beta-blockers cause erectile dysfunction but few responded correctly about other non-cardiac drugs; 77% try to cope with their patient's problematic sexual function, especially younger cardiologists who tended to be more up to date about it. Israeli cardiologists are motivated to assist these patients but demonstrate a general lack of adequate up to date knowledge on the epidemiological, physiological and pharmacological aspects of the problem.

The "SHAHAL" experience in Israel for improving diagnosis of acute coronary syndromes in the prehospital setting.

The diagnosis of acute coronary syndromes is frequently missed, and many high-risk patients fail to be admitted to hospital. The aim of this study was to assess the value of cardiac markers in ruling out acute ischemic events in patients with symptoms of possible cardiac origin and nondiagnostic electrocardiograms. The data collected between May 1999 and April 2000 for this prospective cohort study were retrieved from the records of 777 consecutive prehospital patients (mean age 70 years, 62.9% men) whose symptoms lasted for 6 to 48 hours, who were treated by mobile intensive care teams, and for whom the physician could not reach a clear-cut decision whether they should be taken to hospital or left at home. The cardiac markers, creatine kinase (CK-MB), myoglobin, and troponin I, were measured at the scene using a rapid Stat kit to qualitatively detect their presence in whole blood samples. Results were determined after 15 minutes at the scene. The assay was positive in 30 patients, 11 of whom had a definite cardiac diagnosis (acute myocardial infarction in 4 and unstable angina pectoris in 7). Positive and negative predictive values of the assay for detecting a significant coronary event were 36.7% and 100%, respectively. Of the 747 patients with a negative result, 6 patients had a false result (1 with myocardial infarction and in 5 with unstable angina) (99.2% negative predictive value). Thus, cardiac markers are useful in ruling out high-risk coronary syndromes in the prehospital setting when the clinical presentation and electrocardiogram are inconclusive.

Potential reduction of costs and hospital emergency department visits resulting from prehospital transtelephonic triage--the Shahal experience in Israel.

BACKGROUND: The rising cost of services provided by hospital emergency departments is of major concern. Attempts to reduce the costs of emergency cardiac care have thus far focused primarily on medical and administrative management in the hospital. The role of the patient in appropriate prehospital decision-making has been generally ignored. HYPOTHESIS: Membership in "Shahal" (an integrative telemedicine system) may have beneficial effects on patient decision-making and national health costs. METHODS: During a 6-month period, a random group of subscribers who had called for medical assistance during the previous 24 h were asked what action they would have taken had they not been Shahal subscribers. All study patients were followed for at least 7 days. RESULTS: In all, 1,608 subscribers (age 71 +/- 13 years) were included. Of these, 514 replied that they "would have waited," 363 "would have contacted their physicians," and 731 "would have sought emergency department care." Of the presenting medical problems, 86% were resolved without utilizing hospital facilities. A mobile intensive care unit was dispatched in 412 (26%) cases. A cost estimate of abuse indicated that the service resulted in a savings to the national economy of approximately $830,000 per 10,000 members per year. CONCLUSIONS: This study demonstrated that Shahal membership can reduce costs of medical care and the number of hospital emergency department visits.

Medical history of hypercholesterolaemia adversely affects the outcome of out-of-hospital cardiopulmonary resuscitation; the 'Shahal' experience in Israel.

AIMS: To evaluate the impact selected risk factors for cardiac death may have on the success rate in a large cohort of subscribers to 'SHAHAL' who were resuscitated from out-of-hospital cardiac arrest. METHODS AND RESULTS: In this medical facility currently serving 50 000 subscribers, data were prospectively gathered from between 1987-1998. The information retrieved from the patients' medical records included a medical history of hypertension, diabetes, hypercholesterolaemia (>220.mg. dl(-1)) smoking, angina, previous myocardial infarction, and congestive heart failure. A total of 998 patients aged 74+/-12 years (mean+/-1 SD) were included. Death was announced at the scene for 659 (66%) victims, while 339 (34%) patients were taken to hospital. Of these 140 (14% of the total cohort) survived and were discharged from the hospital. A comparison of various selected parameters between survivors and non-survivors of resuscitation revealed that survivors were younger, had a higher rate of pulseless ventricular tachycardia/ventricular fibrillation, more were among the arrests witnessed by the 'SHAHAL' team, and that more had a shorter time lag to initiation of cardiopulmonary resuscitation than non-survivors. None of the studied risk factors predicted the outcome of cardiopulmonary resuscitation, with the exception of hypercholesterolaemia, which carried a significantly worse prognosis for cardiopulmonary resuscitation (P=0.009). CONCLUSIONS: A medical history of hypercholesterolaemia appears to be an important risk factor which adversely affects the outcome of cardiopulmonary resuscitation.

Circadian variation of symptomatic paroxysmal atrial fibrillation. Data from almost 10 000 episodes.

AIMS: To determine the circadian rhythm of paroxysmal atrial fibrillation in a very large outpatient population. METHODS AND RESULTS: We reviewed all emergency telephone calls received in Shahal (a medical service covering 44 000 subscribers), from 1987 to 1997. Patients were included if new-onset atrial fibrillation was recorded. During this study period, 9989 episodes of paroxysmal atrial fibrillation were recorded. The time of onset was not uniformly distributed throughout the 24 h period. Instead, the distribution of arrhythmic episodes showed a double peak, with a significant increase in the number of episodes in the morning and a second rise in the evening (P<0.001). A non-uniform weekly distribution of events was also noted, with substantially fewer episodes on Saturdays (P<0.001). Finally, more arrhythmias occurred during the last months of each year (P<0.001). CONCLUSIONS: The onset of paroxysmal atrial fibrillation does not occur randomly. The large patient population in the present study suggests that the circadian rhythm of paroxysmal atrial fibrillation is similar to that described for other cardiovascular diseases, with clustering of events in the morning and (to a lesser degree) late in the evening. Weekly and yearly circadian patterns are also prominent.

Assessment of a creatine kinase-MB/myoglobin kit in the prehospital setting in patients presenting with acute nontraumatic chest pain: the "Shahal" experience.

OBJECTIVES: To evaluate the usefulness of a novel qualitative, rapid, bedside immunoassay device for the detection of elevated creatine kinase MBmass (CK-MB) and myoglobin as a supportive tool for decision-making by the physician who is evaluating patients who present with chest pain. DESIGN: Prospective study. SETTING: Prehospital (mobile intensive care units). PATIENTS: Three hundred twenty-eight consecutive patients, age 71+/-13 yrs (64% males), who were admitted to the hospital via Shahal's mobile intensive care units. INTERVENTION: During a 6-month period, based on clinical presentations and electrocardiograms, the mobile's physicians classified patients into groups of high or low probability of having an acute myocardial infarction and, thereafter, used a rapid bedside STATus kit (Spectral Diagnostics, Toronto, Ontario, Canada) to determine blood creatine kinase/MB and myoglobin. MEASUREMENTS AND MAIN RESULTS: Myocardial infarction was confirmed in 59 (18%) patients. If measured >2 hrs after onset, diagnostic sensitivities, specificities, and positive and negative predictive values for physicians were as follows: 71%, 90%, 46%, and 96%, respectively, compared with 100%, 85%, 44%, and 100%, respectively, if assessed by the kit. CONCLUSIONS: If used 2 to 12 hrs from the onset of symptoms, this device is a convenient diagnostic aid to prevent a misdiagnosis of acute myocardial infarction or unnecessary hospitalization to exclude infarction. This tool may be a promising cost-cutting factor in these days of escalating expenses and dwindling resources.

The "telepress" system for self-measurement and monitoring of blood pressure (the "SHAHAL" experience in Israel).

No "white coat" effect contaminated the validity of measurements in 30 participants in a "Telepress" program, in which subscribers to a telecardiologic facility transtelephonically transmit their self-measured blood pressure values.

Usefulness of self-administration of intramuscular lidocaine in the prehospital setting for ventricular tachyarrhythmias unassociated with acute myocardial infarction (the "Shahal" experience in Israel).

We report on the experience accumulated by the subscribers of SHAHAL cardiac services who self-injected intramuscular lidocaine (using an automatic injector "LidoPen") for documented ventricular tachyarrhythmias which were not associated with an acute myocardial infarction. SHAHAL provides professional care to its subscribers who telephone a monitor center and describe their symptoms, whereupon therapeutic measures are decided upon. Patient data are stored in a central computer, and the center can dispatch mobile intensive care units. All subscribers carry a portable transtelephonic electrocardiographic transmitter and are provided with the LidoPen. Indications for self-injection were: transmission of a wide-QRS tachycardia (rate > 100 beats/min), symptomatic multiple or complex ventricular premature complexes in association with chest discomfort, and when the time of arrival of a medical team to the patient was estimated to be at least 8 to 10 minutes. Successful usage of the LidoPen was reported in 137 cases (123 patients). An additional 11 patients failed to use the injector properly. There was a success rate in abolishing rapid sustained ventricular tachycardia (27 of 76 patients) and nonsustained ventricular tachycardia and/or multiple and complex ventricular ectopic activity (8 of 30 patients) of 33% (total 35 of 106 patients). In another 9%, those arrhythmias were slowed markedly. The remaining 31 cases were eventually interpreted as being of supraventricular origin. No complications attributed to the use of the injector were reported and its use was found to be both feasible and effective in the prehospital setting.