Complete atrioventricular block complicating acute myocardial infarction in the thrombolytic era. SPRINT Study Group and the Israeli Thrombolytic Survey Group. Secondary Prevention Reinfarction Israeli Nifedipine Trial.

OBJECTIVES: We assessed the incidence, associated clinical parameters and prognostic significance of complete atrioventricular block (CAVB) complicating acute myocardial infarction (AMI) in the thrombolytic era and compared them to data from the prethrombolytic era. BACKGROUND: The introduction of new therapeutic modalities to treat AMI, aimed to enhance coronary reperfusion and to limit myocardial necrosis, was expected to decrease the incidence of CAVB and to improve prognosis. However, there are only limited data regarding the incidence and the prognosis of AMI patients with CAVB in the thrombolytic era. METHODS: Data from 3,300 patients from the Israeli Thrombolytic Surveys (prospective, nationwide surveys of consecutive patients with AMI in all 25 coronary-care units in Israel in 1992 and 1996) were analyzed and compared with data from 5,788 patients included in the SPRINT (Secondary Prevention Reinfarction Israeli Nifedipine Trial) Registry (1981 to 1983). RESULTS: During the 1990s, the incidence of CAVB was 3.7% compared with 5.3% in the 1980s, p = 0.0007. In the 1990s, mortality of patients with CAVB was significantly higher than in those without CAVB at 7 days (odds ratio [OR] = 4.05 95% CI [confidence interval] 2.34 to 6.82, 30 days OR = 3.98 [95% CI 2.44 to 6.43] and one-year hazard ratio [HR] = 2.36, [95% CI 1.68 to 3.30]) and similar in thrombolysis-treated and not-treated patients. Mortality of patients with CAVB has not changed significantly between the two periods; seven-day OR = 0.82 (95% CI 0.46 to 1.43); 30-day OR = 0.78 (95% CI 0.45 to 1.33) and one-year HR = 0.79 (95% CI 0.54 to 1.56), respectively, in the 1990s as compared to a decade earlier. CONCLUSIONS: The incidence of CAVB complicating AMI is lower in the thrombolytic era than in the prethrombolytic era. Mortality among patients with CAVB is still high and has not declined within the last decade. The AMI patients who develop CAVB in the thrombolytic era have significantly worse prognosis than do patients without CAVB.

Effects of aspirin treatment on survival in non-insulin-dependent diabetic patients with coronary artery disease. Israeli Bezafibrate Infarction Prevention Study Group.

PURPOSE: The benefit of aspirin treatment among diabetic patients with chronic coronary artery disease is not well established. The purpose of this study was to assess the effect of aspirin on cardiac and total mortality in a large cohort of diabetic patients with established coronary artery disease and to compare it with the effect of aspirin in nondiabetic counterparts. PATIENTS AND METHODS: In this observational study among patients screened for participation in the Bezafibrate Infarction Prevention Study, the effects of aspirin treatment in 2,368 non-insulin-dependent diabetic patients with coronary artery disease were compared to those in 8,586 nondiabetic patients. Hazard ratios (HR) and 95% confidence intervals (CI) were estimated with proportional hazards models. RESULTS: Fifty-two percent of diabetic patients and 56% of nondiabetic patients reported aspirin therapy. After 5.1 +/- 1.3 (mean +/- SD) years of follow-up, the absolute benefit per 100 patients treated with aspirin was greater in diabetic patients than in nondiabetic patients (cardiac mortality benefit: 5.0 versus 2.1, and all-cause mortality benefit: 7.8 versus 4.1). Overall cardiac mortality among diabetic patients treated with aspirin was 10.9% versus 15.9% in the nonaspirin group (P < 0.001), and all-cause mortality was 18.4% and 26.2% (P < 0.001). After adjustment for possible confounders, treatment with aspirin was an independent predictor of reduced overall cardiac (HR = 0.8; 95% CI: 0.6-1.0) and all-cause mortality (HR = 0.8; 95% CI: 0.7-0.9) among diabetic patients, similar to those in nondiabetic patients. CONCLUSION: Treatment with aspirin was associated with a significant reduction in cardiac and total mortality among non-insulin-dependent diabetic patients with coronary artery disease. The absolute benefit of aspirin was greater in diabetic patients than in those without diabetes.

Effect of aspirin on mortality in women with symptomatic or silent myocardial ischemia. Israeli BIP Study Group.

The benefit of aspirin therapy among women with coronary artery disease (CAD) is not well established. Previous studies have shown conflicting results among women. Data from 2,418 women with CAD screened for participation in the ongoing Bezafibrate Infarction Prevention (BIP) study were analyzed: 45% reported aspirin therapy. Baseline characteristics were similar in both groups. Cardiovascular mortality at 3.1 +/- 0.9 years of follow-up was 2.7% in the aspirin treated group versus 5.1% in the non-aspirin-treated women (p = 0.002). All cause mortality was 5.1% and 9.1%, respectively (p = 0.0001). Treatment with aspirin emerged as an independent predictor of reduced cardiovascular (RR = 0.61, 95% confidence interval [CI] 0.38 to 0.97) and all cause (RR = 0.66, 95% CI 0.47 to 0.93) mortality after multiple adjustment for possible confounders such as age, history of myocardial infarction, systemic hypertension, diabetes mellitus, peripheral vascular disease, current smoking, New York Heart Association classification, and concomitant treatment with digitalis. Women who benefited the most from aspirin therapy were older, diabetic, symptomatic, or had a previous myocardial infarction. Thus, treatment with aspirin was associated with reduced mortality among women with CAD. This study suggests that women with CAD should be treated with aspirin, unless specific contraindications exist.

Long-term prognosis of patients after a Q wave compared with a non-Q wave first acute myocardial infarction. Data from the SPRINT Registry.

UNLABELLED: OBJECTIVE, DESIGN AND PATIENTS: Between August 1981 and July 1983, 5839 consecutive myocardial infarction patients were hospitalized in 13 coronary care units in Israel. The present study examines 10 year survival among 4037 consecutive patients with a first myocardial infarction with either Q or non-Q waves. Demographic and medical data were collected from hospital records, and 1 year clinical follow-up was complete for 99% of hospital survivors. Mortality follow-up was extended to June 1992 (mean 10 years of follow-up). RESULTS: Five hundred and eighty patients (14%) had first myocardial infarctions of the non-Q wave type and 3457 of the Q wave type. Hospital mortality was significantly higher in patients with a Q wave (10%) than those with a non-Q wave myocardial infarction (7%) (P < 0.05). One year post-discharge, non-fatal reinfarction and mortality rates were comparable in patients with Q wave (4% and 7%) and non-Q wave myocardial infarctions (4% and 7% respectively). Similarly, 5 to 10 year post-discharge mortality rates were equally high in patients with a non-Q wave (26% and 44%) as in those with a first episode of a Q wave myocardial infarction (22% and 40% respectively). CONCLUSIONS: Patients with a first non-Q wave acute myocardial infarction exhibited relatively better in-hospital survival than counterparts with a first Q wave infarction, but the advantage did not persist after discharge. Patients with a non-Q wave infarction deserve particular attention as their post-discharge mortality risk is similar to counterparts with a first Q wave myocardial infarction.

Myocardial bridging: surgical technique and operative results.

We report a case of a 37-year-old symptomatic male with anterior myocardial ischemia. Coronary angiography demonstrated systolic obstruction of the midportion of the left anterior descending coronary artery due to myocardial bridging. The patient was treated with a supra-arterial myotomy. Two years postoperatively, the patient is without evidence of myocardial ischemia. Angiography, 2 years postoperatively, shows no evidence of systolic narrowing of the left anterior descending coronary artery.

Clinical trials in Israel--facts and dilemmas.

A total of 1,186 proposals of clinical trials have been studied by the National Committee for Clinical Trials (NCCT) in 1995, with an annual increase of 15-20% since 1991. Of those, 61.4% dealt with drugs, the others-with medical instruments and techniques. As many proposals were part of multi-center studies, altogether 524 different drug-trials were studied, the leading fields being cardiovascular, nephrology, neurology, oncology, and infectious diseases in this order of importance. Forty two different proposals (8%) were discussed in depth in the NCCT while 92% were approved by hospital-committees and representatives of the national committee. Out of the 44 problematic proposals, discussed by the NCCT, .5 proposals were totally rejected, while 9 were approved following changes suggested by the committee. The ethical, moral and legal dilemmas presented by the proposals will be discussed.

Prognosis of early versus late ventricular fibrillation complicating acute myocardial infarction.

Earlier studies have suggested that patients exhibiting late (> 24 h) ventricular fibrillation during acute myocardial infarction had a poorer outcome in comparison to myocardial infarction patients with early (< 24 h) ventricular fibrillation. Between August 1981 and July 1983, 5839 consecutive patients with acute myocardial infarction were hospitalized in 13 out of 21 operating coronary care units in Israel. Demographic and medical data were collected from hospitalization charts and during 1 year of follow-up. Mortality assessment was done for 99% of hospital survivors up to mid-1988 (mean, 5.5 years). The incidence of ventricular fibrillation in the SPRINT Registry was 6% (371/5839). Patients with ventricular fibrillation in the setting of cardiogenic shock (n = 107) were excluded from analysis. Patients with late ventricular fibrillation (n = 109; 41%) were older and had a more complicated hospital course than patients with early ventricular fibrillation (n = 155; 59%). In-hospital and 1-year post-discharge mortality were significantly higher in patients with late ventricular fibrillation (63% and 17%) as compared to patients with early ventricular fibrillation (26% and 4%, respectively; P < 0.05 for each). This difference vanished 5 years after hospital discharge. After multiple logistic regression analysis late occurrence of ventricular fibrillation emerged as an independent predictor of increased in-hospital mortality (Odds ratio, 4.29; 95% confidence interval, 2.11-8.74) but not for subsequent death. Patients with late ventricular fibrillation during the hospital course of acute myocardial infarction had a poorer immediate and subsequent outcome in comparison to patients with early ventricular fibrillation.

Immediate and long-term prognostic significance of a first anterior versus first inferior wall Q-wave acute myocardial infarction. Secondary Prevention Reinfarction Israeli Nifedipine Trial (SPRINT) Study Group.

Of 3,981 patients with a first Q-wave acute myocardial infarction (AMI), 1,929 (48%) had an anterior and 1,724 (43%) an inferior wall AMI. These 2 groups were well-matched with respect to age, gender and relevant history. The in-hospital mortality rate was 18%, and the 1- and 5-year post-discharge mortality rates were 9 and 25%, respectively, in patients with anterior wall AMI compared with the corresponding rates of 11, 6 and 19% in those with inferior wall AMI (p < 0.0001 for each category). The frequency of recurrent nonfatal AMI in the year after the index AMI was 8% in the patients with anterior wall AMI compared with 4% in those with inferior wall AMI (p < 0.0001). By multiple logistic regression analysis of events, anterior wall AMI was an independent predictor of in-hospital mortality only. The findings indicate that the anatomic location of a Q-wave AMI influences immediate and short-term survival of patients with a first Q-wave AMI.

Evolution of echocardiographic modalities in detection of postmyocardial infarction ventricular septal defect and papillary muscle rupture: study of 62 patients.

Diagnostic sensitivity of various echocardiographic modalities was assessed for postinfarct ventricular septal defect (40 patients) and papillary muscle rupture (22 patients). Two-dimensional transthoracic echocardiography enabled direct visualization of ventricular septal defect in 68% and combined two-dimensional Doppler echocardiography was diagnostic in 95%. Papillary muscle rupture was directly visualized in 45%, and severe mitral regurgitation was present on Doppler color flow images in 100%. Transesophageal echocardiography was diagnostic in all nine patients (five with ventricular septal defect and four with papillary muscle rupture) in whom this modality was applied. Thus two-dimensional Doppler echocardiography (transthoracic and transesophageal if necessary) is highly sensitive in detecting postinfarct ventricular septal defect and papillary muscle rupture.

Rationale and design of a secondary prevention trial of increasing serum high-density lipoprotein cholesterol and reducing triglycerides in patients with clinically manifest atherosclerotic heart disease (the Bezafibrate Infarction Prevention Trial).

Controlled clinical trials have demonstrated the efficacy of reducing the blood levels of low-density lipoprotein cholesterol in reducing the incidence of coronary artery disease in hypercholesterolemic middle-aged men. However, a similar reversibility of the risk of coronary artery disease has not been demonstrated for high-density lipoprotein cholesterol elevation and triglyceride reduction. Therefore, the effect of administering 400 mg of bezafibrate retard daily versus placebo (double blind) to patients with myocardial infarction preceding randomization by 6 months to 5 years, or a clinically manifest anginal syndrome documented by objective evidence of dynamic myocardial ischemia, or both, is being investigated. Three thousand subjects (aged 45 to 74 years) are being enrolled from 19 cardiac departments in Israel, with total serum cholesterol between 180 and 250 mg/dl, high-density lipoprotein cholesterol < or = 45 mg/dl and triglycerides < or = 300 mg/dl. In addition, low-density lipoprotein cholesterol concentrations are required to be < or = 180 mg/dl (< or = 160 mg/dl for patients aged < 50 years). Patients needing lipid-modifying therapy, exhibiting > or = 1 prespecified exclusion criterion or not giving informed consent, or a combination, are not randomized. The primary end points for evaluating efficacy are the incidence of fatal and nonfatal myocardial infarction, and sudden death. The hypothesized effect of bezafibrate administration under the aforementioned protocol is to reduce an estimated cumulative end point event incidence of > or = 15% by 20 to 25% over an average follow-up period of 6.25 years, through early 1998, when the last patient recruited will have completed 5 years.(ABSTRACT TRUNCATED AT 250 WORDS)

Knowledge and attitude of healthy high school students toward bronchial asthma and asthmatic pupils.

One hundred sixteen healthy high school pupils were interviewed and completed a questionnaire concerning their knowledge about asthma and their attitude towards asthmatic peers. They were compared with 35 asthmatic pupils studying at the same school. The level of knowledge was quite satisfactory, with the knowledge of the asthmatic pupils being somewhat higher than that of the healthy pupils, but without statistical significance. There was a correlation with the age of the pupils in both groups (p < 0.0001). The source of pupils' knowledge came principally from the media (television and newspapers), the family (talking with parents), treating physicians, and school nurses. The healthy pupils displayed less tolerance toward the asthmatic disease and its limitations on activity than that displayed by the asthmatic pupils (p < 0.001). A correlation was found between the level of knowledge and attitude, with an increased level of knowledge implying a more tolerant attitude. A correlation was also found between tolerant attitudes and increasing age, increasing parental education, and the pupils' behavior marks. The recommendation of the survey is to improve the instruction regarding bronchial asthmatic diseases with classes taught by physicians or nurses. By increasing the knowledge of the healthy pupils at school, their attitudes will be more tolerant and positive toward the asthmatic pupils.

Mitral valve operation in postinfarction rupture of a papillary muscle: immediate results and long-term follow-up of 22 patients.

The long-term clinical outcome was assessed in 22 patients (15 men and 7 women; mean age, 68 years) who underwent mitral valve replacement or repair for acute mitral regurgitation due to postinfarction rupture of a papillary muscle during the period 1981 through 1990 at the Mayo Clinic. All but three patients underwent operation within the first 3 weeks after acute myocardial infarction. The perioperative mortality was 27%, and the estimated actuarial survival rate at 7 years postoperatively was 47% and 64% for the entire group and for the patients who survived the operation, respectively. The concomitant performance of a coronary artery bypass grafting procedure was the only factor identified that improved both immediate and long-term survival. Patients with a decreased preoperative left ventricular ejection fraction (less than 45%) had somewhat greater short-term and long-term mortality than did those with a left ventricular ejection fraction of 45% or more, but the difference was only of borderline statistical significance. Other factors such as age, sex, severity of coronary artery disease, preoperative existence of congestive heart failure, and timing of the operation in relationship to occurrence of the infarction had no effect on survival. Of the 13 long-term survivors, 10 had significant clinical improvement in comparison with their preoperative state.

Intracardiac primary fibrosarcoma. Case report and literature review.

A 58-year-old woman was hospitalized because of shortness of breath, cough, weakness, and physical signs suggestive of mitral stenosis. Echo-Doppler examination revealed a left atrial mass. This was removed and turned out to be a fibrosarcoma. Recurrence of the tumor with metastases into the pericardium, thyroid goiter, and left kidney led to the patient's death 6 months later. The clinical and pathological features of our rare case are compared with those in the literature.

The prognostic significance of angina pectoris preceding the occurrence of a first acute myocardial infarction in 4166 consecutive hospitalized patients.

We examined the role of chronic (greater than 1 month) angina pectoris (AP) before acute myocardial infarction (AMI) in predicting hospital and long-term mortality rates among 4166 patients with first AMIs. The prevalence of AP in these patients was 43%. Chronic AP was more common in women (49%), patients with hypertension (49%), and diabetic patients (49%) than in men and counterparts free of the former conditions (p less than 0.005). In patients with AP the hospital course was more complicated and non-Q-wave AMI was more common than in counterparts without AP. In-hospital (16%), as well as 1 (8%)- and 5-year postdischarge (26%), mortality rates in hospital survivors were higher among patients with previous AP than in patients without previous AP (12%, 6%, and 19%, respectively) (p less than 0.01). After adjustment for age and all other predictors of increased hospital mortality rates in this cohort of patients, AP preceding AMI emerged as an independent predictor of increased hospital mortality rates (odds ratio 1.30; 90% confidence interval 1.10 to 1.53). For postdischarge mortality rates (mean follow-up 5 1/2 years), the covariate-adjusted relative risk of death in patients with AP was similar at 1.29 (p less than 0.0001; 90% confidence interval 1.16 to 1.44), according to estimation by Cox proportional hazards model. These data support the notion that preexisting AP identifies a group of patients at increased risk of death.

Long-term prognosis after acute myocardial infarction in patients with left ventricular hypertrophy on the electrocardiogram. SPRINT Study Group.

Among 4,720 consecutive hospital survivors from acute myocardial infarction (AMI) treated in 13 coronary care units between July 1981 and August 1983, the estimated prevalence of electrocardiographic left ventricular (LV) hypertrophy was 6.1%. The prevalence of electrocardiographic LV hypertrophy increased with age and was higher in patients with previous myocardial infarction, angina and systemic hypertension. Mean age of patients with electrocardiographic LV hypertrophy was 67.2 vs 61.4 years in counterparts free of electrocardiographic LV hypertrophy. Patients with electrocardiographic LV hypertrophy had a higher rate of congestive heart failure on admission, or developing during their stay in coronary care units. The 1- and 5-year mortality rates were 19.7 and 46.6% among patients with electrocardiographic LV hypertrophy versus 8.7 and 26.2%, respectively (p less than 0.001) in patients without this finding. The covariate-adjusted odds ratio of 1-year mortality was 1.88 for the presence of electrocardiographic LV hypertrophy when age alone was adjusted for, and 1.51 (90% confidence interval, 1.09 to 2.10) when multiple covariate adjustment was undertaken. After multiple covariate adjustment for 5-year mortality after discharge, the relative risk associated with electrocardiographic LV hypertrophy was 1.51 (90% confidence interval, 1.26 to 1.80). The results of the present study showed that the presence of electrocardiographic LV hypertrophy on the discharge electrocardiogram of survivors from AMI is associated with a 1.5-fold increase of short- and long-term mortality. Patients with electrocardiographic LV hypertrophy, potentially at an increased post-discharge risk, may be candidates for early noninvasive testing and more intensive follow-up after recovering from AMI.

Frequency of use of thrombolytic therapy in acute myocardial infarction in Israel.

Thrombolysis is now generally accepted as the initial treatment for patients with acute myocardial infarction (AMI). The extent to which this therapy is implemented in daily practice and the reasons for exclusion from thrombolytic therapy among 413 consecutive patients with AMI hospitalized in 18 coronary care units in Israel during a 1-month survey were prospectively investigated. Thrombolytic therapy administered to 145 patients (35%) was given to 38% of men versus 29% of women (p = not significant), to 38% of patients less than 75 years old compared with 18% of the very elderly (p less than 0.005), and more often to patients with a first or anterior AMI (40 and 48%) than to counterparts with recurrent or inferior AMI (23 and 31%, respectively, p less than 0.005 for both). The 2 most frequent reasons for excluding patients from thrombolysis were late arrivals to coronary care units (33%) and lack of ST elevation on the admission electrocardiogram (28%). Hospital mortality was 6% in the thrombolytic group versus 20% in patients found ineligible for thrombolysis. The significance of this difference is not clear as treatment was not randomized.

Cerebrovascular accident complicating acute myocardial infarction: incidence, clinical significance and short- and long-term mortality rates. The SPRINT Study Group.

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 follow-up 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 less than 0.01). In a multivariate analysis that included age, gender, congestive heart failure, history of previous myocardial infarction, and hypertension, CVA-TIA was independently associated with increased 15-day mortality (covariate-adjusted odds ratio [OR] = 2.62; 90% confidence interval [CI], 1.59 to 4.32), as well as subsequent 1-year (OR = 3.29; 90% CI, 1.70 to 6.36) and long-term (mean follow-up = 5.5 years) mortality (OR = 2.46; 90% CI, 1.30 to 4.69). CONCLUSION: In this large cohort of consecutive patients with myocardial infarction, CVA-TIA 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).

Haloperidol-induced torsades de pointes.

A patient had torsades de pointes ventricular tachycardia related to psychotherapy with haloperidol in conventional doses. The QT interval was prolonged, and shortened after the cessation of the medication and infusion of isoproterenol. Concomitantly, torsades de pointes bursts disappeared. The observation might contribute to the understanding of the mechanism of sudden death of patients during pharmacologic psychotherapy.