Israel Medical Association Journal

Background: Multi-detector computed tomography has advanced enormously and now enables non-invasive evaluation of coronary arteries as well as cardiac anatomy, function and perfusion. However, the role of cardiac MDCT[1] is not yet determined in the medical community and, consequently, many clinically unnecessary scans are performed solely on a self-referral basis.

Objectives: To prospectively evaluate the role of a cardiologist consultation and recommendation prior to the scan, and the influence on the diagnostic yield of cardiac MDCT.

Methods: In our center, a CT service was initiated, but with the prerequisite approval of a cardiologist before performance of the CT. Each individual who wanted and was willing to pay for a cardiac CT was interviewed by an experienced cardiologist who determined whether cardiac MDCT was the most appropriate next test in the cardiovascular evaluation. Subjects were classified into three groups: a) those with a normal or no prior stress test, no typical symptoms and no significant risk factors of coronary artery disease were recommended to perform a stress test or to remain under close clinical follow-up without MDCT; b) those with an equivocal stress test, atypical symptoms and/or significant risk factors were allowed to have cardiac MDCT; and c) those with positive stress test or clinically highly suspected CAD[2] were advised to go directly to invasive coronary angiography. CT findings were categorized as normal CAD (normal calcium score and no narrowings), < 50% and > 50% CAD.

Results: A total of 254 people were interviewed, and in only 39 cases did the cardiologist approve the CT. However, 61 of the 215, despite our recommendation not to undergo CT, decided to have the scan. Assessment of the 100 cases that underwent MDCT showed a statistically significant better discrimination of significant CAD, according to the cardiologist’s recommendation: MDCT not recommended in 3/54 (6%) vs. MDCT recommended in 12/39 (31%) vs. recommended invasive coronary angiography in 4/7 (57%) (P < 0.001).

Conclusions: Detection of coronary calcification, as well as MDCT angiography can provide clinically useful information if applied to suitable patient groups. It is foreseeable that MDCT angiography will become part of the routine workup in some subsets of patients with suspected CAD. Selection of patients undergoing MDCT scans by a cardiologist improves the ability of the test to stratify patients, preventing unnecessary scans in both high and low risk patients

Background: Since surgical repair of tetralogy of Fallot was introduced, follow-up studies have shown that the majority of patients lead actives lives and have no subjective exercise limitation.

Objectives: To examine lung function, cardiopulmonary functional capacity and echo-Doppler assessment of pulmonary pressure in adult patients 20 years after repair of TOF.

Methods: Unselected consecutive patients performed full lung function testing, progressive cardiopulmonary exercise, and echo-Doppler assessments of pulmonary pressure.

Results: Fifty consecutive patients (33 men, 17 women) aged 29 ± 11 years who underwent surgical repair of TOF at age 10.1 ± 10.9 years were enrolled in this study. Patients after TOF showed no restriction (forced expiratory vital capacity 80%, total lung capacity 91%) and had normal oxygen saturation (97%) and 6 minute walking distance (600 meters). Echocardiography showed normal pulmonary pressure and left ventricular ejection function (62%). Cardiopulmonary exercise testing showed mild limitation of exercise capacity with oxygen uptake at maximal effort of 75–78% predicted.

Conclusions: After corrections of TOF the study patients had normal lung function and pulmonary arterial pressure but mild limitation in their exercise capacity.
 

Background: Cardiac computed tomography angiography is a relatively new imaging modality to detect coronary atherosclerosis.

Objectives: To explore the diagnostic value of CTA[1] in assessing coronary artery disease among asymptomatic patients.

Methods: In this retrospective single-centered analysis, 622 consecutive patients underwent CTA of coronary arteries between November 2004 and May 2006 at the Mor Institute for Cardiovascular Imaging in Bnei Brak, Israel. All patients were asymptomatic but had at least one risk factor for atherosclerotic CAD[2]. The initial 244 patients were examined with the 16-slice Brilliance CT scanner (Philips, Cleveland, OH, USA), and in the remaining 378 patients the 64-slice scanner (GE Healthcare, The Netherlands) with dedicated cardiac reconstruction software and electrocardiography triggering was used. Scanning was performed in the cranio-caudal direction. Images reconstructed in different phases of the cardiac cycle using a retrospective ECG-gated reconstruction algorithm were transferred to a dedicated workstation for review by experienced CT radiologists and cardiologists.

Results: Of 622 patients, 52 (8.4%) had severe obstructive atherosclerosis (suspected ≥ 75% stenosis) according to CTA interpretation. Invasive coronary angiography was performed in 48 patients while 4 patients had no further procedure. A non-significant CAD (e.g., diameter stenosis < 70%) was identified in 6 of 48 patients (12%) by selective coronary angiography. Forty-two patients showed severe CAD with at least one lesion of ≥ 70% stenosis. Percutaneous coronary intervention was performed in 35 patients and coronary artery bypass grafting surgery in the other 4 patients. Angioplasty procedures were successful in all 35 patients and stents were utilized in all cases without complications. No further complications occurred among the study cohort undergoing either PCI[3] or surgery. The 6 month survival rate in these patients was 100%.

Conclusions: Non-invasive coronary CTA appears to be a reliable technique, with reasonably high accuracy, to detect obstructive atherosclerosis in asymptomatic high risk patients for atherosclerotic CAD.

Background The temporal behavior of the coronary microcirculation in acute myocardial infarction may affect outcome. Diastolic deceleration time and early systolic flow reversal derived from coronary artery blood flow velocity patterns reflect microcirculatory function.

Objectives To assess left anterior descending coronary artery flow velocity patterns using Doppler transthoracic echocardiography after primary percutaneous coronary intervention, in patients with anterior AMI[1].

Methods Patterns of flow velocity patterns of the LAD[2] were obtained using transthoracic echocardiography-Doppler in 31 consecutive patients who presented with anterior AMI. Measurements were done at 6 hours, 36–48 hours, and 5 days after successful PPCI[3]. Measurements of DDT[4] and pressure half times (Pt½), as well as observation for ESFR[5] were performed.

Results In the first 2 days following PPCI, the average DDT, 600 ± 340 msec, were shorter than on day 5, 807 ± 332 msec (P < 0.012). FVP[6] in the first 2 days were dynamic and bidirectional: from short DDT (< 600 msec) to long DDT (> 600 msec) and vice versa. On day 5 most DDTs became longer. Pt½ at 6 hours was not different than at day 2 (174 ± 96 vs. 193 ± 99 msec, P = NS) and became longer on day 5 (235 ± 98 msec, p = 0.012). Bidirectional patterns were also observed in the ESFR in 6 patients (19%) at baseline, in 4 (13%) at 36 hours, and in 2 (6.5%) on day 5 after PPCI.

Background: Many centers in Israel still use pre-1970 reference data for neonatal weight, length and head circumference. A recently published population-based reference overestimated the weight of premature infants.

Objective: To develop a national reference for birth weight, birth length, and head circumference by gestational age for singleton infants in Israel.

Methods: Data were collected on all singleton live births documented in the neonatal registry of Rabin Medical Center from 1991 to 2005 (n=82,066). Gestational age estimation was based on the last menstrual period until 1977 and early fetal ultrasound thereafter. Neonates with an implausible birth weight for gestational age (identified by the rule of median ± 5 standard deviations or expert clinical opinion) were excluded. Reference tables for fetal growth by gestational age were created for males and females separately.

Results: The growth references developed differed markedly from the Usher curves currently used in our department. Compared to the recently published population-based birth weight reference, our data were free of the problem of differential misclassification of birth weight for gestational age for the premature infants and very similar for the other gestational age groups. This finding reinforced the validity of our measurements of birth weight, as well as of birth length and head circumference.

Conclusions: Use of our new (birth length and head circumference) and improved (birth weight) gender-specific hospital-based reference for fetal growth may help to define normal and abnormal growth in the neonatal population of Israel and thereby improve neonatal care and public health comparisons.
 

Background: Peritoneal carcinomatosis is an advanced form of cancer with poor prognosis that in the past was treated mainly palliatively. Today, the definitive approach to peritoneal surface malignancy involves peritonectomy, visceral resection and perioperative intra-abdominal hyperthermic chemotherapy. The anticipated results range from at least palliative to as far as intent to cure. Proper patient selection is mandatory.

Objectives: To determine whether cytoreductive surgery and intraperitoneal hyperthermic chemotherapy can extend survival, and with minor complications only, in patients with peritoneal carcinomatosis.

Methods: Twenty-two IPHP[1] procedures were performed in 17 patients with peritoneal carcinomatosis in our institution between 1998 and 2007: 6 had pseudomyxoma peritonei, 5 had colorectal carcinoma, 3 had ovarian cancer and 3 had mesotheliomas. All patients underwent cytoreductive surgery, leaving only residual metastasis < 1 cm in size. Intraperitoneal chemotherapy was administered through four large catheters (2F) using a closed system of two pumps, a heat exchanger and two filters. After the patient’s abdominal temperature reached 41°C, 30–60 mg mitomycin C was circulated intraperitoneally for 1 hour.

Results: The patients had a variety of anastomoses. None demonstrated anastomotic leak and none experienced major complications. Six patients had minor complications (pleural effusion, leukopenia, fever, prolonged paralytic ileus, sepsis), two of which may be attributed to chemotherapy toxicity (leukopenia). There was no perioperative mortality. Some patients have survived more than 5 years.

Conclusions: IPHP is a safe treatment modality for patients with peritoneal carcinomatosis. It has an acceptable complications rate and ensures a marked improvement in survival and in the quality of life in selected patients.

Research findings have shown the protective effect of religiosity – among both Christians and Israeli Jews – in terms of morbidity and mortality. To explore the relationship between religiosity and health behavior as a possible explanation for these findings we conducted 3056 telephone interviews, representing the Israeli adult urban Jewish population. Health status, health behavior, frequency of medical checkups, and eating habits were measured. Logistic regressions were used to estimate the religiosity gradient on health behavior, controlling for other personal characteristics. We found a lower prevalence of stress and smoking among religious persons; we also found that religious women exercise less than secular women and that religious people – both men and women – are more obese than their secular counterparts. While no religiosity gradient was found with relation to the frequency of blood pressure, cholesterol and dental checkups, religious women are less likely to undergo breast examinations and mammography. Finally, religious people generally follow a healthier dietary regime, consuming less meat, dairy products and coffee, and much more fish. The lower smoking rates, lower levels of stress, and the healthier dietary regime are consistent with the previously shown longer life expectancy of religious people; however, obesity might become a risk factor in this community.

Background: A paradoxical secular trend of an increase in preterm births and a decrease in low birth weights has been reported in many developed countries over the last 25 years.

Objective: To determine if this trend is true for Israeli neonates, and to add new information on secular trends in crown-heel length and head circumference.

Methods: A hospital-based historic cohort design was used. Anthropometric data for 32,062 infants born at Rabin Medical Center in 1986–1987, 1994–1996, and 2003–2004 were collected from the hospital’s computerized registry and compared over time for absolute values and proportional trends.

Results: For the whole sample (gestational age 24–44 weeks) there was a significant increase in mean birth weight (by 41 g), crown-heel length (by 1.3 cm), and head circumference (by 0.1 cm) from 1986 to 2004 (P < 0.001). A similar trend was found on separate analysis of the post-term babies. Term infants showed an increase in mean length and head circumference (P < 0.001), but not weight, and moderately preterm infants (33–36 weeks) showed an increase in mean weight (81 g, P < 0.001) and mean length (1.0 cm, P < 0.001), but not head circumference. The proportion of post-term (42–44 weeks), preterm (24–36 weeks), very preterm (29–32 weeks), extremely preterm (24–28 weeks), low birth weight (< 2500 g) and very low birth weight (< 1500 g) infants decreased steadily and significantly over time (P < 0.002).

Conclusions: Babies born in our facility, term and preterm, are getting bigger and taller. This increase is apparently associated with a drop (not a rise) in the proportion of preterm infants. These results might reflect improvements in antenatal care and maternal determinants.
 

Background: Despite improved management of heart failure patients, their prognosis remains poor.

Objectives: To characterize hospitalized HF[1] patients and to identify factors that may affect their short and long-term outcome in a national prospective survey.

Methods: We recorded stages B-D according to the American College of Cardiology/American Heart Association definition of HF patients hospitalized in internal medicine and cardiology departments in all 25 public hospitals in Israel.

Results: During March-April 2003, 4102 consecutive patients were recorded. Their mean age was 73 ± 12 years and 57% were males; 75.3% were hypertensive, 50% diabetic and 59% dyslipidemic; 82% had coronary artery disease, 33% atrial fibrillation, 41% renal failure (creatinine ³ 1.5 mg/dl), and 49% anemia (hemoglobin £ 12 g/dl). Mortality rates were 4.7% in-hospital, 7.6% at 30 days, 18.7% at 6 months and 28.1% at 12 months. Multiple logistic regression analysis revealed that increased 1 year mortality rate was associated with New York Heart Association III–IV (odds ratio 2.07, 95% confidence interval 1.78–2.41), age (for 10 year increment) (OR[2] 1.41, 95% CI[3] 1.31–1.52), renal failure (1.79, 1.53–2.09), anemia (1.50, 1.29–1.75), stroke (1.50, 1.21–1.85), chronic obstructive pulmonary disease (1.25, 1.04–1.50) and atrial fibrillation (1.20, 1.02–1.40).

Conclusions: This nationwide heart failure survey indicates a high risk of long-term mortality and the urgent need for the development of more effective management strategies for patients with heart failure discharged from hospitals.

Background: Heart failure with preserved systolic left ventricular function is a major cause of cardiac disability.

Objectives: To examine the prevalence, characteristics and late clinical outcome of patients hospitalized with HF-PSF[1] on a nationwide basis in Israel.

Methods: The Israel nationwide HF survey examined prospectively 4102 consecutive HF patients admitted to 93 internal medicine and 24 cardiology departments in all 25 public hospitals in the country. Echocardiographic LV function measurements were available in 2845 patients (69%). The present report relates to the 1364 patients who had HF-PSF (LV ejection fraction ≥ 40%).

Results: Mortality of HF-PSF patients was high (in-hospital 3.5%, 6 months 14.2%, 12 months 22.0%), but lower than in patients with reduced systolic function (all P < 0.01). Mortality was higher in patients with HF as the primary hospitalization diagnosis (16.0% vs. 12.5% at 6 months, P = 0.07 and 26.2% vs. 18.0% at 12 months, P = 0.0002). Patients with HF-PSF who died were older (78 ± 10 vs. 71 ± 12 years, P < 0.001), more often female (P = 0.05) and had atrial fibrillation more frequently (44% vs. 33%, P < 0.01). There was also a relationship between mortality and pharmacotherapy: after adjustment for age and co-morbid conditions, mortality was lower in patients treated with angiotensin-converting enzyme inhibitors (P = 0.0003) and angiotensin receptor blockers (P = 0.002) and higher in those receiving digoxin (P = 0.003) and diuretic therapy (P = 0.009).

Conclusions: This nationwide survey highlights the very high late mortality rates in patients hospitalized for HF without a decrease in systolic function. The findings mandate a focus on better evidence-based treatment strategies to improve outcome in HF-PSF patients.

Background: Left ventricular outflow gradient is associated with increased morbidity and mortality in hypertrophic cardiomyopathy. Alcohol septal ablation is the alternative to surgery in cases refractory to drug therapy. The implication of LVOG[1] measured 1 week post-ASA[2] for prediction of outcome is unknown.

Objective: To observe the pattern of LVOG course and prediction of long-term clinical and hemodynamic outcome of ASA.

Methods: Baseline clinical and echocardiographic parameters were prospectively recorded in 14 consecutive patients with a first ASA, at the time of ASA, 3 and 7 days after ASA (in-hospital) and 3 and ≥ 12 months after ASA (last follow-up).

Results: There was improvement in NYHA class, exercise parameters and LVOG in 11 of 14 patients (P < 0.005 in all). Maximal creatine kinase level was lower than 500 U/L in those without such improvement and 850 U/L or higher in successful cases. LVOG dropped from 79 ± 30 to 19 ± 6 mmHg after the ASA. LVOG was 50 ± 21 mmHg on day 3, 39 ± 26 on day 7, 32 ± 26 at 3 months and 24 ± 20 mmHg at last follow-up. LVOG identified 27% sustained procedural successes on day 3 and 73% on day 7. The overall predictive accuracy of the test for sustained success and failure was 36% on day 3 and 71% on day 7. Combination of maximal CK[3] and LVOG on day 7 showed four distinct outcome patterns: "early success" with low LVOG and high CK (73% of successful cases), "late success" with high LVOG and high CK, and "early failure" and "late failure" with both low CK and high or low LVOG, respectively
Conclusion: LVOG measurement 7 days post-ASA combined with maximal CK levels predicts late procedural outcome in the majority of patients

Background: Previous studies found some factors such as physical exertion, anger and heavy meals to be triggers for acute coronary syndrome.

Objectives: To estimate the relative risk of an ACS[1] episode associated with positive and negative emotional experiences and anger as potential work-related triggers.

Methods: A total of 209 consecutive patients were interviewed a median of 2 days after a cardiac event that occurred at work or up to 2 hours later. The case-crossover design was used. Positive and negative emotional experiences and anger episodes in the hours immediately before the onset of ACS were compared with episodes in the comparable hours during the previous workday. For anger the episodes were compared with the usual frequency at work during the previous year. Positive and negative emotional experiences were assessed by the PANAS questionnaire (Positive and Negative Affect Scale), and anger by the Onset Anger Scale.

Results: The relative risks of an acute coronary event during the first hour after exposure to negative and positive emotional experiences were RR[2] = 14.0 (95% confidence interval 1.8–106.5) and RR = 3.50 (95% CI[3], 0.7–16.8) respectively and RR = 9.0 (95% CI, 1.1–71) for an episode of anger. Using conditional logistic regression analysis, the highest relative risk was associated with negative emotional experiences.

Conclusions: Negative emotional experiences and anger at work can trigger the onset of an ACS episode. This could have implications for recognizing a cardiac event as a work accident. The implementation of stress-reduction programs in the workplace or use of preventive medications in workers at high risk for coronary heart disease should be investigated.