Acute Stress Disorder Symptoms Predict All-Cause Mortality Among Myocardial Infarction Patients: a 15-Year Longitudinal Study.

BACKGROUND: Studies have recognized myocardial infarction (MI) as a risk for acute stress disorder (ASD), manifested in dissociative, intrusive, avoidant, and hyperarousal symptoms during hospitalization. PURPOSE: This study examined the prognostic role of ASD symptoms in predicting all-cause mortality in MI patients over a period of 15 years. METHODS: One hundred and ninety-three MI patients filled out questionnaires assessing ASD symptoms during hospitalization. Risk factors and cardiac prognostic measures were collected from patients' hospital records. All-cause mortality was longitudinally assessed, with an endpoint of 15 years after the MI. RESULTS: Of the participants, 21.8 % died during the follow-up period. The decedents had reported higher levels of ASD symptoms during hospitalization than had the survivors, but this effect became nonsignificant when adjusting for age, sex, education, left ventricular ejection fraction, and depression. A series of analyses conducted on each of the ASD symptom clusters separately indicated that-after adjusting for age, sex, education, left ventricular ejection fraction, and depression-dissociative symptoms significantly predicted all-cause mortality, indicating that the higher the level of in-hospital dissociative symptoms, the shorter the MI patients' survival time. CONCLUSION: These findings suggest that in-hospital dissociative symptoms should be considered in the risk stratification of MI patients.

Recent temporal trends in the presentation, management, and outcome of women hospitalized with acute coronary syndromes.

BACKGROUND: Few data exist on the recent trends in the outcome of women hospitalized with acute coronary syndrome. We examined temporal trends in the hospital management and outcomes of women hospitalized with acute coronary syndrome in a real-world setting. METHODS: We evaluated time-dependent changes in the clinical characteristics, management strategies, and outcomes of women enrolled in the Acute Coronary Syndrome Israeli Surveys (ACSIS) between 2000 and 2010. Periods were categorized as early (2000-2004) and late (2006-2010). RESULTS: Among 11,536 patients enrolled in ACSIS, 2710 (24%) were women. Frequency of women presenting with acute coronary syndrome had declined from 25% in 2000 to 22% in 2010 (P for trend = .002). Women presented less frequently with ST-elevation myocardial infarction and more frequently with associated comorbidities (P < .001 for both). There was no significant reduction in the time delay from symptom onset to emergency department between early and late periods (median: 128 vs 125 minutes; P = .86). This was further reflected in no increase in the frequency of women meeting the goal of door-to-balloon time of ≤90 minutes. The utilization of evidence-based cardiovascular therapies had increased significantly over the past decade (P < .001 for all). After multivariate adjustment, admission in the late surveys was associated with a significant reduction in 30-day major adverse cardiac events and 1-year mortality (hazard ratio 0.76; 95% confidence interval, 0.65-0.9, and 0.73; 0.59-0.89, respectively). CONCLUSIONS: Despite increased frequency of comorbidities and lack of change in time to admission among women hospitalized with acute coronary syndrome, temporal change in management strategies over the last decade may have contributed to improved outcomes in this population.

Multidisciplinary rehabilitation program in recently hospitalized patients with heart failure and preserved ejection fraction: rationale and design of a randomized controlled trial.

BACKGROUND: Heart failure with preserved ejection fraction (HFpEF) comprises a large portion of heart failure patients and portends poor prognosis with similar outcome to heart failure with reduced ejection fraction (HFrEF). Thus far, no medical therapy has been shown to improve clinical outcome in this common condition. TRIAL DESIGN: The study is a randomized-controlled, multicenter clinical trial aimed to determine whether early posthospitalization comprehensive cardiac rehabilitation (CR) including exercise training (ET) in recently hospitalized HFpEF patients reduces the composite end point of all-cause mortality and hospitalizations in comparison with usual care (UC). After undergoing baseline evaluation, patients are randomized to either UC or to ambulatory comprehensive CR program. Patients in the CR arm will participate in a 6-month biweekly ET program according to a predefined protocol, in addition to a complementary home exercise prescribed by a specialist in CR. Exercise training will include endurance and low-intensity resistance training. Patients in the UC arm will be followed up at the outpatient clinic, with management according to current heart failure guidelines. Physician follow-up visits will be conducted at 3, 6, and 12 months for assessment of adherence to therapy and ET, functional status, quality of life, and clinical events. Secondary end points will include quality-of-life questionnaire, economic end points, blood pressure, and hemoglobin A1C levels. CONCLUSIONS: Cardiac rehabilitation and ET are relatively inexpensive and accessible and can be beneficial in HFpEF patients. Our trial is designed to evaluate the impact of early posthospitalization comprehensive rehabilitation program on clinical end points of mortality, hospitalization, and quality of life in HFpEF patients.

Healthcare associated infective endocarditis: a distinct entity.

The terms hospital- and community-acquired infections do not cover any longer the full spectrum of acquisition of infection. Consequently, the term healthcare associated infection (HCA) has been recently introduced. In order to examine the applicability of 'HCA infection' to patients with infective endocarditis (IE), 125 episodes of culture-positive IE were categorized into 3 groups of acquisition. 14 (11%) of 125 episodes were defined as hospital acquired (HA) IE (onset of more than 72 h after admission), 52 (42%) as HCA (IE on admission in patients with significant previous healthcare contact), and 59 (47%) as community acquired (CA) (IE on admission in people without recent healthcare contact). 41 (77%) of the 53 causative agents in the HCA IE group were typical nosocomial pathogens, whereas these types of pathogens constituted only 22% (14/64) of the microorganisms in the group of CA IE (p<0.0001). Mortality in the HA and HCA groups combined was significantly higher than that in the CA group (19/62, 31%, vs 6/59, 10%, p=0.01). HCA IE should be recognized as a distinct category that constitutes a large proportion of all cases of IE. HCA IE is significantly different from CA IE and, therefore, may require a different therapeutic approach.

Cardiac dysfunction in patients with systemic lupus erythematosus and antiphospholipid syndrome.

OBJECTIVE: To comparatively assess the parameters of systolic and diastolic cardiac function in patients with systemic lupus erythematosus (SLE) and antiphospholipid syndrome (APS). METHODS: Consecutive patients (n=74) who were free of cardiovascular symptoms were divided into four groups: (1) SLE (n=23); (2) SLE with antiphospholipid antibodies (aPL; n=18); (3) SLE with APS (n=20); and (4) primary antiphospholipid syndrome (PAPS; n=13). Pulsed, continuous, colour Doppler echocardiography, and M-mode and B-mode studies were performed. RESULTS: Left ventricular end diastolic and end systolic dimensions were higher in SLE as compared with patients with PAPS (p=0.022 and 0.022, respectively), with a trend towards a lower fractional shortening in SLE (p=0.07), suggesting systolic dysfunction. Parameters of diastolic function were more impaired in patients with APS, reflected by lower left ventricular and right ventricular E wave to A wave (E:A) ratios in patients with APS (groups 3, 4) compared with those without APS (groups 1, 2; 1.15 (0.40) v 1.49 (0.43), p=0.001 and 1.19 (0.31) v 1.49 (0.41), p=0.001, respectively) and a more prolonged left ventricular isovolumic relaxation time (IVRT; 94.2 (24.6) v 84.4 (17) ms, respectively, p=0.055). Patients with APS were older than those without APS (47.12 (14.86) v 34.29 (12.6), p=0.0001). Patients with SLE were younger than those with PAPS (38.19 (14.68) v 48.53 (13.97), p=0.023). CONCLUSION: Abnormal echocardiographic findings were detected frequently in asymptomatic patients with SLE or PAPS. Although patients with SLE were younger, left ventricular systolic function was more impaired in patients with SLE compared with those with PAPS, whereas left ventricular and right ventricular diastolic function, as reflected by IVRT and E:A ratios, were significantly more impaired in patients with APS.

Effects of losartan + L-arginine on nitric oxide production, endothelial cell function, and hemodynamic variables in patients with heart failure secondary to coronary heart disease.

The purpose of the present study was to evaluate the effects of losartan and the combination of losartan and L-arginine on endothelial function and hemodynamic variables in patients with heart failure (HF). Endothelium-dependent vasodilation is impaired in patients with HF. It was hypothesized that the administration of losartan and the combination of losartan and L-arginine might increase nitric oxide production and have a beneficial additive effect on endothelial function and hemodynamic variables in patients with HF. Nine patients with HF (ejection fraction<35%) were given losartan 50 mg orally on 2 consecutive days. On the second day, 1 hour after losartan 50 mg administration, L-arginine 20 g was given by intravenous infusion. Endothelial function in the form of endothelium-dependent brachial artery flow-mediated vasodilation (FMV) was measured by ultrasound. Hemodynamic variables were estimated using Doppler echocardiography at baseline and at 2 and 4 hours after losartan alone and after combination therapy. Urinary levels of nitrite (NO2) or nitrate (NO3) were measured. Four hours after losartan administration, significant reductions in systemic vascular resistance and estimated end-systolic elastase were observed. On the second day, 1 hour after L-arginine infusion, an additive hemodynamic effect was observed, with significant increases in the cardiac index and stroke volume and significant reductions in systemic vascular resistance and calculated left ventricular end-diastolic pressure. A trend toward improved FMV was observed with losartan alone, but without statistical significance. Combination therapy significantly improved postintervention FMV compared with baseline. The increase in urinary nitric oxide excretion after losartan treatment and combination therapy was significantly correlated with improved hemodynamic variables and improved FMV. In conclusion, losartan induces significant afterload reduction, reduced contractility, and increased nitric oxide urinary excretion. The combination of L-arginine and losartan seems to have superior effects on hemodynamic variables and endothelium-dependent vasodilation compared with losartan alone.

Trajectories of posttraumatic stress disorder following myocardial infarction: a prospective study.

BACKGROUND: This study examines the trajectories of posttraumatic stress disorder (PTSD) following myocardial infarction (MI). More specifically, it has 2 aims: (1) to examine whether the trajectory of PTSD is predicted by level of threat and the nature of initial reactions and (2) to examine the associations between the trajectory of PTSD and anxiety, somatization, health-related quality of life, and hospitalization 7 months following MI. METHOD: 116 MI patients were examined twice. At time 1, within a week of the patient's MI, acute stress disorder (ASD) was assessed and medical measures were obtained from patients' hospital records. At time 2, 7 months later, PTSD, anxiety, physical residuals, and health-related quality of life were assessed. Data were gathered in 1999. RESULTS: Six percent of the respondents had both ASD and PTSD, 10% did not have ASD but did have PTSD, and 12% had ASD but not PTSD. The trajectory of PTSD was associated with severity of anxiety, somatic complaints, and health-related quality of life. In addition, while the severity of MI did not predict the trajectory of PTSD, the perceived severity did. Patients without PTSD but with prior ASD did not differ in their initial reactions from those without ASD. CONCLUSION: These findings provide support for the considerable variability in the trajectory of the development of PTSD and suggest that although ASD is associated with subsequent PTSD, the predictive role of initial reactions is limited.