QT Interval Length in Elderly Prostatic Cancer Patients on Anti-Testosterone Treatment.

UNLABELLED: Background: QT segment prolongation is a high risk factor for fatal arrhythmias. Several studies have indicated a possible relation between low testosterone levels and QT interval prolongation. OBJECTIVES: To compare the QT interval length in elderly patients with prostate carcinoma who were on anti-testosterone treatment and those who were not. METHODS: We screened the electrocardiograms (ECGs) of 100 prostate cancer patients divided into two groups: 50 patients on anti-testosterone drug treatment and 50 patients not. QT interval length was measured according to the accepted methods. RESULTS: The mean QTc 12 leads in the entire group was 0.45 ± 0.04 sec, which is close to the upper limit. Mean QTc was actually longer in the control group and there was no QTc difference between the groups after adjustment for possible confounders. Prolonged QTc 12-lead ECG (48% in treated and 54% in non-treated) and lead L2 QT interval (50% in treated and 56% in non-treated) did not differ significantly between the groups. The analysis of QTc 12-lead ECG indicated no significant effects of anti-testosterone drug treatment. Only the use of furosemide was associated with QT prolongation. CONCLUSIONS: The results of this preliminary study do not support our initial concern of an alarmingly prolonged QT interval in the anti-testosterone treated group. However, further prospectively designed studies are needed. In the meanwhile we call for a close follow-up of the QT interval length in patients receiving anti-testosterone treatment.

Vegetation size in patients with infective endocarditis.

AIMS: Infective endocarditis is a serious disease with diverse clinical manifestations. The aim of this work was to analyse vegetations' size in relation to the clinical presentation, course of the disease, and the type of the microorganism. METHODS AND RESULTS: A total of 146 patients with definite diagnosis of infective endocarditis were identified at Assaf Harofeh Medical Center during the years 1998 to 2010. Of them in 102 patients accurate vegetations' size was available. The data of these patients were collected and analysed. Twenty-three per cent of patients died, embolic complications occurred in 20.6% of patients, 16% of patients underwent surgery. Large vegetations (≥1 cm) occurred in 46 patients. Older patients (>60 years) with large vegetations had significantly increased risk of mortality 38% (P< 0.05). The strongest independent predictor of mortality was MRSA endocarditis (45%, P= 0.01), followed by staphylococcal endocarditis associated with large vegetations (43%, P= 0.01), or with older age (41%, P= 0.01). The combination of staphylococcal endocarditis with large vegetations in the older patients was associated with mortality risk of 50%, P= 0.02. Large vegetations were associated with high incidence of abscess formation (17%, P< 0.001), especially in combination with MRSA (27%, P= 0.01), diabetes (25%, P< 0.02), and older age (30%, P= 0.01). CONCLUSION: Our results indicate that in patients with infective endocarditis the strongest predictor of mortality is MRSA infection, followed by staphylococcal infection especially in association with older age or with large vegetations. Older patients with large vegetations are also in significant risk of mortality. In these groups of patients surgery should be considered early.

30-day outcome after percutaneous coronary angioplasty in nonagenarians: feasibility and specific considerations in different clinical settings.

BACKGROUND: Nonagenarians have been systematically excluded from randomized trials dealing with invasive coronary strategies, resulting in a lack of evidence-based guidelines regarding the optimal approach in this population. AIM: To describe the clinical and procedural characteristics and outcomes of patients 90 years of age or older who were treated with percutaneous coronary interventions (PCI). METHODS: We evaluated the 30-day outcomes of patients 90 years or older who underwent PCI at our institution, comparing the ST-segment elevation myocardial infarction (STEMI) subgroup with the non-STEMI/unstable angina (UA) and stable angina (SA) subgroups, who had been referred for coronary angiography. RESULTS: Over the time period 2002-2011, we identified 45 nonagenarians (mean age, 93 years; range, 90-102 years). The majority (59%) presented with an acute coronary syndrome and underwent immediate coronary revascularization by PCI. Technical success rate was 90%. The frequency of in-hospital death, need for urgent coronary artery bypass surgery, periprocedural cerebrovascular accident, and major adverse cardiovascular and cerebral events was 11%, 4.5%, 4.5%, and 18%, respectively. At 30 days, mortality was exclusively related to the STEMI subgroup with hemodynamic instability, compared with the non STEMI/UA and SA population. CONCLUSIONS: In carefully selected nonagenarians, PCI in contemporary practice may be performed with a high technical success rate with relatively low morbidity and mortality. Questions are raised about the feasibility and outcome of invasive coronary strategies in the high-risk clinical subgroup of STEMI and hemodynamic instability.

Intracoronary administration of autologous bone marrow mononuclear cells in patients with chronic ischemic symptomatic cardiomyopathy: 5 years follow-up.

BACKGROUND: Several studies have demonstrated the shortterm safety, feasibility and efficacy of cell transplantation in patients with advanced heart failure. Data on the long-term outcome are lacking. OBJECTIVES: To evaluate the long-term outcome of intracoronary autologous bone marrow administration in patients with stable severe ischemic cardiomyopathy who were not suitable for revascularization. METHODS: We enrolled eight consecutive patients with ischemic cardiomyopathy: all were in NYHA functional class III-IV despite optimal medical treatment. Dobutamine stress echo showed that all had left ventricular ejection fraction < 35% with significant viability or ischemia, or both, in at least two myocardial segments. Based on coronary anatomy none of the patients was suitable for revascularization. Bone marrow was obtained and the cells were injected into all patent conduits after a brief balloon occlusion at a normal coronary segment. Clinical followup was performed periodically at the heart failure clinic, and included electrocardiography, laboratory tests and echocardiography. RESULTS: During 5 years follow-up there were two deaths: one due to leukocytoclastic vasculitis 21 months after intracoronary bone marrow infusion, and the second patient died suddenly during sleep 30 months after the transplant. The other six patients are alive, two of them without any cardiovascular or clinical events. No significant change in systolic and diastolic function was observed on echocardiography. CONCLUSIONS: Despite the small and selected patient group, our long-term follow-up showed a promising outcome for this population of patients suffering from severe cardiac disease. Longer follow-up of a much larger group is needed.

Long-term (>3 Years) outcome and predictors of clinical events after insertion of sirolimus-eluting stent in one or more native coronary arteries (from the Israeli arm of the e-Cypher registry).

The aim of this study was to evaluate long-term (3.4 years) outcomes and predictors of clinical events in patients treated with sirolimus-eluting stents in the Israeli arm of the e-Cypher registry. From July 2002 to October 2003, 488 patients from 8 medical centers in Israel were enrolled in the e-Cypher registry. Nineteen patients with interventions in venous grafts were excluded from the final analysis. Long-term follow-up was completed for 98% of the remaining patients. There were 29 cases (6.3%) of death (3.9% cardiac and 2.4% noncardiac deaths). According to the broad academic research consortium definition of stent thrombosis, there were 19 cases (4%) of stent thrombosis (incidence density 0.9 cases/100 patient-years). There were 46 cases (9.9%) of target lesion revascularization and 76 cases (16.3%) of major adverse cardiac events (combination of death, myocardial infarction, and target lesion revascularization). Independent predictors of stent thrombosis were renal failure (hazard ratio 9.6, 95% confidence interval 1.9 to 47), stent length (hazard ratio 1.1, 95% confidence interval 1 to 1.2), and the off-label use of sirolimus-eluting stents (hazard ratio 5.3, 95% confidence interval 1.2 to 24). In conclusion, during >3 years of follow-up, stent thrombosis, major adverse cardiac events, and target lesion revascularization continued at constant rates over time. Clinical parameters such as renal failure and procedural parameters such as off-label use and stent length were independent predictors of stent thrombosis.

Interventional cardiology in Israel at 2005 - state of practice.

OBJECTIVE: To assess the current practice of interventional cardiology in Israel. METHOD: Under the auspices of the 'Working group of interventional cardiology' of the 'Israel Heart Society,' a questionnaire regarding the practice of interventional cardiology sent to directors of interventional cardiology in all public hospitals. RESULTS: Twenty centers received the questionnaires; however, complete data was obtained from 18. Most interventional cardiology units in Israel are merely engaged in percutaneous coronary interventions (PCIs). PCIs are executed mostly via the femoral artery, using almost exclusively stents, of which 36% were drug eluting. Noted was an infrequent use of other therapeutic, diagnostic devices, or femoral arteriotomy closure devices. Only 22% of the patients receive glycoprotein IIb/IIIa blockers (GPB). Most centers used conventional unfractionated heparin dosing (70 u/kg) and did not routinely monitor activated clotting time. Abciximab, bivalirudin or enoxaparine were rarely used. All laboratories performed both elective and emergency-PCI, although 12 facilities were not supported by on-site surgical backup. CONCLUSION: Most cardiovascular intervention programs have restricted their activity to the coronary stenting, and are using a limited array of diagnostic and therapeutic devices, along with patient-tailored adjunctive pharmacotherapy, to sustain cost-effectiveness. Currently, ambulatory angiography and coronary interventions are not widely practiced in Israel.

Percutaneous coronary intervention of unprotected left main coronary artery in the emergent/urgent setting.

BACKGROUND: Treatment of unprotected left main coronary disease by percutaneous interventions, even in the urgent setting, is still not an approved indication. However, the evolution of transcatheter technology and supporting devices, along with greater skill in high-volume centers, led the interventional community to deal with these cases. This study aimed to investigate whether the percutaneous approach in this cohort could be a viable alternative to coronary artery bypass graft (CABG) surgery in the urgent setting. METHODS: We enrolled 51 acute myocardial infarction patients with left main disease as the culprit lesion and treated them by percutaneous coronary intervention. This cohort was followed for major adverse cardiac and cerebrovascular events (MACCE) in-hospital and at 30 days, 6 months and 1 year, and was compared with a population of 35 CABG patients matched for clinical and angiographic characteristics. RESULTS: The estimated MACCE-free survival at 6 months and 1 year was 90% and 88%, respectively. The overall MACCE was 6%. Analysis of the surgical cohort showed an overall MACCE of 17%. In the final Cox model, significant predictors of MACCE were Parsonnet score for surgical risk (HR 1.93, 95% CI 1.15-7.3; p = 0.04) and diabetes mellitus (HR 1.73, 95% CI 1.03-3.8; p = 0.038). CONCLUSIONS: Angioplasty for unprotected left main coronary disease in the urgent clinical setting is feasible, showing a relatively low short- and long-term rate of MACCE.

Acute myocardial infarction with spontaneous reperfusion: clinical characteristics and optimal timing for revascularization.

BACKGROUND: Spontaneous coronary reperfusion occurs in 7-27% of patients with ST elevation myocardial infarction, and is an independent predictor of myocardial salvage, percutaneous coronary intervention success, and improved outcome. OBJECTIVES: To determine the optimal PCI time for patients admitted to the hospital due to STEMI with SCR. METHODS: We performed a retrospective analysis of all patients admitted to the coronary care unit between July 2002 and November 2004 with a diagnosis of STEMI with SCR. RESULTS: The study group comprised 86 patients. There was not a single reinfarction episode during an observation period of 6579 patient hours. Cardiac catheterization was executed early (< 24 hours from pain onset) in 26 patients and late (> 24 hours) in 55. Pre-PCI angiographic TIMI flow 2-3 was seen in > 95% in both groups. PCI was performed more frequently in the "early" group (P = 0.024), while multi-vessel coronary artery disease (P = 0.094) requiring coronary bypass surgery (P = 0.056) was observed more frequently in the "late catheterization" group. Myocardial infarction and angina pectoris at 30 days occurred more frequently in the early catheterization group (P = 0.039), however no difference in any major adverse cardiac events was detected during long-term follow-up (491 +/- 245 days). CONCLUSIONS: Reinfarction after STEMI with SCR is a rare event. Early PCI in patients with STEMI and SCR, even when executed with aggressive antiplatelet therapy, seems to result in an excess of early MACE without any long-term advantage. Prospective randomized trials should determine the optimal PCI timing for these patients.

Optimization of myocardial perfusion after primary coronary angioplasty following an acute myocardial infarction. Beyond TIMI 3 flow.

UNLABELLED: Primary angioplasty has become the preferred therapeutic modality in patients with acute myocardial infarction (AMI). Despite restoration of antegrade epicardial flow by mechanical reperfusion therapy, angiographically assessed microvascular function and myocardial reperfusion (blush) allows for the stratification of patients with epicardial TIMI 3 flow into different strata of survival. Despite this fact, the best approach to achieving good myocardial blush has not yet been established. We sought to determine the efficacy of 3 different vasodilators. METHODS: A cohort of 40 patients were referred for primary angioplasty in the setting of STEMI; their TIMI 3 flow was achieved and myocardial blush (MB) was 0-1 (no myocardial opacification) according to the vant'Hof classification. The patients were assigned to 1 of 3 investigational groups: intracoronary (IC) injection of nitroprusside, adenosine and verapamil, and were compared with the control group: IC injection of nitroglycerin, their effect on MB, the sum ST-segment resolution and the left ventricular ejection fraction (LVEF) at 30 days. RESULTS: Nitroprusside proved to have the best effect on MB (p = 0.023). This correlated with an improvement in LVEF from the baseline (p = 0.048). Also, the sum ST-segment resolution showed a trend in favor of nitroprusside, but without statistical significance. CONCLUSION: IC injection of nitroprusside was more beneficial in reaching MB grade 3 in the setting of primary angioplasty for AMI, correlating with a significant improvement in LVEF at 30 days. Also, a trend toward the best ST-segment resolution was observed in the nitroprusside-treated group.

Intracoronary administration of autologous bone marrow mononuclear cells after induction of short ischemia is safe and may improve hibernation and ischemia in patients with ischemic cardiomyopathy.

BACKGROUND: Recent studies suggest that myocardial administration of stem cells improves perfusion and function of ischemic myocardium. The present study evaluated the safety and efficacy of simple intracoronary administration of mononuclear autologous bone marrow (BM) cells in patients with ischemic cardiomyopathy without revascularization option. METHODS AND RESULTS: We enrolled 6 consecutive patients with ischemic cardiomyopathy, who were in New York Heart Association classes III to IV despite optimal medical treatment without revascularization options and who, on dobutamine stress echocardiograph (DSE), were found to have left ventricular ejection fraction < 35% with significant hibernation and ischemia in at least 2 myocardial segments. BM cell suspension was collected, and on the next day, during coronary angiography, mild ischemia was induced by a short balloon inflation in each coronary conduit with a TIMI flow of > or = 2 followed by slow infusion of up to 50 mL of BM cells suspension to each conduit. At baseline and 4 months' follow-up, patients underwent clinical evaluation, Holter monitoring, and DSE. BM infusion was successful in all patients. One patient developed postprocedure hypotension and troponin increase. At 4 months' follow-up New York Heart Association class improved from 3.5 +/- 0.5 to 2.3 +/- 1.0, P = .04, and resting ejection fraction improved from 25% +/- 7% to 28% +/- 8%, P = .055. We observed improvement in resting wall motion score only in the segments with hibernation in baseline DSE (2.3 +/- 0.5 to 2.0 +/- 0.6, P = .03) and improvement in high-dose dobutamine wall motion score, only in segments showing significant ischemia at baseline DSE (2.5 +/- 0.5 to 2.0 +/- 0.6, P = .001). There were no clinical arrhythmias or increased arrhythmia burden by Holter monitoring. CONCLUSIONS: In patients with severe symptomatic ischemic cardiomyopathy, mild induction of ischemia followed by intracoronary infusion of unmanipulated autologous BM is feasible and safe and may improve hibernation and ischemia.

The effect of N-acetylcysteine on renal function, nitric oxide, and oxidative stress after angiography.

BACKGROUND: Renal failure induced by radiographic contrast agents is a known complication of coronary angiography, especially among patients with chronic renal failure. Recently, treatment with N-acetylcysteine (NAC) has been shown to have a protective effect but the mechanisms are unknown. We examined the hypothesis that NAC protected against contrast-induced renal impairment through effects on nitric oxide metabolism and oxidative stress. METHODS: Patients with a serum creatinine concentration above 10(6) micromol/L undergoing coronary angiography were randomly assigned to receive either NAC 1 g (N= 24) or placebo (N= 29) twice daily 24 hours before and after angiography with 0.45% saline hydration in a double-blind study. Creatinine clearance was calculated and urinary nitric oxide and F2-isoprostane excretion were measured at baseline, 24 and 96 hours after angiography. RESULTS: Treatment with NAC significantly improved the effect of contrast media on creatinine clearance, and maximal beneficial effect was observed 24 hours after angiography. Creatinine clearance (mL/min) was 59.5 +/- 4.4, 64.7 +/- 5.8, and 58.7 + 3.9 at baseline, 24, and 96 hours after angiography in the NAC group, respectively, and 65.2 +/- 3.2, 51.5 +/- 3.7, and 53.6 +/- 3.9 in the placebo group, respectively (P < 0.0001). NAC treatment prevented the reduction in urinary nitric oxide after angiography. The urinary nitric oxide/creatinine ratio (micromol/mg) was 0.0058 +/- 0.0004, 0.0057 +/- 0.0004, and 0.0052 +/- 0.0004 at baseline, 24, and 96 hours after angiography in NAC group, respectively, and 0.0057 +/- 0.0007, 0.0031 +/- 0.0005, and 0.0039 +/- 0.0005 in the placebo group, respectively (P= 0.013). NAC had no significant effect on urinary F2-isoprostanes. CONCLUSION: NAC treatment has renoprotective effect in patients with mild chronic renal failure undergoing coronary angiography that may be mediated in part by an increase in nitric oxide production.