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Biomedical subjects

Alexander Battler

Publications and source records attributed to Alexander Battler.

66 records · Page 4Linked to original sources
PubMed2003

A prospective national survey of management and clinical outcome of acute myocardial infarction in Israel, 2000.

BACKGROUND: Little information is available on the clinical practice and implementation of guidelines for treating acute myocardial infarction patients in Israel. OBJECTIVE: To assess patient characteristics, hospital course, management, and 30 day clinical outcome of all AMI patients hospitalized in Israel during a 2 month period in 2000. METHOD: We conducted a prospective 2 month survey of consecutive AMI patients admitted to 82 of 96 internal medicine departments and all 26 cardiac departments operating in Israel in 2000. Data were collected uniformly by means of a hospital and 30 day follow-up form. RESULTS: During the survey 1,683 consecutive patients with a discharge diagnosis of AMI were included. Their mean age was 66 years; 73% were male. The electrocardiographic pattern on admission revealed ST elevation, non-ST elevation and an undetermined ECG in 63%, 34% and 4% of patients respectively. Aspirin and heparin were given to 95% of patients. Beta-blockers and angiotensin-converting enzyme inhibitors were given to 76% and 65% of patients respectively. Among hospital survivors, 45% received lipid-lowering drugs. Thrombolytic therapy was administered in 28% of patients, coronary angiography was used in 45%, and 7% of patients underwent primary percutaneous coronary intervention. The 7 and 30 day mortality rates were 7% and 11% respectively. CONCLUSIONS: This nationwide survey shows that one-third of the AMI patients in Israel are elderly (> or = 75 years). The survey suggests that clinical guidelines for the management of patients with AMI are partially implemented in the community. Data from large surveys representing the "real world" practice are of utmost importance for the evaluation of clinical guidelines, research and educational purposes.

Aged↗
PubMed2003

[Preoperative cardiac risk evaluation in non cardiac surgery].

Cardiovascular complications are important causes of morbidity with major non cardiac procedures. Preoperative risk stratification relies on the identification of the cardiac problem, its stability, its severity and previous treatment. The approach to risk stratifying preoperative patients should be performed by accepted guidelines used for patients with suspected coronary artery disease (CAD) or known CAD and not as an "obligatory test" prior to operation. Risk stratification is based on clinical predictors, stress testing, including cardiac imaging if necessary, and the kind of operation. Most of the tests are noninvasive and some invasive tests conducted are intended to identify myocardial ischemia and critical lesions of the coronary arteries. Most of the patients are able to undergo elective procedures without any problem with the perioperative cardiac event rate of up to 2% considered as an accepted goal. The use of invasive diagnostic and therapeutic methods, such as cardiac catheterization, PCI, CABG, has to be restricted only to patients who are at very high risk. The partial reduction of the cardiac event rate in the short term and monitoring for 24 hours after operation is most important, as well as the administration of beta blockers, starting prior to surgery. Furthermore, long term follow-up for cardiac events in these patients in essential, as the clinical predictors and cardiac tests performed for preoperative risk stratification are also used for long term prognosis.

Cardiac Surgical Procedures↗
PubMed2002

Plasma homocysteine, methylenetetrahydrofolate reductase genotypes, and age at onset of symptoms of myocardial ischemia.

Elevated fasting plasma homocysteine is a graded risk factor of coronary artery disease (CAD) and may accelerate onset of CAD. Homozygosity for the C677T mutation in the methylenetetrahydrofolate reductase (MTHFR) gene is commonly but inconsistently associated with hyperhomocysteinemia. In the present study we examined the possible relation between levels of fasting plasma homocysteine and age at CAD onset in different MTHFR genotypes. We studied 182 patients with CAD, 74 patients with early onset CAD (aged < or = 45 years), and 108 patients with later onset CAD (aged 46 to 65 years). Plasma homocysteine levels in 90 subjects without CAD were used for control. Fasting plasma homocysteine levels in T/T homozygotes with early onset CAD (20.2 +/-12.5 micromol/L) was markedly higher than in T/T homozygotes with later onset CAD (13.4 +/- 6.8 micromol/L) and in patients with early onset CAD who were not T/T homozygotes (11.9 +/- 3.7 micromol/L; p = 0.034 and p = 0.0001, respectively). CAD developed earlier in T/T homozygotes who were hyperhomocysteinemic (>15 micromol/L) than in the T/T homozygotes who were not (p = 0.036). Plasma homocysteine levels had no effect on age at onset of CAD in patients who were non-T/T genotypes. Homocysteine levels in control subjects and in patients who were non-T/T genotypes were comparable and were not influenced by age. The results reveal an inverse relation between the level of fasting plasma homocysteine and age at onset of CAD in T/T homozygotes as opposed to no association in patients who were non-T/T genotypes. Additionally, these results show that hyperhomocysteinemia and the T/T genotype have a stronger effect on the pathogenesis of CAD when they are combined, and that a marked increase (>15 micromol/L) in fasting plasma homocysteine in T/T homozygotes is a risk factor for early onset of CAD.

Adult↗
PubMed2002

Low-molecular-weight heparin for the treatment of patients with mechanical heart valves.

BACKGROUND: The interruption of oral anticoagulant (OAC) administration is sometimes indicated in patients with mechanical heart valves, mainly before noncardiac surgery, non-surgical interventions, and pregnancy. Unfractionated heparin (UH) is currently the substitute for selected patients. Low-molecular-weight heparin (LMWH) offers theoretical advantages over UH, but is not currently considered in clinical guidelines as an alternative to UH in patients with prosthetic valves. HYPOTHESIS: The aim of the present study was to review the data accumulated so far on the use of LMWH in this patient population and to discuss its applicability in common practice. METHODS: For this paper, the current medical literature on LMWH in patients with mechanical heart valves was extensively reviewed. RESULTS: There were eight series and six case reports. None of the studies was randomized, and only one was prospective. Data to establish the thromboembolic risk were incomplete. After excluding case reports, the following groups were constructed: (a) short-term administration, after valve insertion (n = 212); (b) short-term, perioperative (noncardiac)/periprocedural (n = 114); (c) long-term, due to intolerance to OAC (n = 16); (d) long-term, in pregnancy (n = 10). The incidence rate of thromboembolism was 0.9% for all the studies and 0.5, 0, 20, and 0% in groups a, b, c, and d, respectively; for hemorrhage, the overall rate was 3.4% (3.8, 2.6, 10, and 0% for the respective groups). CONCLUSIONS: In patients with mechanical heart valves, short-term LMWH therapy compares favorably with UH. Data on mid- and long-term LMWH administration in these patients are sparse. Further randomized studies are needed to confirm the safety and precise indications for the use of LMWH in patients with mechanical heart valves.

Anticoagulants↗
PubMed2002

Nonobstructive aortic valve calcification: a window to significant coronary artery disease.

BACKGROUND: Aortic valve calcification without obstruction (AVC) is common in the elderly and is associated with increased cardiovascular mortality and morbidity. We hypothesized that AVC detected by transthoracic echocardiography (TTE) is a marker for significant coronary artery disease in patients undergoing coronary angiography. METHODS: The study group included 388 patients with AVC (259 males, 129 females; mean age 72.2+/-9 years) who underwent coronary angiography for various indications. Data were compared with 320, age- and sex-matched patients without AVC who underwent coronary angiography for the same indications. AVC was detected in TTE as focal areas of increased echogenicity and thickening of the aortic-valve leaflets without restriction in motion. Significant obstructive coronary artery disease was defined as either a > or = 70% reduction of the internal diameter of the left anterior descending, right coronary, or left circumflex artery distribution or a > or = 50% reduction of the internal diameter of the left main coronary artery. Risk factors for atherosclerosis including hypertension, smoking, hypercholesterolemia and diabetes were also investigated. RESULTS: Compared with control group, the AVC group had a higher prevalence of significant coronary artery disease (90 vs. 85%, P=0.019), and a trend for lower frequency of coronary arteries without obstruction (6 vs. 9%, P=0.l1); a trend was also noted for 3-vessel disease (38 vs. 33%, P=0.14). Multivariate analysis identified age (P=0.000l), sex (P=0.000l), hypercholesterolemia (P=0.005) and AVC (P=0.02) as independent predictors for significant coronary artery disease. CONCLUSIONS: There is a significant association between AVC and significant coronary artery disease in patients undergoing coronary angiography. Thus AVC can serve as a window to atherosclerosis of the coronary arteries. These results reinforce a previous observation regarding association between AVC and increased risk of cardiovascular morbidity.

Adult↗
PubMed2002

Outcome of myocardial infarction in patients treated with aspirin is enhanced by pre-hospital administration.

OBJECTIVE: Reducing time to reperfusion therapy is one of the goals in the management of acute myocardial infarction (AMI). We assessed the association between timing of aspirin administration and outcome of patients with AMI. PATIENTS: We studied 922 consecutive AMI patients with ST-segment elevation in Killip class I-III on admission. Patients were divided into two groups based upon the timing of emergency aspirin administration: before (early aspirin users) or after (late aspirin users) hospital admission. RESULTS: Early aspirin users (n = 338; 37%) were younger, less likely to be women, and more likely to smoke (p < 0.006) than late users (n = 584; 63%). Other baseline and clinical characteristics were similar. Early aspirin users were more likely to be treated with thrombolysis or primary percutaneous transluminal coronary angioplasty. Compared with late users, early aspirin users had significantly lower in-hospital complications and lower mortality rates at 7 (2.4 vs. 7.3%, p = 0.002) and 30 days (4.9 vs. 11.1%, p = 0.001). By multivariate adjustment, pre-hospital aspirin was an independent determinant of survival at 7 (odds ratio 0.43; 95% confidence interval 0.18-0.92) and at 30 days (odds ratio, 0.60; 95% confidence interval 0.32-1.08). Survival benefit associated with aspirin persisted for subgroups treated or not with reperfusion therapy. CONCLUSIONS: Outcome of AMI patients treated with aspirin is improved by pre-hospital administration. Our findings suggest that emergency pre-hospital aspirin might facilitate early reperfusion.

Aged↗
PubMed2002

Safety and efficacy of a 6 French perclose arterial suturing device following percutaneous coronary interventions: a pilot evaluation.

BACKGROUND: Arterial access site management after percutaneous coronary intervention (PCI) is a matter of increasing importance in this era of potent antiplatelet pharmacotherapy. We evaluated the safety and efficacy of a 6 French (Fr) Perclose suturing device in achieving rapid hemostasis of the access site after PCI and thus improving patient comfort. METHODS: The 6 Fr Perclose (Prostar) device consists of a suture-based closure device delivered via introducer sheath designed for suturing of the arteriotomy puncture site. Over a 3-month period, the device was used in 48 consecutive PCI treated patients (age, 62 13 years; 70% male; 44% post myocardial infarction) and in-hospital groin complication rate was compared to 48 consecutive patients (age, 64 12 years; 64% male; 33% post myocardial infarction) who had manual compression hemostasis. RESULTS: Antiplatelet glycoprotein IIb/IIIa antagonists were used more frequently during and following the procedure in 58% of Perclose-treated patients versus 42% of the manual compression group (p = 0.019). Leg immobilization duration was 3 4 hours in all patients sutured by the device; in patients with manual compression, the sheath was removed at an average of 4.8 2.5 hours after termination of the PCI and an additional 6 hours of leg immobilization were subsequently required. No difference in overall major complication rate was found between groups (6.2% in suture-mediated patients versus 9.3% in manual compression group; p = 0.60). In 3 patients (6.2%) treated using the device, adjunctive manual compression was required in addition to groin suturing due to technical failure or residual oozing from the arteriotomy site. CONCLUSION: The 6 Fr Perclose device can be safely used to achieve rapid hemostasis and the device may hasten bed mobilization of PCI-treated patients despite frequent use of potent antiplatelet pharmacotherapy during coronary interventions.

Adult↗
PubMed2000

Augmentation of reperfusion by noninvasive, transcutaneous delivery of low-frequency, high-intensity ultrasound.

There is a need for developing alternative safe, inexpensive and noninvasive methods for rapid and effective recanalization of thrombosed arteries and veins that can be commenced immediately upon admission to hospital, or even prior to admission. Transcutaneous delivery of low-frequency, high-intensity ultrasound has the potential to be used clinically in various types of thrombotically occluded blood vessels including acute myocardial infarction, strokes, ischemic limbs, obliteration of A-V fistulas of patients undergoing hemodialysis, retinal vein thrombosis, deep vein thrombosis, and even thrombotically stuck prosthetic heart valves. Thus far, various noninvasive ultrasound systems have been used in several animal models. These systems vary in the mode of ultrasound delivery (continuous versus pulse, diffuse versus concentrated or pulsed beam), frequency (between 20 kHz and 1 mHz), and intensity. In general, lower frequencies have better penetration through overlying tissue (skin, fat, bone) and, probably, better efficacy.

Journal Article↗
PubMedDate not supplied

Discrepancy between myocardial ischemia and luminal stenosis in patients with left internal mammary artery grafting to left anterior descending coronary artery.

BACKGROUND: Left internal mammary artery (LIMA) grafting to the left anterior descending artery (LAD) is known to have long-term patency. However, myocardial ischemia in the territories supplied by LIMA to LAD is still demonstrated. The aim of this study is to examine the relationships between the extent, location, and clinical outcome of myocardial ischemia in LAD territories (ILAD) by use of myocardial perfusion imaging (MPI) and angiographic characteristics of such a bypass conduit. METHODS AND RESULTS: We studied 38 consecutive patients with prior coronary artery bypass grafting who showed stress-induced ischemia in LIMA to LAD territories by MPI single photon emission computed tomography between the years 1996-2000. All patients underwent quantitative coronary angiography within 6 months of the nuclear study. Single photon emission computed tomography parameters of ILAD were assessed by location (septum, apex, anterior, and anterolateral) and included extension score (1-4 per patient), severity score (0-3 per territory), and total sum score. LIMA to LAD quantitative coronary angiography parameters included minimal lumen diameter, lesion length, reference diameter, and diameter stenosis (percentage). LAD and LIMA diameters and ratio (in normal segments) were determined within 10 mm proximal and distal to the anastomotic site. The study group was compared with 18 control subjects without ischemia or stenosis treated with LIMA to LAD. The patients were followed up for cardiac death at an interval of 3.2 +/- 1.5 years from the time of MPI testing. The patients' mean age was 66 +/- 12 years (31 men and 7 women); the mean period after surgery was 6.2 +/- 1.5 years. The ILAD distribution was as follows: septum, 12 (32%); apex, 20 (52%); anterior, 24 (63%); and anterolateral, 18 (47%). The mean extension score was 1.9 +/- 1.0, and the mean total sum score was 3.4 +/- 2.3. Of 38 patients with ILAD, only 17 (45%) had greater than 50% luminal stenosis (2 LIMA and 15 anastomosis or distal). Among clinical variables during stress testing, the prevalence of angina was significantly higher in the luminal stenotic patients versus patients without stenosis (P =.04). A significant correlation was found between anterior wall ischemia and reference diameter (r = -0.7, P =.002) and between total sum score and minimal lumen diameter (r = -0.48, P =.05). Of note, the LAD-to-LIMA ratio was significantly lower in patients with ILAD and without luminal stenosis compared with the control group (0.73 +/- 0.16 vs 0.87 +/- 0.15, P =.004). Cardiac death occurred in 8 patients (21%), 5 patients with luminal stenosis versus 3 patients without stenosis (P = not significant). CONCLUSIONS: In patients with LIMA to LAD anastomosis, myocardial ischemia could occur even without angiographic luminal stenosis and apparently reflects a mismatch between LAD and LIMA diameters at distal anastomotic sites. Regarding the similar prevalence of cardiacdeath, invasive evaluation and aggressive treatment are recommended in all patients with ischemia in LIMA/LAD territories.

Aged↗
PubMedDate not supplied

Prognostic value of stress myocardial perfusion imaging in octogenarian population.

BACKGROUND: The prognostic value of myocardial perfusion imaging (MPI) in the very elderly population has not been addressed specifically. The aim of this study was to examine the characteristics of the octogenarian population referred for MPI and the prognostic value of the procedure in terms of patient gender. METHODS: The study sample consisted of 162 consecutive patients (61 women, 101 men) of mean age 83 +/- 3 years (range, 80-90) who underwent stress MPI. The duration of follow-up was 45+/-12 months. Outcome measures were cardiac-related death, and nonfatal myocardial infarction (MI). RESULTS: Thirty-one major cardiac events (19%) were recorded, including 26 cardiac deaths and 5 MI events, in 6 of the 61 women (10%) and 25 of the 101 men (25%) (p < 0.03). The univariate predictors of cardiac death or MI, except of known coronary artery disease (CAD), were MPI variables: left ventricular (LV) dilatation, increased lung uptake, abnormal scan, and the presence and extent of myocardial ischemia. However, the only predictors for major cardiac events were: LV dilatation (OR = 6.9, 95% CI 2.7-17.4, p < 0.0001) and ischemia by scan (OR = 2.75, 95% CI 1.09-6.96, p < 0.03). The Kaplan Meier curve demonstrated significant differences in survival between patients with or without LV dilatation and patients with or without ischemia. CONCLUSIONS: LV dilatation and myocardial ischemia were useful predictors of cardiac death and MI in octogenarian patients with CAD or with suspicion of CAD.

Aged, 80 and over↗