Low Cholesterol Levels in Younger Heart Failure Patients May Predict Unfavorable Outcomes.

Background and Objectives: Hypercholesterolemia is a main risk-factor leading to ischemic heart disease (IHD). However, among patients with heart failure, the use of lipid lowering drugs in the presence of low cholesterol might be dangerous. This 18-year longitudinal study of patients ≤51 years old investigated the relationship between baseline total cholesterol, low-density lipoprotein cholesterol (LDL-c) and triglyceride levels, and survival among patients with severe HF. Materials and Methods: The average NYHA score of 82 patients ≤51 years old with heart failure was 2.61. They were followed for a mean of 11.3 years (15 months-20 years). Total mortality was 22%. Patients were divided into three groups. Group 1 had plasma LDL-c levels ≤ 80 mg/dl, Group 2, 80-115 mg/dl and Group 3 > 115 mg/dl. Results: Patients with the highest baseline total cholesterol, triglyceride and LDL-c levels > 115 mg/dl had a better survival rate (83%) compared to those with LDL-c < 80 mg/dl (50% survival, p = 0.043). The association between higher LDL-c levels and lower mortality was most noticeable among patients with heart failure. Conclusion: Longitudinal follow-up found that low LDL-c levels may indicate poorer prognosis among patient with heart failure who are ≤51 years old, similar to elderly heart failure patients. Cholesterol lowering drugs in younger patients with heart failure may increase mortality.

Apolipoprotein E (APOE) Genotypes in the Israeli population.

BACKGROUND: APOE genotype strongly affects plasma lipid levels and risk for cardiovascular disease and cognitive decline. Studies of apo-e allelic and APOE genotype frequencies among several populations have revealed interesting ethnic variations that might affect cardiovascular morbidity and cognition deterioration. OBJECTIVES: To evaluate apo-e allelic frequency among Israeli newborns based on known variances in apo-e allelic frequencies in different countries. METHODS: We examined 498 consecutive neonates born at Tel Aviv Sourasky Medical Center. Umbilical cord blood was sampled for genotyping and lipids. Birth weights were recorded. Demographics and parental risk factors for atherosclerosis were obtained from the mothers. RESULTS: Most parents were native-born Israelis. Other countries of origin of grandparents were Morocco, Russia, and Iraq. The prevalence of APOE genotypes in Israel is APOE 2/2: 1.4%, APOE 2/3: 8.2%, APOE 3/3: 77.7%, and APOE 4/4: 11.8%. There were no associations of APOE genotype with parental country of origin. However, there was a tendency for APOE 3/4 to be more frequent in newborns of parents of Asian and African origin. Genotype 3/3 was more frequent in newborns whose parents came from Europe and America (78%) compared to those from Asia or Africa (69%). CONCLUSIONS: It is important to determine risk factors such as APOE genotype for evaluation of premature atherosclerosis. Determining genetic and environmental risk factors may facilitate earlier treatment and prevent heart and brain atherosclerosis. APOE genotypes did not appear to affect total cholesterol, low-density lipoprotein cholesterol, high-density lipoprotein cholesterol, or triglyceride levels in newborns.

Monitoring Pleural Effusion in Elderly Patients Using Internal Thoracic Impedance.

BACKGROUND: Internal thoracic impedance (ITI) measurement is a sensitive method for detecting preclinical pulmonary edema and pleural effusion. OBJECTIVES: To investigate the efficacy of this non-invasive method for detecting early pleural effusion among geriatric patients and to monitor increased ITI during its resolution. METHODS: This prospective, controlled study was conducted between July 2012 and August 2015. The study comprised 70 patients aged 65 to 94 years; and 39 of the patients had pleural effusion. ITI was measured continuously with a RS-207 monitor. The predictive value of ITI monitoring was determined based on a total of eight measurements taken at 12-hour intervals over 84 hours. RESULTS: As a result of medical treatment, the median ITI of the study group increased from 31 (interquartile range [IQR] 28-33 ohms) to 41 ohms (IQR 38-41 ohms; P < 0.001) compared to non-significant changes in the control group. Average respiratory rate (per minute) in the study group decreased from 29 (IQR 28-34) to 19 (IQR 18-20). CONCLUSIONS: ITI monitoring is efficient for diagnosis and for ongoing clinical evaluation of the treatment of elderly patients with pleural effusion. Timely treatment may prevent serious complications of effusions avoiding extended hospitalization.

Resolution of Cannabinoid Hyperemesis Syndrome with Benzodiazepines: A Case Series.

BACKGROUND: Cannabinoid hyperemesis syndrome (CHS) is under-recognized by clinicians. It is characterized by nausea, severe abdominal pain, and cyclical vomiting in the context of chronic cannabis use. Oral benzodiazepine is a proposed treatment for CHS. It decreases activation of Cannabinoid Type 1 Receptor (CB1) in the frontal cortex, has a sedative and hypnotic effect and reduces the anticipation of nausea and vomiting. These effects on the central nervous system (CNS) might explain its beneficial antiemetic effect for this syndrome. OBJECTIVES: To increase the index of suspicion for CHS, a unique syndrome that requires a unique treatment with benzodiazepines and not antiemetics. METHODS: We describe a series of four patients with documented cannabis use, who were admitted to an internal medicine department of Meir Medical Center due to symptoms consistent with abdominal pain, nausea, and vomiting. They were initially treated with conventional antiemetics and proton pump inhibitors without response. Intensive investigations were conducted to exclude common and sometimes urgent gastrointestinal or CNS syndromes. RESULTS: After excluding urgent gastrointestinal and CNS origins for the vomiting, we suspected CHS. All four patients experienced similar symptoms and failure of conventional treatment with antiemetics and proton pump inhibitors. They experienced relief after administration of benzodiazepines. CONCLUSIONS: A high index of suspicion for CHS allows for rapid, appropriate treatment with benzodiazepines, which in turn may lead to cessation of the debilitating symptoms caused by this syndrome.

Efficacy and safety of the dietary supplement DBCare® in patients with type 2 diabetes mellitus and inadequate glycemic control.

AIMS: DBCare® (Ace Continental Exports Inc., London, UK) is a traditional Indian herbal food supplement marketed as an antidiabetes remedy. This study evaluated the efficacy and safety of DBCare in patients with inadequately controlled type 2 diabetes mellitus (T2DM) despite oral hypoglycemic treatment. METHODS: A 12-week randomized double-blind placebo-controlled trial was conducted. Patients with T2DM on oral hypoglycemic agents with HbA1C > 7.0% were randomized to receive DBCare or placebo tablets. RESULTS: Thirty-five patients (20 male/15 female; mean age 61.2 ± 7.6 years), with a mean baseline HbA1C of 7.9% ± 0.6%, received DBCare (N = 18) or placebo (N = 17). During the study period, HbA1C declined 0.4 ± 0.7% in the DBCare® group and 0.2% ± 0.8% in the placebo group (p = 0.806). No significant changes occurred in fasting plasma glucose, lipid profile, or homeostasis model assessment throughout the study or in body mass index, waist circumference, or blood pressure values. Hypoglycemic episodes (glucose < 70 mg/dL) were more frequent in the treatment group (7 vs 1, p = 0.043), necessitating a decrease in other hypoglycemic medications in 2 patients. DBCare was generally well tolerated, with mild side effects that were not different from those of the placebo group. CONCLUSIONS: This preliminary study did not demonstrate that DBCare was efficacious in improving glycemic control in inadequately controlled patients with T2DM on oral hypoglycemics. A trend toward improved glycemic control was noted in the DBCare group, which correlates with more frequent hypoglycemic episodes. Further studies are needed to elucidate DBCare's hypoglycemic effect in patients with T2DM in general and in specific clinical settings, such as HbA1C ≥ 8%, short (≤10-year) duration of diabetes, or young age in particular.

Low levels of low-density lipoprotein cholesterol: a negative predictor of survival in elderly patients with advanced heart failure.

OBJECTIVES: There are conflicting reports on the role of cholesterol as an adverse prognostic predictor in patients with heart failure (HF). This study aimed to examine the impact of low levels of low-density lipoprotein cholesterol (LDL-c) on cardiac mortality in a cohort of elderly patients with moderate and severe HF. METHODS: Chronic HF patients from the HF Unit at the Tel-Aviv Medical Center (n = 212, 77% males) with an average NYHA classification of 2.8, a mean age of 76.9 ± 7.3 years (range 66-91) and a mean follow-up of 3.7 years were consecutively enrolled. The cohort was divided into tertiles according to LDL-c levels: LDL <90 mg/dl (group 1), LDL 90-115 mg/dl (group 2) and LDL >115 mg/dl (group 3). RESULTS: The Cox regression analysis revealed that group 3 patients had the best outcome (p = 0.01 vs. groups 2 and 3), with 58% of them surviving longer than 50 months compared to 34% in group 1. The same trend was seen in the group of patients suffering from ischemic cardiomyopathy and in patients who were treated by statins (p = 0.04). CONCLUSION: Low LDL-c levels are associated with a reduced survival in elderly patients with clinically controlled moderate and severe HF.

Lymphocyte to White Blood Cell Count Ratio an Independent Risk Factor for Heart Failure.

OBJECTIVE: Heart failure affects 1-2% of the population in developed countries. Hemogram biomarkers are cheap, rapid, readily accessible and are known to have prognostic benefit in cardiovascular, infectious and oncologic diseases. METHODS: The aim of the current study is to evaluate lymphocyte-to-white-blood-cell ratio (LWR) as a prognostic predictor in patients with heart failure. Patients with heart failure were recruited between January 2000 and July 2001. Exclusion criteria included metastatic malignancy, exposure to chemotherapy, radiotherapy or medications known to affect complete blood count. RESULTS: 338 patients were enrolled, 33 were excluded. Mean age was 70.1 ± 10.8, 225 patients were male (73%) and 80 were female (27%). All patients were divided into three groups according to LWR. Group 1 < 0.2, group 2-0.2 < LWR < 0.35 and group 3 > 0.35. Patients with LWR ratio < 0.2 had the poorest survival while patients in the highest LWR (ratio > 0.35) had the best long-term survival. CONCLUSIONS: Patients with congestive heart failure and LWR < 0.2 showed significant increased mortality. LWR was shown as independent prognostic predictor for HF patients compared to other main outcome parameters, including CRP, NYHA, EF and LDL.

Peripheral Vascular Disease and Carotid Artery Disease Are Associated with Decreased Bile Acid Excretion.

Low bile acid excretion (BAE) is associated with a higher risk of coronary artery disease (CAD) and cerebrovascular disease (stroke). This study investigated BAE in patients with peripheral vascular disease (PVD) and carotid artery disease (CA) and those without these diseases, compared to patients with CAD, stroke, or no evidence of atherosclerosis. Patients with complaints of chest pain-suspected CAD, syncope, stroke/TIA, severe headache, intermittent claudication, or falls were enrolled. All received a 4-day standard diet with 490 mg of cholesterol and internal standard copper thiocyanate. Fecal BAE was measured using gas-liquid chromatography. One hundred and three patients, sixty-eight (66%) men and thirty-five women (34%), mean age range 60.9 ± 8.9 years, were enrolled in this prospective, 22-year follow-up study. Regression analysis showed that advanced age, total BAE, and excretion of the main fractions were the only significant independent factors that predicted prolonged survival (p < 0.001). Twenty-two years' follow-up revealed only 15% of those with BAE <262.4 mg/24 h survived, compared to >60% of participants without atherosclerosis and a mean BAE of 676 mg/24 h. BAE was lower in patients with polyvascular atherosclerosis than in those with involvement of 1-3 vascular beds. Pearson correlations were found between total BAE and various fractions of BA, as well as HDL cholesterol. BAE and short-term survival were decreased among patients with PVD compared to those with CAD or stroke. Low BAE should be considered a valuable and independent risk factor for PVD.

Usefulness of cardiac biomarkers for prognosis of better outcomes in chronic heart failure: Retrospective 18-year follow-up study.

ABSTRACT: Brain natriuretic peptide is an established, surrogate follow-up marker, strongly correlated with heart failure severity. Several other biomarkers and tests are useful for assessing the prognosis of patients with HF, such as oxidized low-density lipoprotein antibodies and C-reactive protein. Some inflammatory cells, including monocytes, lymphocytes, and neutrophils, are involved in coronary heart disease and may be useful for prognosis also. This study assessed the potential usefulness of various laboratory biomarkers in predicting long-term outcomes and hospitalization among a cohort of outpatients with chronic, advanced HF.This retrospective, 18-year follow-up study included all patients admitted to the Heart Failure Outpatient Unit in our tertiary care medical center from 2000 through 2001 due to chronic HF. Excluded were patients with malignant disease, severe stroke, active inflammatory disease, or infection. At the first visit, blood was sampled for routine analysis and biomarkers NT-proBNP, C-reactive protein, myeloperoxidase, heat shock protein, and antibodies to oxidized low density lipoprotein. left ventricular ejection fraction and New York Heart Association class class were also established. Patients were followed every 3 months. Study endpoints were mortality or first hospitalization.Among 305 study patients, HF duration ranged from 2 months to 18 years. Mean follow-up was 9.1 ±â€Š6 years. Mean time to first hospitalization was 60 ±â€Š58.1 months, median = 38 (range 0-179). Mortality rate was 41%. Regression analysis showed New York Heart Association class, lymphocyte count and alkaline phosphatase were independent predictors of survival, with hazard ratios of 1.0, 0.973, and 1.006, respectively (P < .05).N-terminal pro-B-type natriuretic peptide, alkaline phosphatase, and lymphocyte count are important prognostic predictors for very long-term follow-up among patients with chronic HF.

Using the Gensini score to estimate severity of STEMI, NSTEMI, unstable angina, and anginal syndrome.

ABSTRACT: Gensini score (GS) provides valuable information on severity and prognosis of coronary artery disease (CAD).To evaluate the relationship between the severity of CAD determined by the GS and relation to ST-elevation myocardial infarction, non-ST segment elevation myocardial infarction (NSTEMI), unstable angina pectoris, chest pain (suspected angina syndrome on admission) and risk-factors for CAD and predictors of severity.Observational cross-sectional study.Consecutive patients who underwent clinically-indicated coronary angiography for ST-elevation myocardial infarction, NSTEMI, unstable angina pectoris or chest pain were enrolled.Among 600 patients, 417 (average age 67.8 ±â€Š12.2 years) had CAD-related symptoms. Mean GS was 66.7 ±â€Š63.8. Patients presenting with NSTEMI had the highest GS (81.3 ±â€Š42.3; P < .001) Regression analysis of risk-factors showed the best association of GS with multivessel disease and coronary artery bypass graft. Regression analysis of medications showed that clopidogrel, had the best association with low GS.GS correlated with the severity of CAD, multivessel disease, coronary artery bypass graft, and troponin. GS was related to the cardiovascular risk-factors of diabetes, hypertension, and high-density cholesterol.

Methylphenidate has mild hyperglycemic and hypokalemia effects and increases leukocyte and neutrophil counts.

Various psychotropic drugs may affect the hematological and biochemical profiles of plasma and its metabolism. Carbamazepine, the most well-known psychotropic drug, can cause substantial hyponatremia. Methylphenidate, a piperidine derivative structurally related to amphetamines, acts as a central nervous system stimulant. The current study evaluated whether methylphenidate affects hematological and biochemical parameters of patients diagnosed with attention deficit hyperactivity disorder.Patients undergoing treatment for attention deficit hyperactivity disorder at our Adolescent Psychiatric Clinic were enrolled in the study. Blood samples for complete blood count and common biochemical analyses were collected before patients started methylphenidate and after 3 months of continuous treatment.Participants included 64 patients comprised the study cohort. There were 48 (75%) males and 16 (25%) females, with a median age of 16 years (range 11-31). The total median potassium level decreased by 0.6 mg/dL (P < .0001), while glucose rose by 15 mg/dL (P < .0001), sodium decreased in 0.7meq/L, (P = .006). The white blood count rose by 1350 cells/µL (P < .033) due to neutrophilia, lymphocytosis and eosinophilia. Hemoglobin rose slightly by 0.1 (P = .041). Changes in calcium, phosphorus, protein, albumin, and liver enzyme levels were not significant.The results indicate that methylphenidate may cause hypokalemia and elevated glucose, leukocyte, neutrophil, lymphocyte and eosinophil counts.

Reduced bile acid excretion is an independent risk factor for stroke and mortality: A prospective follow-up study.

BACKGROUND AND AIMS: Hypercholesterolemia is a major risk factor for atherosclerosis, which is a cornerstone of coronary artery disease (CAD), stroke, peripheral vascular disease, aortic aneurysm and renal artery stenosis. This study investigated the association of bile acid excretion (BAE) with stroke incidence and mortality. METHODS: Patients admitted to Internal Medicine due to chest pain and suspected CAD were enrolled and followed from 1/1998 to 12/2018. Patients received a standard in-hospital diet containing 490 mg/day cholesterol and performed a 24-h stool collection. A continuous, non-absorbable marker was used to evaluate the amount of BAE. RESULTS: This retrospective, historical, follow-up study included 68 men and 35 women (mean age 61.9 ± 8.9 years) admitted to the hospital from 1996 to 1998 due to chest pain and suspected cardiac event. Mean BAE at first admission was higher among survivors (>608.8 mg) than non-survivors (281.5 mg/24h; p<0.001). Total cholesterol, LDL cholesterol and triglyceride levels at baseline did not differ significantly. The main fractions of deoxycholic, lithocholic, and cholic acids were significantly different in the two groups. They were also higher in the survivors. Total BAE was higher in stroke-free patients compared to those who developed stroke: 561.6 mg/24h and 231.2 mg/24h-respectively (p<0.001). Patients with BAE <262.4 developed stroke in 75% cases (18/24). None of 25 patients with BAE >622 mg/24h developed stroke. CONCLUSION: This retrospective, historical cohort follow-up study showed an association between lower amounts of total bile acid, deoxycholic acid and lithocholic acid excretion with stroke risk. Low BAE remained a significant risk-factor after adjusting for main potential confounders and may be an independent risk-factor for stroke.

Antibodies to oxidized LDL as predictors of morbidity and mortality in patients with chronic heart failure.

BACKGROUND: Oxidative stress appears to play a significant role in the pathogenesis of heart failure (HF). Antibodies to oxidized low-density lipoprotein (Ox LDL Abs) reflect an immune response to LDL over a prolonged period and may thus represent oxidative stress over an extended time. Ox LDL Abs have been shown to correlate with clinical control in HF patients. We evaluated the predictive power of Ox LDL Abs on the outcome in patients with HF. METHODS AND RESULTS: Baseline levels of Ox LDL Abs were determined by enzyme-linked immunosorbent assay in 284 consecutive outpatients with severe chronic HF who were being treated in the cardiology services of our medical center. Their mean New York Heart Association (NYHA) Class was 2.8. The mean follow-up for the group was 3.7 years, during which 107 (37%) died. The mean time from symptom onset to first hospital admission from HF was 25.8 months. Ox LDL Abs were found to predict morbidity and mortality as evaluated by a Cox multivariate regression analysis with a hazard ration of 1.013 (P < .013), whereas N-terminal pro-B-type natriuretic peptide (NT pro-BNP) levels achieved a HR of 1.028 (P < .099). CONCLUSIONS: Ox LDL Abs level maybe a useful parameter for monitoring and planning better management of patients with HF. It was superior to pro-BNP as a predictor of clinical course as expressed by time to hospitalization.

Methylphenidate has positive hypocholesterolemic and hypotriglyceridemic effects: new data.

Many psychotropic drugs may affect plasma lipids profile and their metabolism, with carbamazepine being the best known among them. Methylphenidate is a piperidine derivative structurally related to amphetamines and acts as a central nervous system stimulant. Its effect on lipid metabolism has not been investigated. The authors evaluated how methylphenidate affects the lipid profile in the plasma of patients diagnosed as having attention-deficit hyperactivity disorder (ADHD). All consecutive patients undergoing treatment for ADHD at the Adolescent Psychiatric Clinic (2003-2007) were enrolled. Blood samples for total cholesterol, low-density lipoprotein cholesterol (LDL-C), high-density lipoprotein cholesterol (HDL-C), triglycerides, apolipoprotein A, apolipoprotein B, and lipoprotein (a) (Lp(a)) were collected before starting treatment and after 3 months of continuous treatment. Forty-two patients (22 men), median age 16, participated. The median total cholesterol count decreased by 9 mg/dL (P<.0002), LDL-C decreased by 5.0 mg/dL (P<.016), and triglycerides decreased by 8.0 mg/dL (P<.016). Changes in the levels of HDL-C, apolipoprotein A, and apolipoprotein B were nonsignificant, and Lp(a) levels decreased by 2.0 mg/dL (P<.0007). Methylphenidate improves the lipid profile by decreasing total cholesterol, triglycerides, LDL-C, and Lp(a).

Monocytes may be favorable biomarker and predictor of long-term outcome in patients with chronic heart failure: A cohort study.

Although some studies found that an increased monocyte count is a predictive, short-term marker of unfavorable outcomes for patients with acute heart failure (HF), others have reported that monocytosis predicts prolonged survival.The current follow-up study aimed to identify different monocyte count patterns and their prognostic association with HF outcomes.Baseline blood samples for complete blood counts, differential counts, renal function tests, and lipid profiles of 303 chronic HF patients (average NYHA classification 2.8) were prospectively obtained to evaluate whether there is an association between monocyte count and clinical outcomes.Mean follow-up was 11.3 years (range 1 month to 16 years) and 111 (36.6%) patients died during follow-up. Mean monocyte count was 10.6 ±â€Š5.5 and mean left ventricular ejection fraction (LVEF) was 36%. Patients with low monocyte counts (≤6%) had significantly lower survival rates than did those with monocyte counts 6.1% to 14%, or >14% (14.3% vs 70.2% vs. 88%, P < .001). Poorest survival was predicted for patients with NYHA class 3 to 4 and monocyte counts ≤6. Regression analysis showed that monocyte levels, NYHA class, and LVEF values were predictors of mortality, in decreasing importance.The total monocyte count was found to be an important prognostic factor that was inversely associated with predicted long-term mortality among patients with chronic HF. A low total monocyte count was strongly correlated with NYHA class and B-type natriuretic peptide levels, but no correlation was found with LVEF and oxidized low-density lipoproteins. It emerged as an independent risk factor for mortality in patients with chronic HF.

Development of Crohn's disease in a patient with multiple sclerosis treated with copaxone.

BACKGROUND: Copaxone (glatiramer acetate) is a synthetic copolymer mimicking a portion of myelin basic protein, one of several putative autoantigens in multiple sclerosis (MS). Copaxone suppresses the production of tumor necrosis factor (TNF)-alpha, a key mediator of inflammation in MS as well as in other pathologies, such as colitis of interstitial bowel disease (IBD). Copaxone is a drug approved for the treatment of MS, and one that is very well tolerated with a high safety profile and relatively few side effects. Crohn's disease has not been associated with its administration. METHODS: We describe a patient with MS in remission who had not exhibited any signs of IBD in the past. She had been on Copaxone 20 mg/day treatment for 2 years when she first exhibited gastrointestinal symptoms. RESULTS: Our patient developed Crohn's disease while on Copaxone treatment as a consequence of long-term immunosuppression. CONCLUSIONS: Clinicians should be aware that Crohn's disease is a potential novel adverse drug effect of Copaxone.

Diminished bile acids excretion is a risk factor for coronary artery disease: 20-year follow up and long-term outcome.

BACKGROUND: Patients with coronary artery disease (CAD) had significantly lower bile acid excretion (BAE) compared with non-CAD patients, leading to the hypothesis that the inability to efficiently excrete bile acids leads to coronary atherosclerosis development. We investigated the long-term role of BAE in CAD development and related mortality in 50 patients with proven CAD compared with that of 50 patients with chest pain and no CAD (controls) matched for clinical and laboratory characteristics. METHODS: All subjects received a 4-day standard diet that included ~500 mg of cholesterol. Fecal bile acids from 24-h stool collections were measured by gas liquid chromatography. RESULTS: CAD patients excreted lower amounts of total bile acids than controls (p < 0.001), less deoxycholic acid (p < 0.0001) and less lithocholic acid (p < 0.01). BAE was the best significant independent laboratory factor that predicted CAD (p < 0.05). Mortality and CAD development rates were significantly lower for the controls at the 20-year follow up. CONCLUSIONS: These results showed that CAD patients had markedly decreased BAE levels compared with non-CAD controls. BAE <415 mg/day was associated with increased CAD long-term mortality. Impaired ability to excrete cholesterol might be considered an additional independent risk factor for CAD development.

Prediction of cardiogenic pulmonary edema onset by monitoring right lung impedance.

OBJECTIVE: To evaluate the ability of internal thoracic impedance (ITI) monitors to predict cardiogenic pulmonary edema in patients at risk. DESIGN AND SETTING: Prospective, controlled multicenter study. PATIENTS: We examined 328 consecutive patients admitted for cardiac conditions. Of these 265 patients aged 27-83 years with no clinical signs of pulmonary edema, extracardiac respiratory failure or pacemakers comprised the study cohort. INTERVENTION: Monitoring of the lung's electrical impedance was used for predicting cardiogenic pulmonary edema since accumulation of blood and fluid decreases impedance values. MEASUREMENTS AND RESULTS: Impedance of the lung is the main feature of ITI measured by the RS-207 monitor: decreased ITI prior to the clinical signs of cardiogenic pulmonary edema was used as the prediction criterion. The clinical signs used for confirmation of its prediction were dyspnea, cyanosis, pulmonary rales, crepitations, arterial hypoxemia, and radiographic evidence of pulmonary congestion in chest radiographs. Clinicians were blinded to the results of ITI measurements and radiologists were blinded to both ITI and clinical data. Thirty-seven patients developed cardiogenic pulmonary edema while being monitored. ITI decreased by more than 12% of baseline in all of them; this occurred at 30 min or longer (26 patients) and at 60 min or longer (11 patients) before the appearance of clinical signs. ITI fell by less then 10.1% of baseline in all 228 patients who did not develop the edema. CONCLUSION: Monitoring ITI is suitable for early prediction of cardiogenic pulmonary edema, before the appearance of the clinical signs.

Internal thoracic impedance monitoring: a novel method for the preclinical detection of acute heart failure.

BACKGROUND: Acute heart failure (AHF) evolves through two phases. In the first phase, there is interstitial congestion with no clinical sign of edema (preclinical phase); the second, during which lung alveoli begin to fill with fluid, manifests as clinically overt alveolar edema. Treatment of AHF at its preclinical phase can alleviate its clinical impact. Presently, there is no technique that detects the interstitial phase of AHF. We used a device based on a new method of lung bioimpedance measurement. The device measures internal thoracic impedance (ITI), which nearly equals inherent lung bioimpedance. This method can detect small changes in lung fluid that occur during the interstitial stage of AHF. AIM: The objective of this study was to assess the feasibility and efficacy of the said new method in detecting preclinical AHF. METHODS: Internal thoracic impedance and pertinent clinical parameters were monitored for 72 h in 403 patients hospitalized for an acute coronary syndrome without evidence of AHF at study entry. RESULTS: Seventy patients developed AHF during monitoring. Internal thoracic impedance decreased in these patients by 16.4% (95% CI=-12.2% to -20.6%; P<.0001) from the baseline level at 44+/-15.1 min prior to the onset of lung rales. The other 333 patients had no clinical sign of AHF, and their ITI declined only by 4.5% (95% CI=2.5% to -11.5%; P=.3) compared with the baseline level. CONCLUSION: The new method for ITI measurement is sufficiently sensitive in detecting AHF at its preclinical stage. An ITI decrease of more than 12% heralds the appearance of clinically overt AHF and, thus, allows earlier therapy.

Bezafibrates cause moderate, reversible impairment in renal function in patients without prior renal disease.

BACKGROUND/AIMS: To determine whether bezafibrates have adverse effects on renal function. METHODS: (1) A 3-year retrospective survey of 526 patients who were on bezafibrate for a while and 614 controls following fluctuations of serum creatinine levels. (2) A prospective study on 33 patients with previous evidence of bezafibrate-induced elevation in serum creatinine. The patients were examined after 3 months on bezafibrate 400 mg/day and then after 3 months without bezafibrate. Eight patients repeated the tests after 3 months on bezafibrate 200 mg/day. RESULTS: Retrospective: 295 bezafibrate-treated patients (56%) and 67 controls (11%) demonstrated fluctuations > or = 0.2 mg/dl in serum creatinine levels (p < 0.001); 113 patients (21%) and 16 controls (3%) showed fluctuations > or = 0.3 mg/dl (p < 0.001). Prospective: bezafibrate 400 mg/dl increased serum creatinine from 1.16 +/- 0.19 to 1.42 +/- 0.2 mg/dl (p < 0.001) and urea from 37 +/- 8 to 44 +/- 8 mg/dl (p < 0.001); creatinine clearance (Ccr) decreased from 104 +/- 23 to 82 +/- 27 ml/min (p < 0.001). CPK increased from 82 +/- 32 to 130 +/-58 mg/dl (p < 0.0001) and urinary myoglobin increased from 95.4 +/- 21 to 199 +/- 99 mg/dl (p < 0.0001). The 8 patients given bezafibrate 200 mg/dl experienced similar dose-dependent changes. CONCLUSIONS: Bezafibrate causes quiet common, dose-dependent and reversible changes in serum creatinine in patients with normal renal function, associated with a significant increase in serum CPK and urine myoglobin, suggestive of drug-induced mild subclinical skeletal muscle injury compromising renal function.