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Background Thrombolytic therapy is widely accepted for massive pulmonary embolism (PE) due to the high mortality risk associated with standard anticoagulation alone. Its role in submassive PE, however, has remained controversial. We aimed to evaluate whether the selective use of systemic thrombolytic therapy with intravenous tissue plasminogen activator (IV-tPA) improves the survival of patients with submassive PE at increased risk for clinical deterioration. Methods A total of 184 consecutive patients diagnosed with acute PE by chest thoracic angiography (CTA) were included in a retrospective study. Pulmonary artery obstruction and right/left ventricular dysfunction were evaluated by CTA and echocardiography. Medical history and simplified PE Severity Index (sPESI) were assessed at diagnosis. Hemodynamic and respiratory status were recorded at diagnosis, admission to pulmonary unit and prior to thrombolytic therapy. Patient survival was assessed at 30 of 90 days from diagnosis by CTA. Results All low risk patients (36%) per sPESI survived. Among the 117 remaining patients, 31% received IV-tPA. Respiratory failure was associated with decreased age-adjusted survival (P = 0.005). Among patients with respiratory failure selected for IV-tPA, age-adjusted survival was improved significantly compared to others (P = 0.043). Conclusions Thrombolytic therapy for hemodynamically stable PE patients with respiratory failure may improve survival. Trial registration MMC-0216-14

Elevated admission plasma glucose levels140 mg/dl are associated with adverse clinical outcomes in both diabetic and non-diabetic patients admitted with acute coronary syndrome (ACS). We aimed to evaluate the association between admission plasma glucose levels140 mg/dl and the outcome of non-diabetic patients admitted with acute coronary syndrome.The study population consisted of patients with acute coronary syndrome included in the Acute Coronary Syndrome Israeli Survey during 2000-2013. Diabetic patients were excluded. The primary endpoint was all-cause mortality at one year.The 452 0 patients had a mean age of 61.7±13.5 years and were stratified into four quartiles according to admission plasma glucose (60-94, 95-105, 106-119, 120-140 mg/dl). Patients with higher admission plasma glucose were older and included a higher percentage of smokers. In addition, the higher the glucose so also did they have a poorer risk factor profile including a higher body mass index, total and low-density lipoprotein cholesterol and triglyceride levels, and lower high-density lipoprotein cholesterol levels. During the first year 5.2% of patients died. A comparison of one-year mortality according to admission plasma glucose quartiles demonstrated a significant and progressive increase in mortality risk as admission plasma glucose rose (3.5%, 4.1%, 6.1%, 6.4%, respectively, p=0.001). However, this association lost its clinical significance following a multivariate analysis ( p=0.08).High admission plasma glucose levels within the normal to mildly impaired range are associated with increased one-year mortality in non-diabetic acute coronary syndrome patients. However, the higher glucose level is probably not the cause for the adverse outcome but rather a marker for high risk. Our findings support the definition of 140 mg/dl as the cutoff for clinically acceptable admission glucose levels in patients with acute coronary syndrome.

Unrecognized renal insufficiency, defined as estimated glomerular filtration rate60 mL/min/1.73 m(2) in the presence of normal serum creatinine, is common among patients with acute coronary syndrome. We aimed to determine the prevalence and clinical significance of unrecognized renal insufficiency in a large unselected population of patients with acute coronary syndrome.The study population consisted of patients with acute coronary syndrome included in the Acute Coronary Syndrome Israeli biennial Surveys during 2000-2013. The estimated glomerular filtration rate was calculated using the simplified Modification of Diet in Renal Disease formula. Patients were stratified into 3 groups: 1) normal renal function (estimated glomerular filtration rates ≥60 mL/min/1/73 m(2)); 2) unrecognized renal insufficiency (estimated glomerular filtration rates60 mL/min/1/73 m(2) with serum creatinine ≤1.2 mg/dL); and 3) recognized renal insufficiency (estimated glomerular filtration rates60 mL/min/1/73 m(2) with serum creatinine ≥1.2 mg/dL). The primary endpoint was all-cause mortality at 1 year.Included in the study were 12,830 acute coronary syndrome patients. Unrecognized renal insufficiency was present in 2536 (19.8%). Patients with unrecognized renal insufficiency were older and more frequently females. All-cause mortality rates at 1 year were highest among patients with recognized renal insufficiency, followed by patients with unrecognized renal insufficiency, with the lowest mortality rates observed in patients with normal renal function (19.4%, 9.9%, and 3.3%, respectively, P.0001). Despite their increased risk, patients with renal insufficiency were less frequently referred for coronary angiography and were less commonly treated with guideline-based cardiovascular medications.Acute coronary syndrome patients with unrecognized renal insufficiency should be considered as a high-risk population. The question of whether this group would benefit from a more aggressive therapeutic approach should still be evaluated.

Yoram Neuman,1,3 Matthew Koslow,2,3 Alona Matveychuk,2,3 Avigdor Bar-Sef,1 Alexander Guber,2,3 David Shitrit2,3 1Division of Cardiology, 2Pulmonary Department, Meir Medical Center, Kfar Saba, Israel; 3Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel Background and objective: Patients with pulmonary hypertension (PH) are considered to be at risk for complications associated with flexible bronchoscopy (FB), but data concerning the degree of PH are often lacking. We investigated whether COPD patients with PH who undergo bronchoscopy are at greater risk for complications. Methods: This prospective study included 207 consecutive COPD patients undergoing FB. All underwent an echo-Doppler to evaluate pulmonary artery pressure on the day of the bronchoscopy procedure. Pulmonologists were blinded to the echocardiogram results. Results: A total of 167 patients (80.7%) had normal pulmonary pressure. The remaining 40patients (19.3%) had PH: 27 (13.0%) mild, eight (3.9%) moderate, and five (2.4%) severe. Noninvasive hemodynamic parameters between groups before and after FB were similar. Two patients with normal pulmonary pressure developed supraventricular tachycardia. None developed hemodynamically significant dysrhythmia. Bleeding episodes between groups in bronchoalveolar lavage (BAL) and transbronchial biopsy (TBB) did not differ. PH patients who underwent BAL and TBB had decreased O2 saturation during the procedure compared with the non-PH group (23.5% vs 6.9%, P=0.033). No deaths were attributable to FB. Conclusion: PH is common among COPD patients undergoing FB. PH patients undergoing BAL and TBB are at higher risk of decreased O2 saturation than those without PH. Further studies should assess the risk among COPD patients with moderate-to-severe PH. Keywords: bronchoscopy, hypoxemia, pulmonary hypertension

OBJECTIVES Patients with peripheral artery disease (PAD) less frequently achieve secondary prevention goals compared with patients with coronary artery disease (CAD). We aimed to compare mortality rates in patients with PAD and CAD following first vascular intervention. PATIENTS AND METHODS Patients 18 years of age or older without a history of cardiovascular disease, who underwent first coronary or lower limb vascular intervention between 2002 and 2010, were included in this study. The primary endpoint was all-cause mortality. RESULTS Of the 9950 participants, 8242 (82.8%) underwent first coronary revascularization and 1708 (17.2%) received first peripheral vascular intervention. During a mean follow-up period of 5.6±2.3 years, 1283 (12.9%) participants died. Compared with CAD patients, patients with PAD had significantly worse long-term prognosis with an increased risk for all-cause mortality (hazard ratio=2.95, 95% confidence interval 2.6-3.3, P

Guidelines recommend low-density lipoprotein-cholesterol (LDL-C) target of70 mg/dL in patients with coronary disease. However, this goal is not achieved in many patients.We compared LDL-C control in patients with coronary disease treated by a primary care physician or with the addition of a cardiologist.Included were patients with coronary disease who had full lipid profile. Primary end points included the percentage of patients who achieved the LDL-C goals of100 mg/dL and70 mg/dL.Of the 27,172 patients, 12,965 (47.7%) were followed only by a primary care physician and 14,207 (52.3%) were also followed by a cardiologist. Overall, 18,366 patients (67.6%) achieved the LDL-C goal of100 mg/dL, and 6517 patients (24%) achieved the LDL-C goal of70 mg/dL. Patients followed by a cardiologist more frequently achieved the LDL-C goal of100 mg/dL (74.3% and 60.3%; P.0001, in patients treated by a cardiologist or by a primary care physician, respectively), as well as the lower LDL-C goal of70 mg/dL (27.2% and 20.4%; P.0001, in patients treated by a cardiologist or by a primary care physician, respectively). Differences in LDL-C control remained significant after a multivariate adjustment. Patients followed by a cardiologist were more commonly treated with highly potent statins and with non-statin cholesterol-lowering drugs.Among patients with coronary disease, those followed by a cardiologist receive a more aggressive antilipid treatment and more frequently achieve lipids goals. Nevertheless, the disappointingly poor lipid control in both groups warrants an effort to improve adherence for guidelines in both primary care and cardiology clinics.

Background: Chronic kidney disease is a frequent comorbidity among patients with acute coronary syndrome (ACS). We aimed to evaluate treatment characteristics in ACS patients according to their renal function and to assess the effect of differences in therapy on clinical outcomes. Methods: Included were patients with ACS enrolled in the biennial Acute Coronary Syndrome Israeli Surveys (ACSIS) during 2000-2013. Excluded were patients with cardiogenic shock at presentation. The estimated glomerular filtration rate (eGFR) was calculated using the simplified Modification of Diet in Renal Disease (MDRD) formula. The distribution of the eGFRs was divided into 4 categories (2). The primary endpoint was all-cause mortality at 1 year. Results: A total of 13,194 patients with ACS were included. Patients with a reduced eGFR were less likely to be admitted to a coronary care unit and had lower rates of coronary angiograms and subsequent percutaneous coronary interventions. Furthermore, as the eGFR was lower, the patients were less frequently treated with aspirin, clopidogrel, β-blockers, and ACE inhibitors/angiotensin receptor blockers. We demonstrated an inverse association between renal function and 1-year mortality, with the highest mortality rates observed in the group with the lowest eGFR (HR = 3.8, 95% CI 2.9-4.9, p < 0.0001). Differences in mortality remained significant following a multivariate analysis for all the baseline characteristics as well as for invasive and medical treatment (HR = 2.7, 95% CI 1.9-3.7, p < 0.0001). Conclusions: ACS patients with chronic kidney disease represent a high-risk group with an increased mortality risk. Despite this high risk, these patients are less frequently selected for an invasive treatment strategy and are less commonly treated with guideline-based medications. However, reduced renal function was associated with higher mortality regardless of the variations in therapy.

Complementing the physical examination with a point-of-care ultrasound study (POCUS) can improve patient triage. We aimed to study the impact of POCUS on the diagnosis and management of outpatients and hospitalized patients with suspected cardiac disease. In this multicenter study, a pocket-sized device was used to perform POCUS when the diagnosis or patient management was unclear based on anamnesis, physical examination, and basic diagnostic testing. Eighteen physicians (cardiac fellows 49%, cardiologists 30%, and echocardiographers 21%) performed physical examinations extended by POCUS on 207 patients (inpatients 83% and outpatients 17%). POCUS findings resulted in a change in the primary diagnosis in 14% of patients. In patients whose diagnosis remained unchanged, POCUS results reinforced the initial diagnosis in 48% of the cases. In 39% of the patients, the diagnostic plan was altered, including referral (16%) or deferral (23%) to other diagnostic techniques. Alteration in medical treatment (drug discontinuation or initiation) occurred in 11% of the patients, and in 7% POCUS results influenced the decision whether to perform a therapeutic procedure. Hospitalization or discharge was determined after POCUS in 11% of the patients. In conclusion, during patient triage, extension of the physical examination by POCUS can cause physicians to alter their initial diagnosis, resulting in an immediate change of diagnostic and therapeutic procedures. Based on POCUS results, physicians altered the diagnostic plan either by avoiding or referring patients to other diagnostic procedures in almost half of the studied population.

Objectives: We aimed to study the trends in management and outcome of post CABG patients presenting with acute MI. Background: Primary angioplasty is the treatment of choice in patients with acute myocardial infarction. Saphenous vein grafts used for CABG are large-diameter conduits that tend to accumulate a large mass of thrombus when they are the culprit artery for acute myocardial infarction (MI). We hypothesized that performing PCI in these patients is more complex and possibly results in worse outcome compared to non-CABG patients. Methods: Data for patients with STEMI was obtained from five acute coronary syndromes Israeli biennial Surveys (ACSIS) during 2000–2008. Baseline characteristics, management and outcome of post-CABG patients were compared to non-post CABG patients during 2006–2008 surveys. Results: A total of 9,781 patients were included. About 1,002 (10.2%) were post-CABG. Reperfusion therapy for post-CABG patients (34–48%) was consistently lower compared to non-CABG patients (57–65%). Angiographic outcome in patients with STEMI who underwent primary PCI (17 post-CABG, mean age 66.6 ± 9.1 and 821 non-CABG, age 60.1 ± 12.9) was successful (TIMI flow 3) in 86 and 88%, respectively. Thirty-day mortality was 5.9 and 5.1% (P = 0.89) and MACE rates were 17.6 and 12.5%, respectively (P = 0.54). Conclusions: Use of primary PCI in post-CABG patients was lower than in non-CABG patients but increased steadily and to a similar extent in both groups. Angiographic and clinical outcome was similar despite assumingly larger thrombus burden in post CABG patients. Therefore, primary angioplasty is appropriate also in post-CABG patients presenting with STEMI. © 2011 Wiley-Liss, Inc.

AIMS To test the efficacy and safety of a chitosan pad for femoral haemostasis as an adjunct to manual compression. Haemostasis of the femoral artery after coronary angiography by manual compression is time consuming and uncomfortable for the patient. Closure devices are costly and do not reduce vascular complication rate. The HemCon(r) pad is used by the US army to control traumatic bleeding. It consists of chitosan, a positively charged carbohydrate that attracts the negatively charged blood cells and platelets and promotes clotting. METHODS AND RESULTS Patients undergoing percutaneous coronary angiography were 1:1 randomised for manual compression with regular or HemCon(r) pad. All patients were catheterised with 6 Fr sheath and received 2500 u of heparin. Time to haemostasis, incidence of minor and major bleeding, haematoma size, post-procedural stay at the hospital and level of satisfaction were compared between the two groups. Seventy patients in the HemCon group and 66 patients in the regular pad groups were recruited. Activated clotting time (ACT) before manual compression was similar, 183.9 ± 43.4 and 178.3 ± 34.2 seconds in the HemCon(r) and regular pad groups respectively. Time to haemostasis was 5.6 ± 2.1 and 8.4 ± 3.5 minutes in the HemCon® and regular pad groups, respectively (p

The feasibility and diagnostic accuracy of transesophageal pacing stress echocardiography for detection of inducible myocardial ischemia were evaluated in 161 patients 80 years of age or older (mean 84 +/- 3.9, range 80-97). The pacing time was 5.5 +/- 2.5 minutes with a total test time of 37 +/- 7 minutes. The mean achieved heart rate was 96 +/- 7% (83%-121%) of maximum predicted with an average rate pressure product of 21,560 +/- 5175 beats/min x mm Hg. There were minor adverse events in 8% of cases and no major complications occurred. Patient acceptance was high. When compared with myocardial single photon emission computed tomography, pacing stress echocardiography had a sensitivity of 89% and a specificity of 93% for the detection of myocardial ischemia, and 91% agreement (kappa = 0.80, P < .001). We demonstrate that pacing stress echocardiography is safe and accurate for detection of myocardial ischemia and, thus, a reliable substitute to exercise and pharmacologic stress testing in octogenarians.

This study compared the accuracy of cardiovascular diagnoses by medical students operating a small hand-carried ultrasound (HCU) device with that of board-certified cardiologists using standard physical examinations. Sixty-one patients (38% women; mean age 70 +/- 19 years) with clinically significant cardiac disease had HCU studies performed by 1 of 2 medical students with 18 hours of training in cardiac ultrasound and physical examinations by 1 of 5 cardiologists. Diagnostic accuracy was determined by standard echocardiography. Two-hundred thirty-nine abnormal findings were detected by standard echocardiography. The students correctly identified 75% (180 of 239) of the pathologies, whereas cardiologists found 49% (116 of 239) (p0.001). The students' diagnostic specificity of 87% was also greater than cardiologists' specificity of 76% (p0.001). For nonvalvular pathologies (115 findings), students' sensitivity was 61%, compared with 47% for cardiologists (p = 0.040). There were 124 clinically significant valvular lesions (111 regurgitations, 13 stenoses). Students' and cardiologists' sensitivities for recognizing lesions that cause a systolic murmur were 93% and 62% (p0.001), respectively. Students' sensitivity for diagnosing lesions that produce a diastolic murmur was 75%; cardiologists recognized 16% of these lesions (p0.001). The diagnostic accuracy of medical students using an HCU device after brief echocardiographic training to detect valvular disease, left ventricular dysfunction, enlargement, and hypertrophy was superior to that of experienced cardiologists performing cardiac physical examinations.

ObjectivesWe evaluated whether ultrasound improves myocardial tissue perfusion in 14 animals with coronary artery occlusion.BackgroundA recent study demonstrated that low-frequency ultrasound improves tissue perfusion in the rabbit ischemic limb, but there are no data on ultrasound enhancement of myocardial perfusion.MethodsFourteen animals (9 dogs, 5 pigs) underwent thoracotomy and occlusion of a diagonal branch of the left anterior descending coronary artery. Myocardial tissue perfusion units (TPUs) and pH were measured before coronary occlusion, after occlusion, and after direct exposure of the ischemic myocardium in thepresence of fixed occlusion to low-frequency ultrasound (27 kHz).ResultsThe TPU decreased from 100.9 ± 13 at baseline to 71.1 ± 13 (p < 0.01) after 60 min occlusion but rose by 19.7% to 85.1 ± 8 (p < 0.01) after ultrasound exposure for 60 min. After 60-min coronary occlusion, myocardial pH fell from 7.43 ± 14 to 7.05 ± 0.15 (p < 0.01) but then improved to normal (7.46 ± 0.32) after ultrasound for 60 min. Administration of l-Nω-nitro-arginine methyl esther (l-NAME), an inhibitor of nitric oxide synthase, before ultrasound exposure, blocked improvement in myocardial tissue perfusion and pH by ultrasound. Quantitative histomorphology showed a significant increase in the capillary area of myocardium exposed to ultrasound versus non-exposed myocardium (16.2 ± 7.9 vs. 8.2 ± 2.1, p < 0.02).ConclusionsLow-frequency, low-intensity ultrasound improves myocardial tissue perfusion and pH in the presence of a fixed coronary artery occlusion.

One hundred fifty patients with their first acute myocardial infarctions (AMIs) were studied. AMIs were confirmed by troponin levels, ST-segment elevation, or angiographic coronary occlusion. In 36% of patients (16 of 45) with left ventricular (LV) hypertrophy, the wall motion score index was normal, whereas in patients with no LV hypertrophy, only 18% (19 of 105) had no segmental wall motion abnormalities (p = 0.03). When adjusting for troponin level, the odds ratio for normal wall motion of patients with LV hypertrophy was 2.86 (95% confidence interval 1.26 to 6.50) compared with those with normal wall thickness. Consequently, normal LV wall motion by echocardiography in the setting of LV hypertrophy does not exclude AMI.

The accuracy of a hand-carried cardiac ultrasound (HCCU) device for the diagnosis of valvular regurgitations using color-flow Doppler was assessed. One hundred twenty hospitalized patients with at least mild valvular regurgitation by standard echocardiography were evaluated by 2 cardiologists using HCCU. The HCCU operator identified 99% of clinically significant valvular regurgitations and assessed the severity correctly in 83% of cases. For mild regurgitation, the HCCU sensitivity and specificity were 82% and 93%, respectively, resulting in correct assessments of severity in 71% of cases. HCCU used by trained cardiologists has high sensitivity for the detection and accurate assessment of the severity of clinically relevant valvular regurgitation.

Objectives We evaluated the coronary vasodilatory effects of transcutaneous low-frequency (27-kHz) ultrasound (USD). Background Ultrasound has been shown to affect vascular function. Methods Ultrasound energy was administered transcutaneously to 12 dogs. Coronary arterial dimensions were assessed using intravascular coronary ultrasound (IVUS) and quantitative coronary angiography (QCA). Results The IVUS mid-left anterior descending (LAD) luminal area was 6.77 ± 1.27 mm2at baseline. After 30 s of ultrasound, this area increased by 9% (7.40 ± 1.44 mm2, p Conclusions Noninvasive, transthoracic low-frequency USD energy results in coronary artery vasodilation within seconds of exposure. The vasodilation is reversible and is similar in magnitude to that induced by NTG. Further evaluation is needed to assess its potential applications in humans.

Background: We examined the agreement between transthoracic echocardiography (TTE) and intraoperative prepump transesophageal echocardiography (TEE) in the assessment of left-sided regurgitant lesions and echocardiographic variables associated with grading discrepancies. Methods: The TTE and prepump TEE studies of 54 patients undergoing aortic-valve replacement for aortic stenosis were reviewed. Agreement and correlation in assessment of aortic (AR) and mitral regurgitation (MR) severity were evaluated. Results: There was no significant difference between mean TTE and prepump TEE grading of MR (0.23 ± 0.19 vs. 0.21 ± 0.15 jet area/area of the left atrium, p = 0.49), but the correlation between the two methods was weak (r = 0.40, p = 0.003), with an exact agreement of 54%. Prepump TEE tended to grade AR as more severe (mean grade 1.43 ± 0.94 vs. 1.24 ± 0.75, p = 0.058). The correlation between the two methods in AR assessment was fair (r = 0.70, p = 0.0001) with an agreement of 59%. For MR and AR grading, no significant correlations between valvular regurgitation severity and blood pressure differences between preoperative TTE and prepump TEE were found. In 17% of cases, discrepancies in identifying severe mitral or aortic valve regurgitation could have affected patient management. Conclusions: There is modest agreement in MR and AR assessment between TTE and prepump TEE. Cardiologists, cardiac surgeons, and anesthesiologists must be aware of differences between these methods when using prepump TEE to guide intraoperative decisions.

Objectives. This study sought to evaluate expression of adhesion molecules on neutrophils and monocytes throughout the acute phase of myocardial infarction. Background. Neutrophil and monocyte counts increase within days from onset of acute myocardial infarction. Because leukocytes are recruited to the involved myocardial region, we postulated that these activated cells would display an increased expression of adhesion molecules necessary for effective endothelial transmigration. Methods. We measured the expression of neutrophil and monocyte lymphocyte function associated antigen-1 (LFA-1), Mac-1, very late after activation antigen-4 (VLA-4) and intercellular adhesion molecule-1 (ICAM-1) by flow cytometry throughout the acute phase of acute myocardial infarction in 25 patients and 10 age-matched control subjects. Results. Expression of Mac-1 on neutrophils increased significantly, whereas no expression of VLA-4 and ICAM-1 was detected. The expression of LFA-1, Mac-1, VLA-4 and ICAM-1 on the monocyte cell membrane in patients with an acute myocardial infarction was increased compared with that in control subjects by 22% (on day 7), 67%, 13% and 44% (all on day 4), respectively (all p Conclusions. Increased expression of neutrophil and monocyte adhesion molecules may contribute to their adhesion to endothelium in the ischemic territory. This adhesion could feasibly precipitate vasoconstriction or add a local thrombotic effect due to tissue factor expression secondary to Mac-1 engagement. In addition, the manifestation of increased density of LFA-1 and Mac-1 by activated leukocytes with monocytes also expressing ICAM-1 suggests that leukocytes may form microaggregates that could cause microvascular plugging. This mechanism may facilitate the occurrence of the “no-reflow” phenomenon or slow coronary filling after acute myocardial infarction.

Cardiac papillary fibroelastoma is a rare cardiac tumor and occurs mainly on cardiac valves. The incidence of multiple lesions is exceedingly rare and is about 7% of all reported cases. Careful echocardiographic evaluation of the patient before operation is of high importance as the there is no recurrence after surgical excision. We present the first case of a patient with multiple aortic valve papillary fibroelastomas diagnosed before operation. The patient underwent surgical removal of the 3 masses that were confirmed as cardiac papillary fibroelastomas by pathologic examination. There was no evidence of aortic insufficiency after operation.

Peripheral arterial disease (PAD) is a strong risk factor for cardiovascular morbidity and mortality. Therefore, target low-density lipoprotein (LDL) cholesterol level in patients with PAD is ≤70 mg/dl, similar to patients with coronary artery disease (CAD). However, despite their high cardiovascular risk, patients with PAD less frequently achieve LDL cholesterol goals compared to patients with CAD. We aimed to compare LDL cholesterol control in patients after first coronary or peripheral vascular intervention. Included were patients ≥18 years of age without a history of cardiovascular disease who underwent first coronary or peripheral vascular intervention from 2004 through 2010. Primary end points were percentage of patients who achieved the LDL cholesterol goal of100 and70 mg/dl. Of 9,138 patients available for analysis, 7,512 (82.2%) underwent first coronary revascularization and 1,626 (17.8%) underwent first peripheral revascularization. Patients after first coronary revascularization were treated more frequently with any statin and with highly potent statins. Furthermore, they more frequently achieved the LDL cholesterol goals compared to patients after first peripheral intervention. This was true for the LDL cholesterol goal of100 mg/dl (65% and 46.7%, p0.0001) and for the lower LDL cholesterol goal of70 mg/dl (23.3% and 13.3%, p0.0001). Differences in LDL cholesterol control between the 2 groups remained statistically significant after multivariate adjustment. In conclusion, lipid control in patients with PAD is poor and significantly inferior to that of patients with CAD even after the first vascular intervention.

Three sisters in a family with seven children whose grandmother had an ovarian embryonal carcinoma experienced development of malignant and a malignant-like situation in childhood. Two were diagnosed as having malignant germ cell tumors of the ovary, and the third was found to have Langerhans' histiocytosis. The two girls with germ cell tumor shared an identical human leukocyte antigen, whereas the sister with histiocytosis shared one identical haplotype with them. All three children have been treated successfully with chemotherapy and are doing well off of treatment.

A rare case of CNS Burkitt's lymphoma presenting as acute Guillain-Barré syndrome is presented. A 6-year-old previously healthy female presented with acute onset of limb and truncal weakness, involvement of ocular and bulbar nerves, and areflexia. The clinical diagnosis of Guillain-Barré syndrome prompted treatment with intravenous gammaglobulin with no response. A lumbar puncture following revealed marked pleocytosis, elevated protein, and decreased glucose. Immunological, cytological, and molecular studies of these cells confirmed the diagnosis of Burkitt's lymphoma IgM, kappa with t(8;14) and rearrangement of the J and kappa immunoglobulin chains. Aggressive systemic and intrathecal chemotherapy were started and within 5 days remission was achieved. The child is in complete remission 2 years from diagnosis. Although very rare, CNS lymphoma should be taken into account in every patient presenting with the clinical features of acute polyneuropathy.

Subclinical thyroid dysfunction is associated with increased mortality and cardiovascular risk. It is unknown whether this association remains within normal thyroid function range.The study was conducted using the computerized database of the Sharon-Shomron district of Clalit Health services. Included were subjects aged ≥40 years with normal thyroid function. Patients with a history of thyroid or cardiovascular diseases or diabetes were excluded. The primary end points were all-cause mortality and the need for coronary revascularization with either percutaneous coronary intervention or coronary artery bypass grafting.The 42,149 participants were stratified into 3 groups of equal thyrotropin intervals (0.35-1.6, 1.7-2.9, and 3-4.2 mIU/L). During a mean follow-up of 4.5±2.1 years, 4239 (10.1%) participants died and 1575 (3.7%) underwent coronary revascularization. For both women and men, the lowest mortality rates were observed in the intermediate thyrotropin group. Nevertheless, only for the low thyrotropin group, mortality risk remained significantly higher as compared with the intermediate thyrotropin group, even following multivariate model adjusted for the conventional cardiovascular risk factors, in both women (odds ratio 1.22; 95% confidence interval, 1.09-1.36 for the low thyrotropin group, compared with the intermediate group) and men (odds ratio 1.14; 95% confidence interval, 1.01-1.3 for the low thyrotropin group, compared with the intermediate group). There was no significant difference in the need for coronary revascularization among the 3 thyrotropin groups in both men and women.Low thyrotropin level within the reference range is associated with increased risk for all-cause mortality.

A 53-year-old woman was admitted for dyspnoea. Her past history included mitral valve replacement (mechanical, tilting disc) 20 years earlier. The patient was well coumadinized both on admission and during the previous months. X-ray demonstrated pulmonary oedema. A transoesophageal echo (TEE) study was preformed to evaluate a high diastolic pressure gradient across the prosthetic valve ( Figure ). The TEE findings …

Patent foramen ovate is a common finding in the general population. However, interatrial right to left shunt causing severe hypoxemia in the absence of pulmonary hypertension is a rare finding. The authors describe two such patients suffering from severe hypoxemia refractory to oxygen supplementation. The first, a 57-year-old mate, developed severe hypoxemia several months after right pneumonectomy. The second patient, an 83 year old lady was found with severe hypoxemia after an unrelated fall and the degree of hypoxemia was posture related. Regular transthoracic Doppler echocardiography did not explain the hypoxemia in either patient. One hundred percent oxygen breathing test suggested large right to Left anatomic shunt in both patients. Doppler echocardiography with intravenous agitated saline injection demonstrated the existence of interatrial right to left blood shunting in both patients in the absence of elevated systolic pulmonary artery pressure. Both patients underwent right heart catheterization. Pulmonary arterial hypertension was ruled out and the interatrial shunt was successfully occluded percutaneously by an Amplatzer device. In both patients, hypoxemia resolved immediately after the occlusion of the interatrial shunt and their quality of life improved remarkably. In cases of unexplained refractory hypoxemia, in the absence of acute lung disease, and especially if related to upright posture, one should consider platypnea-orthodeoxia syndrome and its most common cause, a right to left interatrial shunt. This can nowadays be successfully treated percutaneously.

The features of infective endocarditis include both cardiac and non-cardiac manifestations. Neurologic complications are seen in up to 40% of patients with infective endocarditis and are the presenting symptom in a substantial percentage. We describe in detail the clinical scenarios of three patients admitted to our hospital, compare their characteristics and review the recent literature describing neurologic manifestations of infective endocarditis. Our patients demonstrate that infective endocarditis can develop without comorbidity or a valvular defect. Moreover, our patients were young and lacked the most common symptom of endocarditis: fever. The most common neurologic manifestations were focal neurologic deficits and confusion. We conclude that infective endocarditis should always be considered in patients presenting with new-onset neurologic complaints, especially in those without comorbidities or other risk factors. A prompt diagnosis should be reached and antibiotic treatment initiated as soon as possible.

Fasting glucose levels elevated beyond the normal range have been associated with increased cardiovascular risk. However, it is unknown whether this association exists for variations of fasting glucose within the normal range. The present study was conducted using the computerized database of the Sharon-Shomron District of Clalit Health Services. Included in the present study were subjects with fasting glucose levels within the normal range (100 mg/dl). We excluded patients with a history of cardiovascular disease or diabetes. The primary outcome was the incidence of coronary revascularization with either percutaneous coronary intervention or coronary artery bypass grafting. The 28,263 participants (age 53.7 ± 12.2 years) were divided into quartiles according to the fasting glucose level (75.4 ± 4.5, 83.6 ± 1.7, 88.9 ± 1.4, and 95.1 ± 2.2 mg/dl). During a mean follow-up of 5.9 ± 0.7 years, 424 subjects required coronary revascularization. A progressive increase was seen in the risk of coronary revascularization as the fasting glucose levels increased within the normal range (hazard ratio 1.73, 95% confidence interval 1.3 to 2.3, p0.001, between the fourth and first quartiles). However, this association lost its statistical significance after adjustments for the conventional coronary risk factors (hazard ratio 1.17, 95% confidence interval 0.85 to 1.62, p = 0.328). In conclusion, elevated fasting glucose levels within the normal range were associated with an increased cardiovascular risk. This association was caused by the greater prevalence of the other conventional risk factors and not by the glucose level itself.

Pulmonary arterial hypertension is a well-established sequel of LV systolic dysfunction; however its association with diastolic dysfunction in subjects with normal LV systolic function has not been thoroughly studied. The aim of this study was to evaluate the correlation between diastolic dysfunction and pulmonary arterial hypertension in patients with normal left ventricular (LV) wall motion.We analyzed retrospectively 477 consecutive echocardiographic studies that were performed in the Meir Medical Center echocardiography laboratory in subjects with normal LV systolic function and correlated the state of diastolic function (normal, impaired relaxation, pseudo normal and restrictive pattern) to the magnitude of pulmonary artery pressure (PAP) assessed by echocardiography. None of the subjects that were studied had any other established causes of pulmonary hypertension.Mean PAP for subjects with normal diastolic function (n=110) was 31.1+/-6 mm Hg; for grade 1 diastolic dysfunction (impaired relaxation ) (n=256) 35.6+/-10.2 mm Hg; for grade 2 (pseudo normal) (n=102) 38.9=10.6 mm Hg and for grade 3 (restrictive pattern) (n=9) the pressure was 55.1+/-11.4 mm Hg (p0.001 by one-way ANOVA, the differences were between each 2 groups of diastolic dysfunction).LV diastolic dysfunction is associated with an increase in PAP in subjects with normal systolic function. PAP is significantly increased for each step-up in diastolic dysfunction grade.

This report describes the echocardiographic diagnosis of an intracardiac mass in a heart transplant patient. The typical morphology of the lesions, its attachment to the interatrial septum, and the absence of a nidus focus for thrombus formation led to the preoperative assumption that it was a myxoma. The mass was successfully excised at the time of operation and the patient had an uneventful recovery. Pathology findings revealed a thrombus. Thus, echocardiography may have limited specificity for the differentiation of intracardiac tumors and thrombus.

Ischemic heart disease is a chronic illness that causes major mortality and morbidity. Angiographic studies have shown the effectiveness of exercise programs, in combination with aggressive lipid management, in reversing or slowing the progression of atherosclerotic coronary disease. Despite these studies, participation in supervised programs that combine exercise and risk-factor management is limited. The authors measured the ability of a community hospital-based ambulatory cardiac rehabilitation program to recruit patients and to facilitate reduction of risk factors that have been demonstrated to influence progression of disease. Patients were recruited from a single community hospital for an ambulatory exercise training and cardiac risk-factor management program, and clinical and laboratory data was collected periodically. Recruited patients participated in a minimum 3-month period of training and counseling by a multidisciplinary team with follow-up measurements of weight, lipid profile, blood pressure, and exercise capacity. Thirty-two percent of the eligible hospitalized patients were successfully recruited into the program. Dropout rates over the initial 3 months were low (25%). Improvement in low-density lipoprotein cholesterol level (−4.5%), high-density lipoprotein cholesterol level (+7%), body mass index (−2%), systolic blood pressure (−3%), and maximum metabolic equivalents (+25%) were comparable to levels achieved in studies showing angiographic stabilization and/or regression of disease. Implementation of a community hospital-based risk management exercise program is an effective method for improving the long-term management of patients with chronic ischemic heart disease.

The availability of cardiac ultrasound is limited in developing countries. We evaluated the feasibility and diagnostic capability of a hand-carried cardiac ultrasound device in 126 patients (age 44 +/- 24 years) referred for consultation to a cardiology clinic in rural Mexico. The hand-carried cardiac ultrasound device identified 86 cardiac findings and obviated the need for further comprehensive echocardiographic evaluation in 90% of patients (113 of 126).

Background: Aspirin, glycoprotein IIb/IIIa inhibitors and heparin are routinely used in acute coronary syndromes. Previously we showed that there is synergism between ultrasound and heparin and tirofiban in augmenting blood clot disruption. However, there is a little data on a possible synergism of low-frequency ultrasound with aspirin for in-vitro clot dissolution, and especially on the combination of aspirin with heparin and/or glycoprotein IIb/IIIa inhibitors. Materials and Methods: Human blood clots (n = 320) were incubated for 10 or 20 minutes in saline containing aspirin alone or combined with heparin and/or tirofiban and/or eptifibatide. Clots were randomly treated with low-frequency ultrasound (27.3 kHz) or incubation only. The percent clot weight loss and the incremental effect of ultrasound were calculated. Results: The most significant incremental effect of ultrasound on clot weight reduction was detected with aspirin alone (5.2 ± 2.3% and 5.2 ± 2.6% after 10′ and 20′, p = 0.04 and p = 0.06, respectively) and in combination with heparin (8.8 ± 2.5% and 11.5 ± 2.7% after 10′ and 20′, p = 0.01 and p = 0.0001, respectively). The greatest absolute magnitude of clot weight reduction was observed with ultrasound combined with aspirin and heparin (48.5 ± 9.5% after 20′). The addition of tirofiban or eptifibatide to aspirin, heparin and ultrasound did not increase clot lysis. However, eptifibatide had significantly better synergism than tirofiban (p = 0.025 and p = 0.015, after 10 and 20 minutes, respectively). Conclusions: Aspirin alone or in combination with heparin results in significant augmentation of clot lysis and is synergistic with application of low-frequency ultrasound for 10 and 20 minutes only. These results may have important implications for a possible use of low-frequency ultrasound in treatment algorithms of acute coronary syndromes.

Introduction: Ultrasound can accelerate clot dissolution in vitro and in vivo. We used an ex vivo canine shunt to investigate low frequency ultrasound effects on platelet-rich stent thrombosis. Methods and results: Nitinol stents were expanded to 2 mm in diameter in two perfusion chambers in a parallel shunt and exposed to flowing arterial blood at 2100 s−1 to generate stent thrombi (n=224 perfusion runs). Dethrombotic effects were assessed during treatment with saline and combined treatment with aspirin and heparin. One stent was exposed to ultrasound (27 kHz, 1.4 W/cm2), while the other was not. Stent thrombi were weighed before and after treatment. There was no significant effect of ultrasound during saline infusion. Treatment with aspirin+heparin alone reduced thrombus weight by 37±25% (18.9±6.1 to 11.8±7.7 mg, p

We evaluated the coronary vasodilatory effects of transcutaneous low-frequency (27-kHz) ultrasound (USD).Ultrasound has been shown to affect vascular function.Ultrasound energy was administered transcutaneously to 12 dogs. Coronary arterial dimensions were assessed using intravascular coronary ultrasound (IVUS) and quantitative coronary angiography (QCA).The IVUS mid-left anterior descending (LAD) luminal area was 6.77 +/- 1.27 mm(2) at baseline. After 30 s of ultrasound, this area increased by 9% (7.40 +/- 1.44 mm(2), p0.05), after 3 min by 19% (8.05 +/- 1.72 mm(2), p0.05) and after 5 min increased by 21% (8.16 +/- 1.29 mm(2), p0.05). The mean coronary diameter (2.69 +/- 0.33 mm) at baseline (QCA of three segments of LAD and three segments of left circumflex coronary artery) increased by 19.3% (3.21 +/- 0.28 mm) after 5 min of USD exposure. After a 90-min observation period there was a return to baseline values (p = NS). Intracoronary nitroglycerin (NTG) administered to five dogs revealed a similar magnitude of vasodilation as USD.Noninvasive, transthoracic low-frequency USD energy results in coronary artery vasodilation within seconds of exposure. The vasodilation is reversible and is similar in magnitude to that induced by NTG. Further evaluation is needed to assess its potential applications in humans.

To identify the incidence of pericardial effusion in patients after cardiac surgery using a hand-carried cardiac ultrasound device, 200 patients were assessed on postoperative day 3. If a pericardial effusion was found, patients were monitored for 3 consecutive days with a hand-carried cardiac ultrasound device. Within 72 hours after surgery, 43 patients (21.5%) had developed an effusion, of whom 2 patients had cardiac tamponade and 41 patients (21%) had a small pericardial effusion. No difference was found in the incidence of effusion based on the type of cardiac surgery. Of patients with a small pericardial effusion on day 3 after surgery, an additional 2 of 41 (5%) developed cardiac tamponade.

We assessed aortic regurgitation (AR) severity by utilizing multiple echo-Doppler variables in comparison with AR severity by aortic root angiography. Patients were divided into 3 groups: mild, moderate, and severe. An AR index (ARI) was developed, comprising 5 echocardiographic parameters: ratio of color AR jet height to left ventricular outlet flow diameter, AR signal density from continuous-wave Doppler, pressure half-time, left ventricular end-diastolic diameter, and aortic root diameter. There was a strong correlation between AR severity by angiography and the calculated echo-Doppler ARI (r = 0.84, p = 0.0001). As validated by aortic angiography, the ARI is an accurate reflection of AR severity.

• Objective. —To evaluate the workup and treatment of children with lymphoma and superior vena cava syndrome. Design. —A retrospective survey. Setting. —State hospital serving as a secondary and tertiary referral center for pediatric oncology and pediatric cardiac surgery. Participants. —Eleven children aged 11 months to 12 years diagnosed as having lymphoma or T-cell acute lymphoblastic leukemia who presented with superior vena cava syndrome during an 11-year period. Interventions. —Lymph node biopsy (two patients), thoracenthesis (five patients), bone marrow aspiration (two patients), and thoracenthesis in addition to bone marrow aspiration (two patients). All aspirates were evaluated with immunohistochemical studies. Chemotherapy was the only management intervention. Results. —T-cell lymphoma or leukemia accounted for nine cases and Hodgkin's disease for two cases. Respiratory symptoms occurred in 10 patients, including tracheal compression in six patients (compression was life-threatening in one patient). Diagnosis of superior vena cava syndrome was achieved in eight patients using surface-marker analysis of aspirates. The syndrome disappeared within 2 to 10 days. Seven of nine children whose conditions were diagnosed more than 1 year before this writing were alive and free of disease after mean follow-up of 37 months. Conclusions. —(1) A specific diagnosis can be achieved in most children with superior vena cava syndrome and lymphoma; (2) Thoracic computed tomographic scans are essential, identifying minute pleural effusions that can aid diagnosis; (3) Anesthetic hazard is related only to severe tracheal compression; (4) Chemotherapy achieves excellent symptomatic relief; and (5) Long-term survival, without disease, is achievable. ( AJDC. 1992;146:1060-1063)

A 68-year-old woman with acute myelomonocytic leukemia, who was treated annually for 21 consecutive years by “therapeutic” low-dose radon gas radiation because of spondyloarthritis, is described. The karyotype of the malignant clone was 45,XX, −17, −18, del(5)(q15q33), +t(17;18)(q11.2q23). In 45% of the metaphases, the modal number was between hyperdiploid to near tetraploid. Double minute chromosomes were demonstrated in 60% of the cells. These chromosomal aberrations are suggestive of mutagen-related leukemia.

This study is an empirical examination of equity theory as a predictor of pay satisfaction among managers. A contingency model is developed and confirmed. The basic idea is that equity theory does not apply universally for all situations, but is rather restricted to tasks with a high level of perceived certainty. In other situations, where information concerning the tasks and their characteristics is quite unpredictable and less certain, the assessment of the reward system as equitable or inequitable can be a very difficult task and maximization is often used as the operating norm. Consequently, three hypotheses were tested and supported: (1) Under conditions of high uncertainty, maximization has a stronger relationship with pay satisfaction than equity; (2) Under conditions of low certainty, equity has a stronger relationship with pay satisfaction than maximization; (3) Under conditions of moderate uncertainty, both equity and maximization have strong direct relationships with pay satisfaction. The implications of this study for other studies of organizations are discussed.

Neuman, Yoram, Abraham Pizam and Arie Reichel, Values as Determinants of Motivation: Tourism and Other Career Choices. Annals of Tourism Research 1980, VII (3): 428–442. This study examined the predictive validity of work values in explaining motivational patterns of three groups of career preparation differing in their occupational specificity: Tourism/Hospitality, Management, and Liberal Arts. It was found that the higher the occupational specificity of a career preparation the higher is the predictive validity of work values in explaining work motivations. As predicted, the best relationships between values and motivation was found in the maximally specified occupation, namely: tourism/hospitality students, followed by management students with the liberal arts students — the most flexible occupational group — having the lowest relationship between values and motivation. The implications of the findings for employee selection and motivation prediction in the tourism/hospitality industry are discussed.

During the period from 1978 to 1981, 52 patients with ALL were diagnosed and treated at the Chaim Sheba Medical Center. Using standard cell markers to subtype the blasts, 49 of the patients could be classified: 16 were found to be T-cell ALL, 10 common ALL, five null ALL, four pre-B and 14 were partially characterized as non-B, non-T. Analysis of the series revealed two distinctive features: high prevalance (30%) of T-cell ALL among both Jews and Arabs and a high proportion, two-thirds, of high risk patients due to high initial WBC counts, unfavourable age or T-cell characteristics. The minimal incidence of ALL among the Gaza Strip Arab children during the study period is 4: 100,000, which is close to the incidence in the Western world. During previous years the leukemia incidence in the Gaza Strip was very low while the most common lymphatic malignancies were Burkitt tumor and other non-Hodgkin lymphomas.

Sixteen children with high risk acute lymphoblastic leukemia (ALL) who had one or more of the following risk factors: white cell count over 50 X 10(9)/liter, mediastinal mass, age under 2 or over 10 years, extramedullary involvement, or T-cell markers, were treated by a new protocol. All attained complete remission and 11 are still in their continuous first remission for 6-53 months. High activity of adenosine deaminase (ADA) in the leukemic cells seems to be an independent risk factor, as in the high ADA level group, 4 out of 7 patients relapsed and died, while none of the 8 patients with low ADA levels relapsed or died.

Childhood lymphoproliferative disorders have multifactorial etiologies, in which environmental and genetic factors playa major role in determining the age distribution, clinical presentation, and course of the disease. Most of the data, however, are indirect. The gradual appearance of the 3–5 years age peak of common ALL in developed countries and its absence in developing countries and the marked decrease in the incidence of alpha heavy chain disease in Israel are two examples of changes in patterns of disease that can be attributed to environmental factors.