Atrial Fibrillation Ablation Success Rate - A Retrospective Multicenter Study.

Atrial fibrillation (AF) has become a major health and economic burden. Pulmonary veins isolation (PVI) based ablation for rhythm control of AF is well established. Furthermore, recent studies show its superiority over anti-arrhythmic therapy. However, most of these studies were performed in highly experienced centers, that may not necessarily reflect real world outcomes. We evaluated the outcome (success rate and complications) of 300 consecutive procedures, performed on 291 patients (during 2014-2015) of a major HMO. All had undergone PVI for AF by experienced electrophysiologists in 8 medical centers (85% RF technique). Data were retrospectively collected using computerized medical records. Variables included demographic and clinical characteristics, acute procedural success and complications, long term success rate based on multiple ECGs and Holter monitoring. The average age was 63 years, 61% were male, 79% had paroxysmal AF. Sinus rhythm at 2 years was considered success. The overall success rate of maintaining sinus rhythm at 2 years was 56%. Success rate correlated significantly with age and standard risk factors. Those patients in whom the index procedure was the first ablation, success rate was 78%. Sixty-one patients underwent a second ablation with success rate of 64%, 32 underwent a 3rd/4th procedure with success rate of 56%. The probability to be in sinus rhythm after 2 years regardless of the number of ablations was 78%. Thirty-five percent of the patients were still on anti-arrhythmic therapy at 2 years post procedure. Complication rate was 6.6% (2.5% serious), among them 2 deaths, 1 procedure related. PVI in a real-world large unselected population is a valid therapeutic option for AF with an overall 2-year success rate of 56%. In our group higher complication rate was observed compared to the reported rate in the literature. The use of cryo-ablation for PVI and further improvements in both technique and experience may improve both efficacy and safety profile.

Appropriateness and complications of the use of spironolactone in patients treated in a heart failure clinic.

OBJECTIVES: The widespread use of spironolactone in patients with congestive heart failure (CHF) has resulted in side effects and complications. We analyzed a cohort of patients treated by a dedicated CHF team, in order to examine the tolerability and safety of spironolactone in clinical practice. METHODS: We retrospectively evaluated data on 157 patients who were followed by the Heart Failure clinic of whom 100 patients on maximal treatment (all on ß blockers, 99% on ACE inhibitors) received spironolactone. The complications following spironolactone use were defined as: hyperkalemia with serum K 5.2 mEq/l; creatinine 2.0 mg/dl; hyponatremia with serum Na 135 mEq/l, hypotension and side effects such as gynecomastia and abdominal pain. RESULTS: At 1 year follow-up 6 patients developed hyperkalemia (range 5.3-5.9), 4 of them had K>5.5 mEq/l. Two patients developed hyponatremia. Six patients stopped spironolactone for: 1-gynecomastia, 2-worsening renal failure and hyperkalemia, 2-hyperkalemia (5.9 mEq/l) and 1 for bradycardia. There was an increase in mean creatinine level at 1 year (1.12±0.35 vs. 1.21±0.38 mg/dl, p=0.02), however, no significant changes were found in GFR (99.9±33.5 vs. 65.7±27.7 ml min(-1)1.73 m(-2), p=ns) and potassium (4.5±0.4 vs. 4.6±0.5 mEq/l, p=ns). We found improvement of GFR by >10% in 19 patients and worsening by >10% in 38 patients. No patient was hospitalized or required urgent treatment for spironolactone-related side effects. CONCLUSIONS: In patients with CHF on optimal therapy with ACE inhibitors and ß blockers appropriate spironolactone use and close follow-up by a dedicated HF team can minimize the risk for adverse events and complications.

Atrial fibrillation and long-term prognosis in patients hospitalized for heart failure: results from heart failure survey in Israel (HFSIS).

AIMS: Atrial fibrillation (AF) and heart failure (HF) commonly coexist, and each adversely affects the other. The aim of the study was to prospectively evaluate the impact of AF and its subtypes on management, and early and long-term outcome of hospitalized HF patients. METHODS AND RESULTS: Data were prospectively collected on HF patients hospitalized in all public hospitals in Israel as part of a national survey (HFSIS). Atrial fibrillation patients were subdivided into intermittent and chronic AF subgroups. During March-April 2003, we enrolled 4102 HF patients, of whom 1360 (33.2%) had AF [600 (44.1%) intermittent, 562 (41.3%) chronic]. Patients with AF were older (76.9 +/- 10.5 vs. 71.7 +/- 12.6 years, P = 0.0001), males, with preserved LV systolic function. Crude mortality rates for AF patients were progressively and consistently higher during hospitalization and during the 4-year follow-up period, especially in the chronic AF group (P = 0.0001). After covariate adjustment, AF was associated with increased 1-year mortality [HR 1.19, 95% CI (1.03-1.36)]. CONCLUSION: AF was present in a third of hospitalized HF patients, and identified a population with increased mortality risk, largely due to co-morbidities.

Prevalence and significance of unrecognized renal insufficiency in patients with heart failure.

AIMS: Renal insufficiency (RI) is a strong predictor of adverse outcome in patients with heart failure (HF). We aimed to determine the prevalence of RI being unrecognized and its significance in patients hospitalized with HF. METHODS AND RESULTS: We analysed data from a prospective survey of 4102 hospitalized patients with HF. RI [defined as estimated glomerular filtration rate (eGFR) <60 mL/min/1.73 m2] was present in 2145 (57%) patients but, based on medical records, was unrecognized in 872 [41%, 95% confidence interval (CI) 39-43%] of them. Patients with unrecognized RI were more likely to be women, elderly, and with better functional class, compared with patients with recognized RI. In-hospital and 1 year mortality was significantly higher among patients with recognized and unrecognized RI compared with patients without RI: 6.5 and 7.1 vs. 2.1%, and 38.8 and 30.9 vs. 18.8% (P < 0.001), respectively. After adjustment, recognized and unrecognized RI comparably predicted increased in-hospital mortality: odds ratio (OR) and 95% CI of 2.34 (1.43-3.87), P < 0.001, and 2.30 (1.45-3.72), P < 0.001. After 1 year, recognized RI remained an independent predictor for mortality: OR 1.79 (1.45-2.20), P < 0.001, whereas there was a trend for increased mortality predicted by unrecognized RI: OR 1.22 (0.97-1.53), P = 0.08. CONCLUSION: A high proportion of RI remains unrecognized among hospitalized patients with HF. As co-morbid RI has important prognostic and therapeutic implications, patients with HF may benefit from routine assessment of GFR.

Bioactivity of beer and its influence on human metabolism.

Extracted total phenols, flavanols and flavonoids were measured in beer samples and their quality as antioxidants was measured by two modified antioxidant methods: the 2,2'-azinobis (3-ethylbenzothiazoline-6-sulfonate) radical cation (ABTS * +) and the beta-carotene-linoleate model system (beta-carotene). It was found that the antioxidant potential of beer was well correlated with flavanols and flavonoids and was slightly lower with total polyphenols (R2 values from 0.8203 to 0.9393). Forty-two male non drinkers, hypercholesterolaemic volunteers ages 43-71 after coronary bypass surgery, were randomly divided into experimental (EG) and control (CG) groups, each of 21 participants. The antiatherosclerotic diet of the EG group was supplemented for 30 consecutive days with 330 ml beer per day. Could short-term beer consumption affect not only the risk factors of coronary atherosclerosis, but also the markers of this process: plasma albumin and its antioxidant activity? For this goal, total cholesterol, low-density lipoprotein cholesterol, high-density lipoprotein cholesterol, triglycerides, plasma albumin and fibrinogen, and the antioxidant activity were determined. After the trial a significant improvement in the plasma lipid levels, and an increase in the plasma antioxidant and anticoagulant activities in patients of the EG group was registered. A parallel increase in the plasma albumin concentration and its antioxidant activity was observed. In conclusion, short-term beer consumption on the basis of the bioactivity of the beverage positively affects plasma lipid levels, plasma antioxidant and anticoagulant activities. The increase in the plasma albumin concentration and its antioxidant activity could be the markers of atherosclerosis status.

The management, early and one year outcome in hospitalized patients with heart failure: a national Heart Failure Survey in Israel--HFSIS 2003.

BACKGROUND: Despite improved management of heart failure patients, their prognosis remains poor. OBJECTIVES: To characterize hospitalized HF patients and to identify factors that may affect their short and long-term outcome in a national prospective survey. METHODS: We recorded stages B-D according to the American College of Cardiology/American Heart Association definition of HF patients hospitalized in internal medicine and cardiology departments in all 25 public hospitals in Israel. RESULTS: During March-April 2003, 4102 consecutive patients were recorded. Their mean age was 73 +/- 12 years and 57% were males; 75.3% were hypertensive, 50% diabetic and 59% dyslipidemic; 82% had coronary artery disease, 33% atrial fibrillation, 41% renal failure (creatinine > or = 1.5 mg/dl), and 49% anemia (hemoglobin < or = 12 g/dl). Mortality rates were 4.7% in-hospital, 7.6% at 30 days, 18.7% at 6 months and 28.1% at 12 months. Multiple logistic regression analysis revealed that increased 1 year mortality rate was associated with NYHA III-IV (odds ratio 2.07, 95% confidence interval 1.78-2.41), age (for 10 year increment) (OR 1.41, 95% CI 1.31-1.52), renal failure (1.79, 1.53-2.09), anemia (1.50, 1.29-1.75), stroke (1.50, 1.21-1.85), chronic obstructive pulmonary disease (1.25, 1.04-1.50) and atrial fibrillation (1.20, 1.02-1.40). CONCLUSIONS: This nationwide heart failure survey indicates a high risk of long-term mortality and the urgent need to develop more effective management strategies for patients with heart failure discharged from hospitals.

Late mortality and determinants in patients with heart failure and preserved systolic left ventricular function: the Israel Nationwide Heart Failure Survey.

BACKGROUND: Heart failure with preserved systolic left ventricular function is a major cause of cardiac disability. OBJECTIVES: To examine the prevalence, characteristics and late clinical outcome of patients hospitalized with HF-PSF on a nationwide basis in Israel. METHODS: The Israel nationwide HF survey examined prospectively 4102 consecutive HF patients admitted to 93 internal medicine and 24 cardiology departments in all 25 public hospitals in the country. Echocardiographic LV function measurements were available in 2845 patients (69%). The present report relates to the 1364 patients who had HF-PSF (LV ejection fraction > or = 40%). RESULTS: Mortality of HF-PSF patients was high (in-hospital 3.5%, 6 months 14.2%, 12 months 22.0%), but lower than in patients with reduced systolic function (all P < 0.01). Mortality was higher in patients with HF as the primary hospitalization diagnosis (16.0% vs. 12.5% at 6 months, P = 0.07 and 26.2% vs. 18.0% at 12 months, P = 0.0002). Patients with HF-PSF who died were older (78 +/- 10 vs. 71 +/- 12 years, P < 0.001), more often female (P = 0.05) and had atrial fibrillation more frequently (44% vs. 33%, P < 0.01). There was also a relationship between mortality and pharmacotherapy: after adjustment for age and co-morbid conditions, mortality was lower in patients treated with angiotensin-converting enzyme inhibitors (P = 0.0003) and angiotensin receptor blockers (P = 0.002) and higher in those receiving digoxin (P = 0.003) and diuretic therapy (P = 0.009). CONCLUSIONS: This nationwide survey highlights the very high late mortality rates in patients hospitalized for HF without a decrease in systolic function. The findings mandate a focus on better evidence-based treatment strategies to improve outcome in HF-PSF patients.

[Brugada syndrome--unique ECG pattern].

In 1992, the Brugada brothers, cardiologists from Spain, described 8 patients who survived sudden cardiac death and had a unique ECG pattern. Electrocardiographically characterized by a distinct ST-segment elevation in the right precordial leads. The syndrome is associated with a high risk for sudden cardiac death in young and otherwise healthy adults. Since then, thousands of cases were published. The syndrome is still under-diagnosed which has a serious implication on patient's prognosis. We described one patient who was misdiagnosed at the ER.

Red grapefruit positively influences serum triglyceride level in patients suffering from coronary atherosclerosis: studies in vitro and in humans.

The contents of the bioactive compounds in red and blond grapefruits and their influence on humans suffering from hypertriglyceridemia were studied. It was found that red grapefruit has a higher content of bioactive compounds and a higher antioxidant potential than blond grapefruit, determined by oxygen radical scavenging capacity, 1,1-diphenyl-2-picrylhydrazyl, carotenoid bleaching, and Folin-Ciocalteu assays. Fifty-seven hyperlipidemic patients, ages 39-72 years, after coronary bypass surgery, recruited from the Institute's pool of volunteers, were randomly divided into three equal in number (19) groups: two experimental (red and blond groups) and one control group (CG). During 30 consecutive days of the investigation the diets of the patients of the red and blond dietary groups were daily supplemented with one equal in weight fresh red or blond grapefruit, respectively. Before and after this trial, serum lipid levels of all fractions and serum antioxidant activity were determined. It was found that serum lipid levels in patients of the red and blond groups versus the CG after treatment were decreased: (a) total cholesterol, 6.69 versus 7.92 mmol/L, 15.5%, and 7.32 versus 7.92 mmol/L, 7.6%, respectively; (b) low-density lipoprotein cholesterol, 5.01 versus 6.29 mmol/L, 20.3%, and 5.62 versus 6.29 mmol/L, 10.7%, respectively; (c) triglycerides, 1.69 versus 2.32 mmol/L, 17.2%, and 2.19 versus 2.32 mmol/L, 5.6%, respectively. No changes in the serum lipid levels in patients of the CG were found. In conclusion, fresh red grapefruit contains higher quantities of bioactive compounds and has significantly higher antioxidant potential than blond grapefruit. Diet supplemented with fresh red grapefruit positively influences serum lipid levels of all fractions, especially serum triglycerides and also serum antioxidant activity. The addition of fresh red grapefruit to generally accepted diets could be beneficial for hyperlipidemic, especially hypertriglyceridemic, patients suffering from coronary atherosclerosis.

Adherence to guidelines for patients hospitalized with heart failure: a nationwide survey.

BACKGROUND: Despite significant advances in the therapy of heart failure, many patients still do not receive optimal treatment. OBJECTIVES: To document the standard of care that patients hospitalized with HF in Israel received during a 2 month period. METHODS: The Heart Failure Survey in Israel 2003 was a prospective 2 month survey of patients admitted to all 25 public hospitals in Israel with a diagnosis of HF. RESULTS: The mean age of the 4102 patients was 73 years and 43% were female. The use of angiotensin-converting enzyme/angiotensin receptor blockers and beta blockers both declined from NYHA class I to IV (68.8% to 50.6% for ACE-inhibitor/ARB and 64.1% to 52.9% for beta blockers, P < 0.001 for comparisons). The percentage of patients by NYHA class taking an ACE-inhibitor or ARB and a beta blocker at hospital discharge also declined from NYHA class I to IV (47.5% to 28.8%, P < 0.002 for comparisons). The strongest predictor of being discharged with an ACE-inhibitor or ARB was the use of these medications at hospital admission. Negative predictors for their usage were age, creatinine, disease severity class, and functional status. CONCLUSIONS: Despite the dissemination of guidelines many patients did not receive optimal care for HF. Reasons for this discrepancy need to be identified and modified.

Clinical effects of endothelin receptor antagonism with bosentan in patients with severe chronic heart failure: results of a pilot study.

BACKGROUND: Endothelin receptor antagonism produces favorable short-term hemodynamic effects in heart failure, but the clinical effects of longer term therapy have not been evaluated. METHODS AND RESULTS: Three hundred and seventy patients with symptoms of heart failure at rest or on minimal exertion and a left ventricular ejection fraction <35% were randomly assigned (double-blind) to placebo (n = 126) or the endothelin receptor antagonist bosentan, titrated slowly (n = 121) or rapidly (n = 123) to a target dose of 500 mg twice daily. Treatment with the study drug was to be maintained for 26 weeks, whereas background medications for heart failure were kept constant. Safety concerns led to early termination of the trial when only 174 patients had had an opportunity to complete 26 weeks of therapy. Bosentan exerted no apparent benefit when all randomized patients were analyzed (P = .709). However, in the first 174 patients who were recruited at least 26 weeks before study termination and who could therefore be followed for the planned duration of the trial, patients in the bosentan groups were more likely to be improved (26% versus 19%) and were less likely to be worse (28% versus 43%), P = .045. When compared with placebo-treated patients, bosentan-treated patients had a increased risk of heart failure during the first month of treatment but a decreased risk of heart failure during the fourth, fifth, and sixth months of therapy. The major noncardiac adverse effects of bosentan included an increase in hepatic transaminases (in 15.6% of patients) and a decrease in hemoglobin (of about 1 g/L). CONCLUSION: Although bosentan exerted no favorable effects in the overall study, our findings suggest that the clinical responses to endothelin antagonism with bosentan in patients with severe chronic heart failure may be dependent on the duration of treatment.

Reduced glomerular filtration rate in asymptomatic diabetic patients: predictor of increased risk for cardiac events independent of albuminuria.

OBJECTIVES: This study aimed to investigate the prevalence of a reduced glomerular filtration rate (GFR) with and without albuminuria and its ability to predict cardiac events in asymptomatic diabetic patients undergoing stress-rest thallium-201 myocardial perfusion single-photon emission computed tomography. BACKGROUND: Diabetic patients have a higher prevalence of asymptomatic coronary heart disease. Therefore, identifying predictors of cardiac events in asymptomatic diabetic patients is needed. METHODS: In 269 asymptomatic patients, baseline evaluation included diabetes-related complications, including creatinine clearance (CrCl) and albuminuria. During follow-up (mean 2.3 +/- 1.0 years), all cardiac events were recorded. RESULTS: Seventy-seven patients (29%) had a reduced GFR defined by CrCl <60 ml/min/1.73 m(2). Compared with the 177 patients with CrCl >/=60 ml/min/1.73 m(2), the reduced GFR group was older (p < 0.0001), had a longer duration of diabetes (p = 0.002), and had a higher prevalence of albuminuria (p = 0.04). Nevertheless, 35% of the reduced GFR group had normoalbuminuria. Patients with reduced GFR had a significant two-fold increase in total cardiac events (unstable angina, nonfatal myocardial infarction, and cardiac procedures) (25% vs. 13%, p = 0.019), and multivariate analysis found that reduced GFR was an independent predictor of cardiac events (odds ratio [OR] 2.2, 95% confidence interval [CI] 1.1 to 4.46). Other independent predictors of cardiac events included stress-induced abnormal myocardial perfusion imaging (OR 3.1, 95% CI 1.3 to 7.5), an electrocardiographic ischemic response (OR 2.7, 95% CI 1.01 to 7.14), and peripheral artery disease (OR 2.1, 95% CI 1.05 to 4.23); however, albuminuria was not. CONCLUSIONS: A reduced GFR was common in our group of asymptomatic diabetic patients and was associated with a two-fold increase in cardiac events. Multivariate analysis found that reduced GFR independent of albuminuria was a significant predictor of cardiac events.

Hemochromatosis mutations are not linked to dilated cardiomyopathy in Israeli patients.

AIMS: Hemochromatosis is a condition in which iron loading impairs the function of many organs, including the heart. Congestive heart failure with left ventricular dilatation is commonly found in patients with hemochromatosis. Two missense mutations (C282Y and H63D) have been shown to be responsible for the majority of cases of hemochromatosis. METHODS AND RESULTS: We examined 156 patients with congestive heart failure due to dilated cardiomyopathy. Details were recorded of clinical and echocardiographic parameters. DNA was extracted from peripheral blood and checked for the presence of the C282Y and H63D mutations by a commercially available single nucleotide primer extension assay. A control group of 98 healthy blood donors was also checked for the presence of these mutations. Of the 157 patients, 42 (26.75%) had at least one mutation. Five (3.65%) were homozygotic for the H63D mutation and 37 (23.6%) were heterozygotic for the H63D mutation. The C282Y mutation was not present. In a control population of 98 healthy blood donors, 27 (27.6%) were heterozygous for the H63D population and none had the C282Y mutation (no significant difference between the patients with cardiomyopathy and the healthy blood donors, chi(2) test 0.754). There was a non-significant trend to a difference in the prevalence of homozygotic H63D between the cardiomyopathy patients and the healthy blood donors (3.18% vs. 0%, P=0.076, chi(2) test). There was no statistically significant difference between the cardiomyopathy patients with and without the mutations in terms of age, gender, hemoglobin, iron, transferrin, ferritin, presence of diabetes mellitus, hypertension and previous coronary artery bypass grafting. CONCLUSION: In our population of patients with dilated cardiomyopathy, there was no evidence for hemochromatosis being an important etiology.

Fresh israeli jaffa sweetie juice consumption improves lipid metabolism and increases antioxidant capacity in hypercholesterolemic patients suffering from coronary artery disease: studies in vitro and in humans and positive changes in albumin and fibrinogen fractions.

The contents of the bioactive compounds in the pummelo-grapefruit hybrid juice named Israeli Jaffa Sweetie and their influence on humans suffering from hypercholesterolemia were studied. It was found that Sweetie juice has a high content of bioactive compounds and a high antioxidant potential. Then 72 hypercholesterolemic patients, ages 43-71 years, after coronary bypass surgery recruited from the Institute pool of volunteers, were randomly divided into two experimental (EG1 and EG2) groups and one control (CG) group, each comprising 24 patients. The diets of EG1 and EG2 patients were daily supplemented with 100 or 200 mL of fresh Sweetie juice, respectively. Before and after diet consumption serum lipid levels, albumin and fibrinogen fractions, and their antioxidant capacities were determined. After 30 consecutive days of Sweetie juice supplemented diets, improvements in serum lipids levels were found in EG1 and EG2 versus CG: (a) total cholesterol, 7.34 versus 8.02 mmol/L, -9.5%, and 6.73 versus 8.02 mmol/L, -16.1%, respectively; (b) low-density lipoprotein cholesterol, 5.63 versus 6.37 mmol/L, -11.6%, and 5.03 versus 6.37 mmol/L, -21.0%, respectively; (c) total glycerides, 2.01 versus 2.27 mmol/L, -11.5%, and 1.71 versus 2.27 mmol/L, -24.7%, respectively. Serum albumin concentration was increased but not significantly in EG1 and EG2 versus CG: 47.5 versus 44.5 g/L, +6.7%, and 47.9 versus 44.5 g/L, +7.6%, respectively. A significant increase in the serum, albumin, and fibrinogen antioxidant capacities in EG2 and to a lesser degree in EG1 was observed. No changes in the CG were found. In conclusion, fresh Sweetie juice contains high quantities of bioactive compounds and has a high antioxidant potential. Diet supplemented with this juice positively influences serum lipid, albumin, and fibrinogen levels and their antioxidant capacities. Addition of fresh Sweetie juice to generally accepted diets may be beneficial for hypercholesterolemic patients.

Preventive effects of diets supplemented with sweetie fruits in hypercholesterolemic patients suffering from coronary artery disease.

BACKGROUND: Diets rich in vegetables and fruits prevent development of atherosclerosis. OBJECTIVE: To investigate the preventive effects of diets supplemented with a new kind of citrus fruit-pummelo-grapefruit hybrid in hypercholesterolemic patients suffering from coronary artery disease (CAD). SUBJECTS AND METHODS: Sixty-six hypercholesterolemic volunteers after coronary bypass surgery ages 47-68 years were randomly divided into two experimental (EG1 and EG2) groups and one control (CG) group, 22 each. The diets of the patients of the experimental groups (EG1 and EG2) were supplemented with one or two peeled sweeties, respectively. A comprehensive clinical investigation of all 66 patients was done. Blood samples were collected before and after the investigation for a wide range of laboratory tests. RESULTS: A high content of dietary fibers and antioxidant compounds in peeled sweeties was found. After 30 days of the investigation, peeled sweeties-supplemented diets have decreased plasma lipids levels in EG1 and EG2 vs. CG group: (a) total cholesterol (TC)-7.38 vs. 8.08 mmol/L, - 8.7%, and 6.78 vs. 8.08. mmol/L, -16.1%, respectively; (b) low-density lipoprotein cholesterol (LDL-C)-5.65 vs. 6.39 mmol/L, - 1.6%, and 5.04 vs. 6.39 mmol/L, -21.2%, respectively; (c) triglycerides (TG)-2.01 vs. 2.27 mmol/L, -11.5%, and 1.71 vs. 2.27 mmol/L, -24.7%, respectively. In addition, a significant increase in the plasma antioxidant capacity in EG2, and to a lesser degree in EG1 groups, was observed. No changes in the studied indices in the patients of the CG were detected. CONCLUSION: Peeled sweeties have high contents of dietary fibers and antioxidant compounds. Diets supplemented with peeled sweeties positively influence plasma lipid metabolism and plasma antioxidant capacity in patients suffering from hypercholesterolemia. Therefore, the addition of peeled sweeties to a generally accepted antiatherosclerotic diet may be beneficial in prevention of atherosclerosis, mainly in hypercholesterolemic patients.

Plasma circulating fibrinogen stability and moderate beer consumption.

MODERATE BEER CONSUMPTION (MBC) IS CARDIOPROTECTIVE: it positively influences plasma lipid levels and plasma antioxidant activity in beer-consuming individuals. The connection between MBC and blood coagulation is not clearly defined. Forty-two volunteers were equally divided into experimental (EG) and control (CG) groups following coronary bypass surgery. For 30 consecutive days, only patients of the EG consumed 330 mL of beer per day (about 20 g of alcohol). A comprehensive clinical investigation of 42 patients was done. Blood samples were collected before and after the investigation for a wide range of laboratory tests. The plasma fibrinogen was denatured with 8 M urea and intrinsic fluorescence (IF), hydrophobicity and differential scanning calorimetry (DSC) were used to reveal possible qualitative changes. After 30 days of moderate beer consumption, positive changes in the plasma lipid levels, plasma anticoagulant and plasma antioxidant activities were registered in patients of the EG group. In 17 out of 21 patients of the same group, differences in plasma circulating fibrinogen's (PCF), secondary and tertiary structures were found. The stability of fibrinogen, expressed in thermodynamic parameters, has shown that the loosening of the structure takes place under ethanol and urea denaturation. Also fluorescence stability of PCF was decreased. No changes in the lipid levels, anticoagulant and antioxidant activity or changes in PCF were detected in patients of CG. In conclusion, for the first time after a short term of moderate beer consumption some qualitative changes in the plasma circulating fibrinogen were detected: differences in the emission peak response, fluorescence intensity and all thermodynamic data. Together, with the decrease in the PCF concentration it may lead to an elevation of the blood anticoagulant activity.

Perioperative myocardial ischemia in patients undergoing sternectomy shortly after coronary artery bypass grafting.

UNLABELLED: Coronary revascularization reduces cardiac complications associated with noncardiac surgery in patients with severe coronary disease. However, patients undergoing emergency noncardiac surgery soon after coronary bypass operations may still be vulnerable to ischemic myocardial events. We prospectively evaluated the incidence of myocardial ischemia in 82 consecutive patents scheduled for sternectomy in the first (Group 1; 35 patients) or second (Group 2; 47 patients) week after coronary artery bypass graft (CABG) surgery. The interval between CABG surgery and sternectomy in Groups 1 and 2 was 6 days (range, 4-7 days) and 11 days (range, 8-14 days), respectively. Electrocardiographic (ECG) changes consistent with myocardial ischemia were assessed with a two-channel Holter system for 48 h. There were no between-group differences in updated Acute Physiology and Chronic Health Evaluation score, use of beta-blockers, or perioperative hemodynamic changes. The incidence of ECG changes consistent with myocardial ischemia was fivefold more frequent in Group 1 (22.85% versus 4.25%; P < 0.05). Of the ischemic patients in Group 1, 25% experienced a perioperative acute myocardial infarction (one was fatal). There were no infarcts in Group 2. Thus, patients appear to be prone to coronary events during sternectomy performed early after CABG surgery. Although the incidence of ischemia did not differ from that previously reported after CABG surgery alone, further investigation is required to determine whether the findings obtained in this high-risk population are generalizable to patients undergoing noncardiac surgery soon after uneventful CABG surgery. IMPLICATIONS: This study demonstrates an increased incidence of myocardial ischemia when sternectomy for mediastinitis is performed within one week of coronary artery bypass graft surgery, and this ischemia is associated with a 25% incidence of myocardial infarction.

Improvement in mitral regurgitation after aortic valve replacement.

BACKGROUND: Concomitant mitral valve regurgitation is often present in patients with aortic stenosis. The additional MV replacement is associated with high operative risk. Previous studies have shown an amelioration of MV regurgitation after aortic valve replacement but most of the patient groups were heterogenous. OBJECTIVES: To determine whether AV replacement for aortic stenosis has any effect on MV regurgitation. METHODS: We reviewed two-dimensional echocardiography and color flow Doppler assessment of both aortic stenosis and MV regurgitation severity in 30 patients. Patients with previous MV surgery, organic MV disease, occlusive carotid artery disease, ejection fraction < 50%, and coexisting significant AV regurgitation were excluded. Preoperatively, MV regurgitation was mild in 23 patients (77%) and moderate in 7 (23%); in no patient was the condition severe. All patients had severe atrial stenosis (peak average aortic gradient 86 +/- 22 mmHg in the mild MV regurgitation group and 83 +/- 26 mmHg in the moderate group). The patients were divided into two groups according to the severity of MV regurgitation (associated mild, and moderate). Group 2, with moderate MV regurgitation, was the most problematic in terms of decision making for concomitant MV surgery. Therefore, additional assessment of several parameters was required. RESULTS: There was a significant decrease in MV regurgitation area (7.6 +/- 1.9 vs. 3.0 +/- 1.2 cm2, P < or = 0.012) and percent (28 +/- 5% vs. 12 +/- 6%, P < or = 0.001) between pre- and postoperative evaluation. Thus, the severity of the condition in all patients with moderate MV regurgitation decreased after AV replacement; in the mild group it remained unchanged in 53% or improved in 47%. There was no association between the preoperative gradient on the aortic valve and the degree of MV regurgitation. CONCLUSIONS: In our population of patients with severe atrial stenosis there were no patients with coexisting severe MV regurgitation. The decision to repair or replace a severely leaking mitral valve is an easy one, as in mild MV regurgitation. The clinical problem often presents in patients with severe aortic stenosis and moderate MV regurgitation. We believe that additional MV surgery is not necessary, at least in patients with preserved left ventricular function and without organic MV disease.

Structural changes in plasma circulating fibrinogen after moderate beer consumption as determined by electrophoresis and spectroscopy.

The effects of short-term moderate beer consumption (MBC) on plasma circulating fibrinogen (PCF) in patients suffering from coronary atherosclerosis were investigated by use of 2-dimensional electrophoresis (2-DE), circular dichroism (CD), and Fourier transform infrared spectroscopy (FT-IR). Forty-eight volunteers after coronary bypass surgery were divided into experimental (EG) and control (CG) groups, each of 24. Patients of the EG group consumed 330 mL of beer/day (about 20 g of alcohol) for 30 consecutive days, and CG volunteers drank mineral water instead of beer. Blood samples were collected before and after the experiment. In 21 out of 24 patients after beer consumption the plasma circulating fibrinogen was compromised: changes in its secondary structure were found. These changes were expressed in relatively low electrophoretic mobility and charge heterogeneity, decrease in alpha-helix and increase in beta-sheet, and in slight shift of amide I and II bands. Our findings indicate that one of the positive benefits of moderate beer consumption is to diminish the production of fibrinogen and its stability, which reduces the potential risk exerted by this protein. Thus, in most of beer-consuming patients some qualitative structural changes in plasma circulating fibrinogen were detected.