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עמוד בית
Thu, 29.02.24

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June 2017
Yaniv Levi MD, Aaron Frimerman MD, Avraham Shotan MD, Michael Shochat MD PhD, David S Blondheim MD, Amit Segev MD, Ilan Goldenerg MD, Mark Kazatsker MD, Liubov Vasilenko MD, Nir Shlomo PhD and Simcha R Meisel MD MSc

Background: Trials have shown superiority of primary percutaneous intervention (PPCI) over in-hospital thrombolysis in ST-elevation myocardial infarction (STEMI) patients treated within 6-12 hours from symptom onset. These studies also included high-risk patients not all of whom underwent a therapeutic intervention. 

Objectives: To compare the outcome of early-arriving stable STEMI patients treated by thrombolysis with or without coronary angiography to the outcome of PPCI-treated STEMI patients.

Methods: Based on six biannual Acute Coronary Syndrome Israeli Surveys comprising 5474 STEMI patients, we analyzed the outcome of 1464 hemodynamically stable STEMI patients treated within 3 hours of onset. Of these, 899 patients underwent PPCI, 383 received in-hospital thrombolysis followed by angiography (TFA), and 182 were treated by thrombolysis only.

Results: Median time intervals from symptom onset to admission were similar while door-to-reperfusion intervals were 63, 45 and 52.5 minutes for PPCI, TFA and thrombolysis only, respectively (P < 0.001). The 30-day composite endpoint of death, post-infarction angina and myocardial infarction occurred in 77 patients of the PPCI group (8.6%), 64 patients treated by TFA (16.7%), and 36 patients of the thrombolysis only group (19.8%, P < 0.001), with differences mostly due to post-infarction angina. One-year mortality rate was 27 (3%), 13 (3.4%) and 11 (6.1%) for PPCI, TFA and thrombolysis only, respectively (P = 0.12).

Conclusions: PPCI was superior to thrombolysis in early-arriving stable STEMI patients with regard to 30-day composite endpoint driven by a decreased incidence of post-infarction angina. No 1 year survival benefit for PPCI over thrombolysis was observed in early-arriving stable STEMI patients.

 

September 2016
Rotem Sivan-Hoffmann MD, Benjamin Gory MD MSc, Muriel Rabilloud MD PhD, Dorin N. Gherasim MD, Xavier Armoiry PharmD PhD, Roberto Riva MD, Paul-Emile Labeyrie MD MSc, Udi Gonike-Sadeh MD, Islam Eldesouky MD and Francis Turjman MD PhD

Mechanical thrombectomy with stent retrievers is now the reference therapy for acute ischemic stroke (AIS) in the anterior circulation in association with thrombolysis. We conducted an extensive systematic review and meta-analysis to evaluate the clinical and angiographic outcomes of stent-retriever thrombectomy in patients with acute anterior circulation stroke. Available literature published to date on observational studies and three randomized trials (MR CLEAN, ESCAPE, and EXTEND-IA) involving the stent-retriever device were reviewed. Successful recanalization and favorable clinical outcome were defined by a TICI ≥ 2b and modified Rankin Scale score of ≤ 2 at 90 days following AIS, respectively. A total of 2067 patients harboring an anterior circulation stroke were treated with a stent retriever: 433 patients from 3 randomized trials involving the device and 1634 patients from observational studies. Mean NIH Stroke Scale score on admission was 16.6, and mean time from onset to recanalization was 300 minutes. Successful recanalization was achieved in 82% (95%CI 77–86, 31 studies). The 90 day favorable outcome was achieved in 47% (95%CI 42–5.2, 34 studies) with an overall mortality rate of 17% (95%CI 13–20, 31 studies). Symptomatic intracerebral hemorrhage was identified in 6% (95%CI 4–8, 32 studies). In patients with AIS caused by a proximal intracranial occlusion of the anterior circulation, stent-retriever thrombectomy is safe and restores brain reperfusion in four of five treated patients, allowing favorable clinical outcome in one of two AIS patients with large vessel occlusion. 

December 2013
Yacov Shacham, Eran Leshem-Rubinow and Arie Roth
 Studies on trials conducted before the use of thrombolysis demonstrated both short- and long-term benefits of beta-blockers, and one meta-analysis of those trials showed a 25% reduction in 1 year mortality. Treatment with beta-blockers was and continues to be recommended for patients following ST elevation myocardial infarction (STEMI), but many patients failed to receive these agents, mostly because physicians were unconvinced of their benefit. A similar analysis of the studies in STEMI patients treated with thrombolysis also showed an overall 23% reduction in mortality associated with β-blocker use in the era of primary percutaneous coronary intervention (PCI). In the present review, we examine the relationship between the pharmacology of β-blockers and their potential utility in order to review early trials on their post-infarct efficacy and to place these findings in the context of this specific patient population in the era of primary PCI.

August 2012
R. Eichel, D. Arkadir, S.T. Khoury, A. Werber, S. Kahana-Merhavi, J.M. Gomori, T. Ben-Hur, J.E. Cohen and R.R. Leker
Background: Only 0.5% of stroke patients in Israel are treated with endovascular multi-modal reperfusion therapy (MMRT) each year.

Objectives: To assess our experience with MMRT over the last decade.

Methods: We analyzed data from our stroke registry of patients undergoing MMRT during 2002¨C2011. All patients underwent multi-parametric imaging studies including subtraction angiography according to a predetermined algorithm. Stroke severity was measured with the National Institutes of Health Stroke Scale (NIHSS). Disability was measured with the modified Ranking Scale (mRS) and classified as favorable (mRS ¡Ü 2) or unfavorable. Target vessel recanalization was determined with the thrombolysis in myocardial infarction (TIMI) scale.

Results: During the study period 204 patients were treated 166 of them had complete data sets including mRS scores at 90 days and were included in the analysis. Favorable outcomes at 90 days post-stroke were observed in 37% of patients and the mortality rate was 25%. Patients with favorable outcomes were younger, had significantly lower NIHSS scores on admission and discharge, and more often had complete target vessel recanalization (TIMI 3). On regression analysis the only factor associated with favorable outcome was TIMI 3, whereas increasing age and NIHSS scores on admission and discharge were predictors of poor outcome.

Conclusions: Our data show that MMRT can be successfully implemented in patients with severe stroke in Israel. More than a third of our patients with severe ischemic strokes who could not receive acute treatment were functionally independent after MMRT, demonstrating that this procedure is an important alternative for patients who are not candidates for intravenous tissue plasminogen activator (tPA) or do not achieve recanalization with tPA.
November 2010
S.D Israeli-Korn, Y. Schwammenthal, T. Yonash-Kimchi, M. Bakon, R. Tsabari, D. Orion, B. Bruk, N. Molshatzki, O. Merzeliak, J. Chapman and D. Tanne

Background: Multiple case series, mostly highly selected, have demonstrated a very high mortality following acute basilar artery occlusion. The more widespread availability and use of non-invasive vascular imaging over recent years has increased the rate of ABAO[1] diagnosis.

Objectives: To estimate the proportion of diagnosed ABAO among all-cause ischemic stroke in an era of increasing use of non-invasive vascular imaging and to compare the characteristics and outcomes between these two groups.

Methods: We compared 27 consecutive cases of ABAO identified in a university hospital between 2003 and 2007 to 311 unselected cases of ischemic stroke from two 4 month surveys.

Results: ABAO diagnosis increased from 0.3% of all-cause ischemic stroke (2003–2004) to 1.1% (2007), reflecting the increased use of non-invasive vascular imaging. In comparison to all-cause ischemic stroke, ABAO patients were younger (mean age 60 vs. 71 years), were more likely to be male (89% vs. 60%), had less atrial fibrillation (7% vs. 26%), more severe strokes (baseline NIHSS over 20: 52% vs. 12%), higher admission white cell count (12,000 vs. 9000 cells/mm3) lower admission systolic blood pressure (140 ± 24 vs. 153 ± 27 mmHg), higher in-hospital mortality rates (30% vs. 8%) and worse functional outcome (modified Rankin scale ≤ 3, 22% vs. 56%) (P < 0.05 for all). Rates of reperfusion therapy for ABAO increased from 0 in 2003–2004 to 60% in 2007.

Conclusions: In this study, ABAO patients represented approximately 1% of all-cause ischemic stroke and were about a decade younger than patients with all-cause ischemic stroke. We report a lower ABAO mortality compared to previous more selected case series; however, most survivors had a poor functional outcome. Given the marked clinical heterogeneity of ABAO, a low threshold for non-invasive vascular imaging with a view to definitive reperfusion treatment is needed.






[1] ABAO = acute basilar artery occlusion


April 2010
A. Hamdan, R. Kornowski, E.I. Lev, A. Sagie, S. Fuchs, D. Brosh, A. Battler and A.R Assali

Background: Myocardial blush grade is a useful marker of microvascular reperfusion that may influence left ventricular dilatation.

Objectives: To assess the impact of myocardial blush grade on LV[1] remodeling in patients undergoing successful primary  PCI³ for first anterior ST elevation myocardial infarction.

Methods: In 26 consecutive patients MB[2] grade was evaluated immediately after primary PCI[3]. Each patient underwent transthoracic echocardiography at 24 hours and 6 months after PCI for evaluation of LV volumes. LV remodeling was defined as an increase in end-diastolic volume by ≥ 20%.

Results: The presence of myocardial reperfusion (MB 2-3) after primary PCI was associated with a significantly lower rate of remodeling than the absence of myocardial reperfusion (MB 0-1) (17.6% vs. 66.6%, P = 0.012). Accordingly, at 6 months, patients with MB 2-3 had significantly smaller LV end-diastolic volume (94 ± 21.5 ml vs. 115.2 ± 26) compared with patients with MB 0-1. In univariate analysis, only MB (0-1 versus 2-3) was associated with increased risk of LV remodeling (odds ratio 9.3, 95% confidence interval 1.45–60.21, P = 0.019).

Conclusions: Impaired microvascular reperfusion, as assessed by MB 0-1, may be associated with LV remodeling in patients with STEMI[4] treated successfully with primary PCI.

 






[1] LV = left ventricular

[2] MB = myocardial blush

[3] PCI = percutaneous coronary intervention

[4] STEMI = ST elevation myocardial infarction


March 2009
December 2008
A. A. Wanderer

The histopathology of severe persistent asthma and chronic obstructive pulmonary disease is predominantly characterized by neutrophilic inflammation. It is posited that chronic hypoxia from hypoventilation in combination with hypoperfusion and hypercapnia are associated with induction of pulmonary tissue acidosis in SPA[1] and COPD[2], which in turn provide ideal conditions to induce danger-associated molecular patterns, i.e., crystallized and calcium pyrophosphate. These stimuli in combination with other danger-related biochemical signals are capable of stimulating an innate immune receptor (cryopyrin inflammasome, NALP3) and cause interleukin-1β secretion with subsequent neutrophilic inflammation. There is evidence to suggest that the mechanisms and pathobiology associated with chronic hypoxia, reduced perfusion and reoxygenation in SPA/COPD may exhibit similarities to the biphasic pathobiology involved in ischemia-reperfusion injury. A rationale is suggested for trials of IL-1β[3] targeted therapies as an adjunct strategy to control neutrophilic inflammation in these conditions.






[1] SPA = severe persistent asthma

[2] COPD = chronic obstructive pulmonary disease

[3] IL = interleukin


April 2007
N. Uriel,G. Moravsky, A. Blatt, A. Tourovski, Z. Gabara, I. Yofik, V. Danicek, A. Hendler, R. Braunstein, R. Krakover, Z. Vered and E. Kaluski

Background: Spontaneous coronary reperfusion occurs in 7–27% of patients with ST elevation myocardial infarction, and is an independent predictor of myocardial salvage, percutaneous coronary intervention success, and improved outcome.

Objectives: To determine the optimal PCI[1] time for patients admitted to the hospital due to STEMI[2] with SCR[3].

Methods: We performed a retrospective analysis of all patients admitted to the coronary care unit between July 2002 and November 2004 with a diagnosis of STEMI with SCR.

Results: The study group comprised 86 patients. There was not a single reinfarction episode during an observation period of 6579 patient hours. Cardiac catheterization was executed early (< 24 hours from pain onset) in 26 patients and late (> 24 hours) in 55. Pre-PCI angiographic TIMI flow 2–3 was seen in > 95% in both groups. PCI was performed more frequently in the “early” group (P = 0.024), while multi-vessel coronary artery disease (P = 0.094) requiring coronary bypass surgery (P = 0.056) was observed more frequently in the “late catheterization” group. Myocardial infarction and angina pectoris at 30 days occurred more frequently in the early catheterization group (P = 0.039), however no difference in any major adverse cardiac events was detected during long-term follow-up (491 ± 245 days).

Conclusions: Reinfarction after STEMI with SCR is a rare event. Early PCI in patients with STEMI and SCR, even when executed with aggressive anti-platelet therapy, seems to result in an excess of early MACE, without any long-term advantage. Prospective randomized trials should determine the optimal PCI timing for these patients.








[1] PCI = percutaneous coronary intervention

[2] STEMI = ST elevation myocardial infarction

[3] SCR = spontaneous coronary reperfusion


January 2007
R. Ilia, D. Zahger, C. Cafri, A. Abu Ful, J. Marc Weinstein, S. Yaroslavtsev, H. Gilutz, G. Amit

Background: The significance of arrhythmia occurring after successful recanalization of an occluded artery during treatment following primary percutaneous coronary intervention for ST-segment elevation myocardial infarction is controversial.

Objectives: To study the association of reperfusion arrhythmia with short and long-term survival.

Methods: We used a prospective registry of consecutive STEMI[1] patients undergoing PPCI[2]. Patients with an impaired epicardial flow (TIMI flow grade < 3) at the end of the procedure were excluded.

Results: Of the 688 patients in the study group, 22% were women. Mean (± SD) age of the cohort was 61 (± 14) years and frequent co-morbidities included diabetes mellitus (25%), dyslipidemia (55%), hypertension (43%) and smoking (41%). RA[3] was recorded in 200 patients (29%). Patients with RA had lower rates of diabetes (16% vs. 30%, P < 0.01) and hypertension (48% vs. 62%, P < 0.01), and a shorter median pain-to-balloon time (201 vs. 234 minutes, P < 0.01) than patients without RA. Thirty day mortality was 3.7% and 8.3% for patients with and without RA, respectively (P = 0.04). After controlling for age, gender and pain-to-balloon time the hazard ratio for mortality for patients with RA during a median follow-up period of 466 days was 0.46 (95% confidence interval 0.23–0.92).

Conclusions: The occurrence of RA immediately following PPCI for acute STEMI is associated with better clinical characteristics and identifies a subgroup with a particularly favorable prognosis.






[1] STEMI = ST-segment elevation myocardial infarction



[2] PPCI = primary percutaneous coronary intervention



[3] RA = reperfusion arrhythmia


November 2006
Y. Schwammenthal, R. Tsabari, M. Bakon, D. Orion, O. Merzeliak and D. Tanne
 Background: Rapid restoration of cerebral blood flow is the principle goal of acute ischemic stroke therapy. Intravenous recombinant tissue plasminogen activator is an effective therapy for acute ischemic stroke, has been available in the United States for over a decade and was approved for use in Israel at the end of 2004.

Objectives: To assess the implementation of intravenous rt-PA[1] in routine clinical care at our center after its formal approval in Israel, and the therapeutic and logistic implications for reperfusion therapy for acute ischemic stroke in Israel.

Methods: Patients with acute ischemic stroke, admitted between January 2005 and June 2006, who were treated with intravenous rt-PA or endovascular-based reperfusion were reviewed. Implementation, timing, safety and clinical outcomes were assessed.

Results: Forty-six patients received reperfusion therapy (37 with intravenous rt-PA and 9 with endovascular-based therapy), corresponding to 4.0% of ischemic stroke patients in 2005 and a projection of 6.2% in 2006. Mean age of intravenously treated patients was 67 years (range 22–85 years), median baseline NIHSS score was 14 (range 10–18, 25–75%) and the median ‘onset to drug time’ was 150 minutes (range 120–178, 25–75%). Symptomatic intracerebral hemorrhage and orolingual angioedema each occurred in one patient (2.7%). Significant clinical improvement occurred in 54% of treated patients and 38% of patients were independent at hospital discharge.

Conclusions: Use of reperfusion therapy for acute ischemic stroke has increased in our center after the formal approval of rt-PA therapy to over 5%, with ‘onset to drug time’, safety and outcome after intravenous rt-PA treatment comparing favorably with worldwide experience. A prerequisite for the implementation of effective reperfusion therapy and expansion of the proportion of patients treated nationwide is the establishment of a comprehensive infrastructure.


 





[1] rt-PA = recombinant tissue plasminogen activator


August 2006
A. Hamdan, R. Kornowski, A. Solodky, S. Fuchs, A. Battler and A.R. Assali

Background: The degree of left ventricular dysfunction determines the prognostic outcome of patients with acute myocardial infarction.

Objectives: To define the clinical, angiographic and procedural variables related to LV[1][1] dysfunction in patients with  with anterior wall AMI[1][2] referred for primary percutaneous coronary intervention.

Methods: The sample included 168 patients treated by primary PCI[1][3] for first anterior wall AMI. Clinical, demographic and medical data were collected prospectively into a computerized registry, and clinical outcome (death, reinfarction, major cardiovascular event) were evaluated during hospitalization and 30 days after discharge. Patients were divided into three groups by degree of LV dysfunction (mild, moderate, severe) and compared for clinical, angiographic and procedural variables.

Results: LV dysfunction was associated with pre-PCI renal failure (serum creatinine > 1.4 mg/dl), peripheral vascular disease, high peak creatine kinase level, longer door to balloon time, low TIMI flow grade before and after PCI, and use of an intraaortic balloon pump. On multivariate analysis adjusted for baseline differences, peak creatine kinase level (r = 0.3, P = 0.0001) and door to needle time (r = 0.2, P = 0.008) were the most significant independent predictors of moderate or severe LV dysfunction after anterior AMI.

Conclusion: Abnormal LV function after first anterior AMI can be predicted by door to balloon time and the size of the infarction as assessed by creatine kinase levels. Major efforts should be made to decrease the time to myocardial reperfusion.







[1][1] LV = left ventricular

[1]
[2] AMI = acute myocardial infarction

[1]
[3] PCI = percutaneous coronary intervention 

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