Attitudes of attending physicians to the incidental diagnosis of hypercholesterolemia in hospitalized patients.
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Aged↗
Biomedical subjects
S Laniado
Publications and source records attributed to S Laniado.
Safety of coronary ultrasound angioplasty: effects of sonication on intact canine coronary arteries.
The purpose of this work was to examine in vivo the safety of sonication in the coronary arteries in a live animal model. In intact dogs (n = 8), balloon dilatation was performed on the proximal left anterior descending artery (LAD) followed by sonication to the left circumflex artery (LCX) in power levels found to be optimal for thrombus ablation. Post-dilatation and post-ultrasound coronary angiography, echocardiography, histopathology, CK-MB, indices of hemolysis, and coagulation were compared. Sonication did not induce changes in the ECG or blood pressure. Coronary angiography revealed no adverse side effects or change in arterial diameter (2.3 +/- 0.7 vs. 2.4 +/- 0.3 mm). Echocardiography showed transient opacification of the myocardium. Histopathology revealed a comparable minimal degree of endothelial denudation. After sonication there were no changes in the level of CK-MB (312 +/- 168 vs. 283 +/- 207 IU), hemoglobin (11.3 +/- 0.9 vs. 12.7 +/- 1.1 gr%), haptoglobin (479 +/- 136 vs. 451 +/- 121 mg/dL), fibrinogen (142 +/- 18 vs. 165 +/- 28 mg%), partial thromboplastin time (17.3 +/- 3.2 vs. 17.6 +/- 3.4 sec), prothrombin time (13.3 +/- 7.8 vs. 11.5 +/- 2.9 sec), and degree of platelet aggregation (55 +/- 17 vs. 62 +/- 8%). Thus, the data suggest that transluminal coronary sonication exerts no overt adverse effects in vivo.
Angioplasty, Balloon↗
Treatment with beta-adrenergic blocking agents after myocardial infarction: from randomized trials to clinical practice.
OBJECTIVES: Our aim was to determine the percent of patients with myocardial infarction who are treated with beta-adrenergic blocking agents in dosages proved to be effective in preventing death after a heart attack. BACKGROUND: In the prospective randomized trials showing that beta-blocker treatment improves survival rates after myocardial infarction, relatively high dosages of these agents were used. However, it is not known whether these dosages are used in current clinical practice. METHODS: In a retrospective analysis of clinical data from 606 consecutive survivors of myocardial infarction at four university hospitals in three countries, we assessed the number of infarct survivors receiving prospectively defined "effective dosages" of beta-blockers. We defined these dosages as those that demonstrated improved survival rates of infarct survivors who received active drug in large, prospective, double-blind, placebo-controlled trials. RESULTS: Only 58% of infarct survivors with no contraindications to beta-blockers received these drugs at the time of hospital discharge, and only 11% received dosages equivalent to > 50% of the effective dosages. Independent predictors of failure to prescribe beta-blockers to infarct survivors without contraindications to these drugs were the use of diuretic agents, transient heart failure, impaired left ventricular function and increased patient age. Among patients receiving beta-blockers, only the use of propranolol predicted prescription of a low beta-blocker dosage. CONCLUSIONS: Failure to prescribe beta-blockers after myocardial infarction is common but in most cases is not due to clear contraindications. Many patients not receiving beta-blockers belong to subgroups that would derive the greatest benefit from such treatment. Finally, even when beta-blockers are prescribed, the dosages used are considerably lower than those proved to be effective in preventing death after myocardial infarction.
Adrenergic beta-Antagonists↗
Right bundle branch block of unknown age in the setting of acute anterior myocardial infarction: an attempt to define who should be paced prophylactically.
It is widely accepted that patients presenting with acute anterior myocardial infarction and acute onset of right bundle branch block should be prophylactically paced in contrast with those who have a chronic bundle branch block. The admitting physician is faced with the dilemma of how to act if the age of this conduction disturbance is unknown. This problem has further intensified in recent years, with the introduction of thrombolytic treatment, where insertion of a central vascular line is associated with increased morbidity. The objectives of this study were to define clinical or electrocardiographic parameters that may help the admitting physician to decide whether patients presenting with an anterior wall myocardial infarction and a right bundle branch block of unknown age should be prophylactically paced. We examined prospectively the in-hospital clinical course of 39 consecutive patients presenting with an acute myocardial infarction in whom the age of a right bundle branch block upon admission was unknown (group C, n = 39) and compared with two similar groups of patients who presented with an acute right bundle branch block (group A, n = 38) and with a known chronic right bundle branch block (group B, n = 22). Thirty-three patients (33%) died, with cardiogenic shock being the leading cause of death in the entire population. Prophylactic pacing, which was carried out in 66% and 54% of patients in groups A and C, respectively, did not reduce mortality rates. No clinical or electrocardiographic variables on admission were predictive to support prophylactic pacing in group C. In 10 of 46 (22%) patients who were prophylactically paced with a transvenous electrode, the following complications attributed to the procedure were detected: (1) either rapid sustained ventricular tachycardia (during implantation) that was unresponsive to overdrive pacing, or ventricular fibrillation necessitating electrical defibrillation (4 patients); (2) recurrent episodes of rapid nonsustained ventricular tachycardia, which stopped only after the pacemaker was turned off (1 patient); (3) complete AV block (1 patient); (4) fever appearing on the third or fourth day after implantation (3 patients); and (4) a large hematoma in the groin in 1 patient who was treated with thrombolysis shortly before pacemaker electrode insertion. Thus, the complications of transvenous temporary pacing in the era of thrombolysis may outweight any theoretical advantage.
Acute Disease↗
Coronary ultrasound angioplasty: an update of an expanding technology.
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Angioplasty↗
Study of the mechanism of ultrasound angioplasty from human thrombi and bovine aorta.
Ultrasound angioplasty is a newly developed technology for percutaneous arterial recanalization. Data suggest that ultrasound is particularly effective in ablating fresh thrombi. Arterial walls were found to be resistant to ultrasound ablation. Thrombi, aortic wall segments, and hydroxyproline gelatin were studied in vitro to determine their respective ablation rates. The elasticity of the samples was determined in a force-mode apparatus. The cavitation threshold was determined in an arterial phantom apparatus. Thrombi displayed ablation rates that were > 20 times higher than those of aortic wall samples (591 +/- 82 vs 25 +/- 14 mg/s, p < 0.001). The differences in ablation rates were accompanied by significantly lower elasticities in the thrombus group compared with those in the aortic wall group (0.16 +/- 0.05 vs 312 +/- 37 g/cm2, p < 0.001). Experiments with hydroxyproline gelatin suggest a negative correlation (r = -0.90) between elasticity and ultrasound ablation. Ultrasound ablation of thrombi was evident only above the cavitation threshold. Thus, ultrasound angioplasty has the potential to induce the selective injury required for successful transluminal intervention in the treatment of thrombus-rich lesions.
Angioplasty↗
Serum lipids and restenosis after successful percutaneous transluminal coronary angioplasty. Ichilov Magnesium Study Group.
The effects of plasma lipids on the clinical and angiographic parameters of 134 patients, in whom coronary angioplasty was performed in 157 vessels, were prospectively examined. During a 6-month follow-up, restenosis was detected angiographically in 39 patients (29%; 45 vessels). None of the clinical, biochemical, or angiographic variables examined was predictive of stenosis and the tendency of a vessel to restenose was not patient-dependent but rather lesion-related. However, restenosis developed in 31 of 102 vessels (30%) in patients with high-density lipoprotein (HDL) cholesterol < or = 40 mg/dl, compared with restenosis in 10 of 55 vessels (19%) in patients with HDL cholesterol > 40 mg/dl (p = 0.092). No significant differences were observed when restenosis rates were compared in patients with total cholesterol levels > 250 mg/dl or < 250 mg/dl; no differences were seen in low-density lipoprotein (LDL) cholesterol levels when comparing patients with > 160 mg/dl and < 160 mg/dl. In 117 patients (132 vessels), complete serial blood specimens were obtained until the concluding angiography at 6 months. During follow-up, both groups (those with and without restenosis) had almost similar findings. Triglycerides decreased equally in both groups, and total cholesterol increased mildly in those who had restenosis; HDL and LDL cholesterol levels increased significantly in each group. No significant differences were observed with respect to extent of these changes between the groups. Thus, although lipid levels at the time of angioplasty and at 6 months follow-up were not found to predict the occurrence of restenosis, the association of low high-density lipoprotein levels and the tendency for restenosis should not be overlooked.
Angioplasty, Balloon, Coronary↗
Intravascular ultrasound characterization of thrombi of different composition.
An in vitro model was designed to test the hypothesis that thrombi of varying composition have different echogenic patterns. Thrombi were prepared in specially designed tubes, mounted on a holder that allows introduction of an intravascular ultrasound catheter rotated inside a subselective sheath. The thrombi were made by the addition of thrombin to whole blood, platelet-rich plasma, and to mixtures of whole blood and platelet-rich plasma with increasing concentration of whole blood relative to the volume of the mixture in the following ratios: 1:5, 2:5, 3:5 and 4:5. Sixty-six thrombi prepared from 11 blood samples of healthy subjects were studied and compared with control tubes filled with saline solution. Platelet-rich thrombi showed low echogenicity similar to saline solution. Whole blood thrombi appeared uniformly "speckled." Mixtures of whole blood and platelet-rich plasma showed a gradual increase in echogenicity with an increasing amount of whole blood in the mixture. Quantitative videodensitometry compared the gray scale intensity of each image relative to background saline. The mean value of echogenicity of platelet-rich thrombi was 0.9 +/- 1.2, and the mean value of whole blood thrombi was 13 +/- 5.3. Platelet-rich thrombi are echo-lucent, and the main echogenic reflectance of thrombi originates from red blood cells. The ultrasound intensity is in linear relation to the amount of red blood cells in the thrombus.
Adult↗
Effect of magnesium on restenosis after percutaneous transluminal coronary angioplasty: a clinical and angiographic evaluation in a randomized patient population. A pilot study. The Ichilov Magnesium Study Group.
Restenosis is a major clinical problem following successful percutaneous transluminal coronary angioplasty. Since magnesium has vasodilator and antithrombotic effects, this study was designed to evaluate its potential to decrease the rate of restenosis. In an open-labelled, randomized controlled study, 148 patients underwent successful coronary angioplasty. Ninety-eight patients were treated with 46-52 mmol/18-20 h intravenous magnesium sulphate (groups M1 and M2), and 49 of them continued with oral supplements of magnesium hydroxide 600 mg.day-1 (group M2). The other 50 patients served as controls (group C). Coronary angiography was performed before, immediately after and at 6 months follow-up or earlier if clinically indicated. Clinical, laboratory, ergometric and radionuclide evaluations were also carried out. One hundred and thirty-nine patients (94%) with 163 dilated segments completed the study. Intravenous magnesium was well tolerated. The cross-sectional area at the site of angioplasty increased by 3.55 +/- 2.01 mm2 in groups M1 and M2 compared with an increase of 2.90 +/- 1.63 mm2 in the control group, (P = 0.03). A trend towards a lower rate of restenosis (> 50% reduction in luminal diameter) was noticed in the magnesium groups (28/110, 25%) compared with the control group (20/53, 38%) P = 0.10. Oral administration of magnesium was well tolerated, did not have an additive effect on restenosis, but an improved clinical course was noted. It is concluded that intravenous administration of magnesium in patients undergoing coronary angioplasty is feasible and safe and that the beneficial trend of magnesium to prevent acute recoil and late (within 6 months) restenosis is encouraging and should promote further investigation in a larger patient population.
Administration, Oral↗
Detection of restenosis following percutaneous coronary angioplasty in single-vessel coronary artery disease: the value of clinical assessment and exercise tolerance testing.
Chest pain and submaximal exercise testing were prospectively assessed over a 6-month period, for detecting the evolution of restenosis in patients undergoing percutaneous coronary angioplasty, following either acute myocardial infarction or treatment of an anginal syndrome. Seventy-eight patients with one-vessel coronary artery disease underwent a modified treadmill exercise test at the 1-week, 3-month and 6-month follow-up after angioplasty, when a final angiogram was also performed. Forty-four patients (group A) were examined after myocardial infarction; in 34 patients (group B) angioplasty was done for incapacitating angina. Both groups showed similar results with low sensitivity and relatively moderate specificity of both chest pain and exercise tests; this was also the case for the time of restenosis to occur. It is thus concluded that the parameters examined are somewhat limited markers of restenosis following coronary angioplasty.
Adult↗
Percutaneous transluminal coronary angioplasty in elderly patients.
Fifty-six patients aged 75 years and older underwent percutaneous transluminal coronary angioplasty (PTCA) at our institution from 1984 to 1991. The average age was 76.7 +/- 1.5 years, and 84% of the patients were males. Single-vessel disease occurred in 21 patients, double-vessel disease in 16, and three-vessel disease in 19 patients. The mean left ventricular ejection fraction was 57 +/- 5%, and 8 patients had an ejection fraction of < 40%. The anginal functional class was I in 1 patient, II in 3, III in 6, and IV in 46 patients. Single-vessel PTCA was attempted in 43 patients, two-vessel PTCA in 8, and three-vessel PTCA in 5 patients. Revascularization was complete in 35% of the patients, incomplete in 57, and no revascularization was obtained in 8% of the patients. Ninety-one percent of the patients had a successful procedure. In 5 patients there was severe dissection, 1 patient died, 1 patient had an acute myocardial infarction, and 1 patient had emergency bypass surgery. Long-term follow-up (6-96 months, mean 21 +/- 4) in the 51 successfully treated patients revealed late cardiac death in 1 patient, repeated PTCA for restenosis in 9, and coronary bypass surgery in 2 patients. Twenty-two patients were asymptomatic, 12 had improved symptoms, and 5 remained symptomatic. PTCA appears to be a safe and effective treatment in elderly patients with one- and two-vessel disease, with excellent long-term results. Age is not a contraindication to PTCA. The results in elderly patients with three-vessel disease are less encouraging.
Aged↗
One-year clinical and echocardiographic follow-up of patients with congestive cardiomyopathy treated with captopril compared to placebo.
The beneficial hemodynamic and clinical effects of angiotensin-converting enzyme (ACE) inhibition in patients with severe congestive heart failure has recently been documented in large-scale studies. This mode of therapy when added to digitalis and diuretics improves survival. To evaluate the clinical effect and the changes in cardiac dimensions of captopril compared to placebo we followed 50 patients with severe congestive heart failure over 1 year using echo-Doppler cardiography. After randomization, 25 patients were started on captopril and 25 patients on placebo. At baseline and at 6 and 12 months, each patient underwent exercise tolerance test, radionuclide angiography to estimate left and right ventricular ejection fraction, M mode and two-dimensional echocardiography and Doppler cardiography to calculate cardiac dimensions and stroke volumes. During follow-up two patients in the captopril group and four in the placebo group died. Due to clinical deterioration nine patients in the placebo group had to be started on open-label captopril. Treatment with captopril was associated with a more significant improvement in functional class and exercise duration compared to placebo. Forward stroke volume estimated from Doppler echocardiography increased significantly by captopril from 47 +/- 3 to 55 +/- 3 ml and decreased in the placebo-treated patients from 49 +/- 5 to 44 +/- 4 ml. This improvement was associated with a trend towards reduced heart rate by captopril. Left ventricular end diastolic volume tended to increase in the placebo group and did not change in the captopril group. Calculated mitral regurgitant volume at 6 and 12 months tended to be lower in the captopril-treated patients. Thus captopril therapy proved efficacious in patients with severe congestive heart failure and resulted in increased forward stroke volume; it may have a beneficial effect on cardiac dimensions and on mitral regurgitation.
Analysis of Variance↗
Aminophylline for bradyasystolic cardiac arrest refractory to atropine and epinephrine.
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Aged↗
Mental stress and acute myocardial infarction.
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Adult↗
Time-consuming procedures and prehospital thrombolytic treatment.
OBJECTIVES: To assess time-consuming procedures in the prehospital stage of acute myocardial infarction patients who had received thrombolytic therapy at the scene, and to evaluate their effect on the clinical outcome. DESIGN: Prospective study. SETTING: Mobile intensive care unit staffed by an intern or a hospital-based physician. PARTICIPANTS AND INTERVENTIONS. Thrombolytic therapy with recombinant tissue-type plasminogen activator (total dose of 120 mg/6 hrs) was initiated at the scene in 167 patients. Treatment continued during transportation and thereafter in the cardiac care unit. During hospitalization, radionuclide ventriculograms and coronary angiography were performed in most patients. MEASUREMENTS AND MAIN RESULTS: Correct diagnosis was confirmed in 165 of 167 patients. Mean time to treatment was 96 +/- 42 (SD) mins with no significant difference between patients treated at home (n = 105) or in public places (n = 60). Global duration of treatment was significantly shorter when thrombolytic therapy was given in public as compared with treatment applied at home (50 +/- 13 vs. 57 +/- 16 mins, respectively, p < .002). CONCLUSION: If patients and physicians become aware of the potential advantages of prompt initiation of thrombolytic therapy at the scene, critical time may be saved in delivering thrombolysis to the clotted coronary artery.
Emergency Medical Services↗
Rapid resolution of new right bundle branch block in acute anterior myocardial infarction patients after thrombolytic therapy.
The objectives of this retrospective study are to describe the effect of thrombolytic treatment on the clinical course of patients with acute anterior myocardial infarction complicated by acute right bundle branch block. Patients admitted to the intensive cardiac care unit within < 4 hours from onset of symptoms, and demonstrating an acute right bundle branch block with, or without left axis deviation, on the qualifying ECG were included. All were given intravenous thrombolytic treatment consisting of: streptokinase (1,500,000 IU/40 min) or recombinant tissue type plasminogen activator (120 mg/6 hours). Following admission, patients were continuously monitored and a 12-lead ECG was recorded during each of the first 3 hours and then every 3 hours over the next 21 hours. Eight patients were included (8/211 = 3.8%). Their mean age was 62 +/- 7 years and time elapse from onset to treatment was 122 +/- 26 minutes. Complete resolution of the right bundle branch block occurred within < 3 hours in all and left axis deviation normalized in two patients. Mean peak creatine kinase was 1214 +/- 604 IU and global left ventricular ejection fraction, measured by isotope ventriculography within 24 hours from admission, was 39% +/- 15%. Only one patient was prophylactically paced. In the others, rapid normalization of the conduction block with reperfusion exceeded the logistics required for the transvenous pacemaker implantation procedure. Coronary angiography performed in six patients during 72 hours from admission revealed high grade stenoses in the proximal portion of the left anterior descending coronary artery in five patients and complete occlusion in one.(ABSTRACT TRUNCATED AT 250 WORDS)
Bundle-Branch Block↗
The use of transcranial Doppler in the hemodynamic assessment of implanted pacemakers.
Twenty patients with DDD pacemakers had their intracranial cerebral circulation assessed in different pacing modes, using transcranial Doppler. The studies were performed at the vertebral artery in a sitting position. Although DDD pacing was preferred to VVI pacing in 18 of the 20 patients, the figures did not reach statistical significance. There was no statistical difference in maximal blood flow velocity between DDD pacing at 60 and 80 beats/min. Varying the AV interval from 150-250 msec also demonstrated no clear difference in maximal peak Doppler velocity, in the group as a whole, though there was a greater individual preference for 150 msec. Transcranial Doppler assessment of the hemodynamics of the cerebral circulation is of limited value as an indicator of mode or rate preference in the pacemaker population.
Adult↗
[Impact of Shahal (Cardiac Emergency Services) on daily life of subscribers].
SHAHAL (Cardiac Emergency Services) provides professional 24-hour mobile emergency medical service monitored by intensive care nurses via a central computerized operations unit. All subscribers carry a "cardiobeeper" for transtelephonic transmission of a 3-lead electrocardiogram, and an automatic intramuscular self-injector containing 300 mg lidocaine. In this retrospective study we assessed the impact of SHAHAL on subscribers' mental stress, self-confidence and ultimately, quality of life. Answers to a written questionnaire (n = 1034) and a personal interview (n = 55) were analyzed. It was shown that SHAHAL is effective in decreasing mental stress and improving self-confidence in the majority of subscribers. It was especially beneficial in women, the elderly, those of lower socioeconomic status, pessimists and chronic worriers, and the ill more than the healthy. Those whose functional capacities were very limited benefited less, but for them SHAHAL's function as a life-saving and rescue system is more valuable. Lastly, subscription to SHAHAL also improved the self-confidence of the subscriber's family.
Aged↗