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S Behar

Publications and source records attributed to S Behar.

At least 127 records · Page 7Linked to original sources
PubMed1993

Early administration of nifedipine in suspected acute myocardial infarction. The Secondary Prevention Reinfarction Israel Nifedipine Trial 2 Study.

BACKGROUND: The administration of nifedipine, 30 mg/d, between 7 and 22 days after hospitalization for an acute myocardial infarction (Secondary Prevention Reinfarction Israel Nifedipine Trial study) showed no effect on subsequent mortality and morbidity. Since a possible indication of benefit was observed in patients with a second- or higher-order infarction, a second trial was conducted with a higher dose (60 mg/d), early administration (usually within 3 hours of hospital admission), and in high-risk patients only. METHODS: A total of 1358 men and women with suspected acute myocardial infarction (MI), judged not to require calcium antagonist therapy, were randomized to receive nifedipine, 60 mg/d, or placebo between November 1985 and July 1986. Study medication was discontinued in 352 patients because they did not exhibit study criteria for MI or lacked high-risk criteria, or because they decided to discontinue the study. Thus, the treated high-risk group included 1006 patients, of whom 826 were successfully titrated to the target dose of 60 mg/d and were treated for up to 6 months. RESULTS: In the 1006 patients, mortality was 18.7% among those randomized to nifedipine and 15.6% in the patients randomized to placebo. This reflected an increased mortality of 7.8% as compared with 5.5% during the first 6 days in the nifedipine and placebo groups, respectively (adjusted mortality odds ratio by logistic regression, 1.60; 95% confidence interval, 0.86 to 3.00). Among the 826 patients who continued treatment, mortality was equal in the nifedipine (9.3%) and placebo (9.5%) groups. No differences in the rates of nonfatal MI (5.1% and 4.2% in the nifedipine and placebo groups, respectively), hospitalization due to unstable angina, and frequency of chest pain reported during follow-up were observed. An increased rate of sudden death (4.9%) in the placebo group in comparison with the nifedipine group (2.3%) was not statistically significant on post hoc testing, nor was an effect of nifedipine demonstrable in post hoc analyses by congestive heart failure status of randomized patients. CONCLUSION: Nifedipine as a prophylactic treatment in patients immediately after acute MI or in survivors recovering 1 week or longer after acute MI appears ineffective. Early routine administration of nifedipine in acute MI, other than to patients in whom it may be specifically indicated (eg, those with Prinzmetal's variant angina or severe hypertension) may be hazardous and seems to be contraindicated.

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PubMed1993

Frequency and prognostic significance of secondary ventricular fibrillation complicating acute myocardial infarction. SPRINT Study Group.

The incidence of secondary ventricular fibrillation (VF) complicating acute myocardial infarction (AMI) was 2.4% in a large cohort of unselected patients with AMI (142 of 5,839). Secondary VF was more frequent in patients with recurrent AMI (4%) than in those with a first AMI (1.9%) (p < 0.01). The hospital course was more complicated and in-hospital mortality was significantly higher in patients with secondary VF than in those with the same clinical hemodynamic condition but without VF (56 vs 16%; p < 0.0001). Multivariate analyses confirmed secondary VF complicating AMI as an independent predictor of high in-hospital mortality, with an odds ratio of 7 (95% confidence interval 4.6-10.6). However, long-term mortality after discharge (mean follow-up 5.5 years) was not increased in patients with as compared with those without secondary VF (39 vs 42%). These findings were also true when patients receiving beta blockers and antiarrhythmic therapy were excluded from analysis. Thus, this life-threatening arrhythmia occurring during hospitalization is not a marker of recurrent susceptibility to VF or an indicator of increased mortality after discharge from the hospital.

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PubMed1993

Complete atrioventricular block complicating inferior acute wall myocardial infarction: short- and long-term prognosis.

The incidence of complete atrioventricular block (AVB) in a large group of patients with Q-wave inferior acute myocardial infarction (AMI) was 251 (11%) of 2273 patients. This incidence was significantly higher in women (14%) and patients > 70 years old (15%) than in men and patients < 70 years old (10% and 9%, respectively). Patients with complete AVB exhibited more serious arrhythmic and mechanical complications during hospitalization and included more patients with very high enzyme levels than their counterparts without AVB. The in-hospital mortality rate was 92 (37%) of 251 patients with complete AVB versus 200 (11%) of 1890 in those without AVB (p < 0.0001). After adjustment for age, gender, and important anamnestic, medical, and enzymatic findings, complete AVB emerged as an independent predictor of in-hospital mortality, yielding an odds ratio of 2.0 (90% confidence interval 1.12 to 3.57). The long-term (5-year) mortality rate in hospital survivors was slightly but not significantly higher in patients with complete AVB (28%) during hospitalization than in their counterparts with no AVB (23%). In view of these data, patients with inferior AMI in whom complete AVB develops are at increased risk and may benefit from urgent revascularization; the postdischarge management of survivors with complete AVB should be no different from that of patients without AVB.

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PubMed1993

Cardiogenic shock complicating acute myocardial infarction in patients without heart failure on admission: incidence, risk factors, and outcome. SPRINT Study Group.

PURPOSE: Patients with large myocardial infarction (MI) presenting with clinical signs of heart failure are at increased risk for subsequent development of cardiogenic shock and death. Little is known, however, about the development of cardiogenic shock among patients with acute MI presenting without clinical signs of heart failure. The aim of the present study was to examine the incidence, predictors for occurrence, and outcome of in-hospital development of cardiogenic shock among patients with acute MI without heart failure on admission. PATIENTS AND METHODS: Clinical data of 5,839 consecutive patients hospitalized with acute MI were analyzed. RESULTS: Of 3,465 (59%) patients without heart failure on admission (Killip class I), 89 (2.6%) developed cardiogenic shock during their hospital stay. This represented 24% of all cases of in-hospital cardiogenic shock in the entire group. Cardiogenic shock developed more than 24 hours after admission in 66% of cases. All but three patients with cardiogenic shock died whereas a 5% in-hospital mortality was found among patients without cardiogenic shock. Independent predictors for in-hospital shock were age (for a 10-year increment, adjusted relative odds [RO] = 2.45, 90% confidence interval [CI] = 1.50 to 4.02); female gender (RO = 1.51, 90% CI = 0.91 to 2.50); history of angina (RO = 2.64, 90% CI = 1.36 to 3.76); history of stroke (RO = 2.12, 90% CI = 1.26 to 6.35); peripheral vascular disease (RO = 1.99, 90% CI = 0.95 to 4.18); peak lactate dehydrogenase (LDH) greater than four times the normal (RO = 3.16, 90% CI = 1.79 to 5.57); and hyperglycemia on admission (RO = 3.52, 90% CI = 2.13 to 5.84). Patients with six risk factors (excluding LDH values) had an estimated probability of 35% for developing in-hospital cardiogenic shock. CONCLUSIONS: (1) A significant proportion of MI patients who developed cardiogenic shock during hospitalization were free of heart failure on admission. (2) Our study identified several risk factors facilitating early identification of subgroups at risk for cardiogenic shock within otherwise low-risk patients.

Age Factors↗
PubMed1993

Infarct site-related mortality in patients with recurrent myocardial infarction. SPRINT Study Group.

PURPOSE: The purpose of this study was to determine the effect of acute and old myocardial infarction (MI) sites on early (15 days) mortality in patients with a second MI. PATIENTS AND METHODS: Data are derived from the SPRINT 2 study population that included 1,161 consecutive patients with acute MI, aged 50 to 79 years, recruited from 14 coronary care units in Israel between November 1985 and July 1986. Two hundred twenty-six of these patients (19.5%) had a previous MI prior to the index acute MI. Sixty-two patients were excluded from the analysis either because the MI site was not of anterior or inferior location, or because of incomplete data. In the 164 (73%) remaining patients, acute and old MI locations were determined to be either anterior or inferior and were accordingly divided into 4 groups: acute anterior-old anterior (Group 1-23 patients); acute anterior-old inferior (Group 2-86 patients); acute inferior-old anterior (Group 3-34 patients); acute inferior-old inferior (Group 4-21 patients). RESULTS: Significant differences in clinical parameters among the four groups included a higher proportion of Q-wave MI (p = 0.04), severe congestive heart failure during admission (p = 0.04), and markedly elevated serum lactate dehydrogenase levels (p = 0.05) in Group 3. High-degree atrioventricular block (p = 0.001) and cardiogenic shock (p = 0.05) also developed more often in this group during hospitalization. Twenty-three patients (14%) died within 15 days. Death rates in the acute anterior (Group 1 plus Group 2) and the acute inferior (Group 3 plus Group 4) groups were 11% versus 20%, respectively (NS). However, death rate variability across the four groups was statistically significant (p = 0.018), with the highest mortality observed in Group 3 (old anterior-acute inferior MI-29%). Multivariate analysis identified acute inferior MI following old anterior MI as a strong independent predictor of early death (relative odds vis-à-vis other combinations 5.0, 95% confidence interval 1.5 to 16.6). CONCLUSION: This study identifies a subgroup of patients with acute inferior MI at high risk for early mortality. It is possible that such patients would benefit from early reperfusion therapy.

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PubMed1993

Circadian variation and possible external triggers of onset of myocardial infarction. SPRINT Study Group.

PURPOSE: To determine whether a circadian pattern in onset of symptoms existed and possible external triggers were implicated in the precipitation of acute myocardial infarction (AMI). PATIENTS AND METHODS: One thousand eight hundred eighteen consecutive patients with AMI hospitalized in 14 of the 21 existing coronary care units in Israel during the study period were assessed. RESULTS: The frequency of onset of symptoms by 6-hour intervals showed a predominant morning peak (6 AM to noon) (32%, p < 0.01) in comparison with the other three 6-hour intervals of the day. The preponderance of the morning peak persisted for subgroup analysis by gender (males 32%, females 31%); age (less than or equal to 65 years--32%; greater than 65 years--33%); diabetes mellitus (present or absent, 32%). However, patients with peripheral vascular disease and those with stroke in the past had a predominant evening peak. Possible external triggers of onset of AMI were present in 10% of patients. Exceptional heavy physical work, violent quarrel at work or at home, and unusual mental stress were the three most frequent possible external triggers reported immediately before or within the 24 hours preceding pain onset. Patients with possible external triggers were more likely to be males (85%) and were somewhat but not significantly younger (63.1 years) in comparison with patients without external triggers (73% and 64.3 years respectively). CONCLUSIONS: In a large group of consecutive patients with AMI, a predominant cyclic morning peak of pain onset was found in comparison with the other hours of the day. Possible external triggers precipitating AMI were involved in a minority of cases, suggesting that endogenous changes occurring in the morning hours are generally responsible for the increased rate of myocardial infarction occurring after awakening.

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PubMed1993

Frequency and prognosis of stroke/TIA among 4808 survivors of acute myocardial infarction. The SPRINT Study Group.

BACKGROUND AND PURPOSE: Stroke complicating acute myocardial infarction is associated with substantial morbidity and mortality. The purpose of this study was to assess the incidence, predictors, and impact on mortality of stroke/transient ischemic attacks occurring after hospital discharge in a large unselected population of acute myocardial infarction survivors. METHODS: During a secondary prevention study with nifedipine (SPRINT), demographic, anamnestic, and clinical data were collected for 5839 consecutive acute myocardial infarction patients admitted to 13 coronary care units in Israel. Hospital survivors (n = 4808) were followed for a year after their discharge. Mortality was assessed for a mean follow-up of 5.5 years (range, 4.5 to 7 years). RESULTS: One percent (48/4808) of hospital survivors from acute myocardial infarction experienced a stroke/transient ischemic attack in the year after acute myocardial infarction. Thirty-one percent (15 of 48) of events occurred in the first month after hospital discharge. Incidence was higher among older patients (> 70 years; 1.9%), those with anterior site of myocardial infarction (1.35%), a previous history of myocardial infarction (1.8%), hypertension (1.4%), stroke in the past (4.1%), and chronic atrial fibrillation (9%). Multivariate analysis identified the following as independent predictors of stroke/transient ischemic attacks occurring in the year after hospital discharge: chronic atrial fibrillation, older age, history of previous myocardial infarction, anterior myocardial infarction site, serum glutamic oxaloacetic transaminase levels more than four times above upper normal limits, and stroke in the past. The age-adjusted 1-year and long-term mortality rates (4.5 to 7 years; mean, 5.5 years) were significantly higher in patients with (31% and 62%) than in those without stroke/transient ischemic attacks (9% and 31%, respectively; P < .01). CONCLUSIONS: Stroke/transient ischemic attack is a relatively rare (1%) complication in the year after hospital discharge from acute myocardial infarction, though more frequent in the first month. Chronic atrial fibrillation, older age, anterior myocardial infarction site, serum glutamic oxaloacetic transaminase levels more than four times above upper normal limits, past myocardial infarction, and stroke identify high-risk patients. Patients suffering from subsequent stroke/transient ischemic attacks experienced higher mortality than counterparts who remained free from this complication.

Age Factors↗
PubMed1992

Primary ventricular tachycardia in acute myocardial infarction: clinical characteristics and mortality. The SPRINT Study Group.

OBJECTIVE: To examine the immediate and long-term clinical and prognostic significance of primary ventricular tachycardia, defined as tachycardia of ventricular origin occurring within 48 hours of acute myocardial infarction in patients without hemodynamic compromise (Killip class I). DESIGN: Prospective cohort study. SETTING: Intensive coronary care units in eight regional, referral, and university hospitals. PATIENTS: A total of 162 patients with primary ventricular tachycardia, both sustained and nonsustained (study group), and 2578 counterparts without ventricular tachycardia (reference group). MEASUREMENTS: In-hospital rates of atrial fibrillation, atrioventricular block, congestive heart failure, cardiogenic shock, and cardiac arrest. In-hospital and 1-year follow-up rates of sudden death, nonsudden cardiac death, and noncardiac death. RESULTS: The study and reference groups had similar mortality (in-hospital, 6.8% and 9.6%, P greater than 0.2 and at 1 year after discharge, 3.7% and 5.4%, P greater than 0.2, respectively) and in-hospital complication rates (atrioventricular block, 13.0% and 9.7%, P greater than 0.2; cardiogenic shock, 3.7% and 3.0%, P greater than 0.2; cardiac arrest, 1.8% and 4.4%, P greater than 0.2, respectively). Patients with sustained ventricular tachycardia (28 patients) compared with those with nonsustained ventricular tachycardia (134 patients) had higher rates of polymorphic tachycardia (50% compared with 6%, P = 0.001), in-hospital total cardiac mortality (21% compared with 4%, P = 0.003) and sudden-death mortality (14% compared with 2%, P = 0.001); they also showed a trend toward a higher in-hospital mortality than the reference group (21.4% compared with 9.6%, P = 0.15) but had no increased mortality 1 year after discharge (4.6% compared with 5.4%, P greater than 0.2). CONCLUSIONS: As a group, patients with primary ventricular tachycardia do not differ from counterparts without primary ventricular tachycardia in their in-hospital clinical course and 1-year prognosis. Primary sustained ventricular tachycardia is often polymorphic and carries worse in-hospital prognosis than nonsustained tachycardia. However, it does not predict recurrent ventricular tachycardia or increased sudden-death rates during the next year.

Coronary Care Units↗
PubMed1992

[Use of thrombolysis for myocardial infarction in Israel].

Thrombolysis is generally accepted as the initial treatment for acute myocardial infarction. The extent to which this therapy is being implemented in Israel and the reasons for exclusion of cases from thrombolytic therapy were prospectively investigated. 413 consecutive patients with acute myocardial infarction hospitalized during January 1990 in 18 of Israel's 25 coronary care units were studied. Thrombolytic therapy was administered to 145 patients (35%: 38% of the men and 29% of the women; NS). It was used more often in those up to the age of 75 (38%) than in those over (18%, p less than 0.005) and in those with a first or anterior infarction (40% and 48%, respectively) than those with recurrent or inferior infarction (23% and 31%, respectively; p less than 0.005 for both). The 2 most frequent reasons for not using thrombolysis were late arrival in the coronary care unit (33%) and absence of ST elevation on the admission electrocardiogram (28%). Hospital mortality was 6% in the thrombolytic group versus 20% in those ineligible for thrombolysis. The significance of this difference is not clear as there was no randomization to treatment.

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PubMed1992

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

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

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PubMed1992

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

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

Angina Pectoris↗
PubMed1992

Prevalence and prognosis of chronic obstructive pulmonary disease among 5,839 consecutive patients with acute myocardial infarction. SPRINT Study Group.

PURPOSE: The purpose of this study was to report the prevalence and the clinical significance of clinically recognized chronic obstructive pulmonary disease (COPD) during acute myocardial infarction. PATIENTS AND METHODS: During 1981 to 1983, a secondary prevention study with nifedipine (SPRINT) was conducted in Israel among 2,276 survivors of acute myocardial infarction. During the study, demographic, historical, and medical data were collected on special forms for all patients with diagnosed acute myocardial infarction in 13 hospitals (the SPRINT Registry, n = 5,839). Mortality follow-up was completed for 99% of hospital survivors for a mean follow-up of 5.5 years (range: 4.5 to 7 years). RESULTS: The prevalence of COPD was 7% (406 of 5,839). The latter rate increased significantly in men (7.6%), smokers (9.7%), and older patients (70 years or older, 10.0%). Patients with COPD exhibited a complicated hospital course with an in-hospital mortality rate of 23.9%. Subsequent mortality rates in survivors at 1 and 5 years were 12.3% and 35.9%, respectively. Rates at the same time periods in patients without COPD were 17.2%, 9.2%, and 26.9% (p < 0.005 for in-hospital and 5 years). In a multivariate analysis that included age, gender, and history of myocardial infarction and congestive heart failure, COPD was not independently associated with either in-hospital or postdischarge excess fatality rates. CONCLUSION: In this large cohort of consecutive patients with myocardial infarction, the prevalence of COPD was 7% and higher among smokers, men, and elderly patients. Although in-hospital and postdischarge mortality rates were higher among patients with COPD, this condition did not independently increase either the risk of early death or the risk of long-term mortality among survivors of acute myocardial infarction.

Actuarial Analysis↗
PubMed1992

Long-term prognosis of patients with paroxysmal atrial fibrillation complicating acute myocardial infarction. SPRINT Study Group.

The aim of the study was to assess the relationship between paroxysmal atrial fibrillation during acute myocardial infarction and the long-term prognosis of patients after acute myocardial infarction. The incidence of paroxysmal atrial fibrillation among 5803 consecutive hospitalized patients was 9.9% (557/5803). Incidence rose with increasing age (less than or equal to 59 years, 4.2%), (60-69 years, 10.5%), (greater than or equal to 70 years, 16.0%) and was slightly (but not significantly) higher in women (11.0%) than in men (9.6%). The presence of congestive heart failure and mean age represented two major discriminants between patients with paroxysmal atrial fibrillation (70% and 68.6 years) in comparison with their counterparts (35% and 62.3% years). Hospital mortality was significantly higher (25.5%) in patients with paroxysmal atrial fibrillation than in those without (16.2%). However, the effect of paroxysmal atrial fibrillation disappeared when other factors influencing the short term prognosis (i.e. heart failure) were taken into account by a multivariate logistic regression analysis. The covariate adjusted relative odds of in-hospital mortality then fell to 0.82. The 1- and 5-year mortality rates were 18.6% and 43.3% in patients with paroxysmal atrial fibrillation as compared to 8.2% and 25.4% (P less than 0.001), respectively, in patients free of paroxysmal atrial fibrillation. Using a proportional hazards analysis of mortality through the first quarter of 1988 (average follow-up time, 5.5 years) the net risk of dying among patients with paroxysmal atrial fibrillation complicating the acute myocardial infarction is estimated at 1.28 (90% confidence interval, 1.12-1.46) relative to counterparts free of the complication.(ABSTRACT TRUNCATED AT 250 WORDS)

Age Factors↗
PubMed1991

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

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

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