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Self-terminating ventricular fibrillation (VF) was recorded in a 42-year-old woman without coronary artery or structural heart disease. Reviewing the scientific literature, we found that this type of VF had appeared in vivo in some animal models but was sparsely described in clinical practice. This most unusual case shows that potentially lethal arrhythmias may be self-terminating.

Objectives: Patients arriving in the emergency department (ED) need rapid and reliable evaluation of their respiratory status. Mainstream end tidal carbon dioxide (ETCO(2)) is one of the methods used for this purpose during general anaesthesia of intubated patients in the operating theatre. Sidestream ETCO(2) (SSETCO(2)) might be a non-invasive, rapid, and reliable predictor of arterial Pco(2) in non-intubated patients in respiratory distress. The aim of this study was to verify whether SSETCO(2) can accurately predict the arterial Pco(2) and to detect variables that may affect this correlation., Methods: A prospective semi-blind study. The participants were 73 patients (47 men, 26 women) referred to the ED for respiratory distress. Arterial blood gas pressures and SSETCO(2) measurements were performed and recorded for all patients. Other parameters recorded were: age; body temperature; respiratory rate; blood pressure; pulse rate; and medical diagnosis., Results: A significant correlation was found between SSETCO(2) and arterial Pco(2) (r = 0.792). Compared with the correlation curve of the whole group, age under 50 years deflected the correlation curve to the left, while temperature above 37.6 degrees C deflected it to the right. The rest of the parameters had no clear influence on the SSETCO(2)/Pco(2) correlation curve., Conclusions: There is a good correlation between SSETCO(2) and arterial Pco(2) in the ED setting. Young age may increase the arterial Pco(2)/SSETCO(2) gradient while raised temperature may decrease this gradient. Further studies are needed to confirm these findings in the normal healthy population.

This report describes a patient who suffered multiple-vein thrombosis following permanent pacemaker implantation and developed a pulmonary embolism while on anticoagulation treatment, which was successfully treated by thrombolytic therapy.

Objectives: The false positive rate of electrocardiographic exercise testing (ET) for coronary artery disease (CAD) in women ranges from 38 to 67%, using the ST-T changes (ST-T) criteria. The aim of this study was to compare the diagnostic accuracy of QRS duration change criteria with ST-T change criteria during ET., Methods: We studied 234 women (mean age 58+/-17 years, range 27-83 years), of whom 160 were pre-menopausal (PrMW; mean age 41+/-9, range 27-56) and 74 were post-menopausal (PoMW; mean age 65+/-7, range 57-83). All participants underwent ET to rule out CAD, followed by thallium stress testing (TL). QRS duration, measured with a computerized optical scanner and ST-T changes at peak ET were compared with TL. An ischemic QRS response was defined as an exercise-induced prolongation of QRS duration >3 ms., Results: The sensitivities of QRS duration changes for the entire study group, the PrMW group and the PoMW group in comparison with TL, were 93, 88 and 92%, respectively, while the corresponding rates of specificity were 91, 85 and 91%, respectively. The sensitivities of ET ST-T changes for the entire study group, for the PrMW group and for the PoMW group were 48, 46 and 54%, respectively, while the corresponding rates of specificity were 62, 75 and 79%, respectively. The false-positive rate was 20% for ischemic ST-T and 4% for ischemic QRS duration for the entire study population., Conclusions: Computer-measured QRS duration changes during ET are more sensitive and specific than ST-T changes for the detection of ischemia in women.

Cardiovascular (CV) nursing as an entity in Israel dates back to 1952, when the nurses in Tel-Hashomer hospital took care of postoperative heart surgery patients. The first intensive cardiac care units (ICCUs) were established in 1971. In 1982, the first ICCU course was established in Tel-Hashomer hospital nursing school. Today, most of the nursing staff in Israels ICCUs are graduates of ICCU courses. The nurses professional society, the Society for Nursing of Israel, was established in 1947. In 1989 the Society for Advancement of Cardiac Nursing in Israel (SACN) was established. The main goals of the society were: the exchange of CV nursing knowledge, CV nursing research, CV nursing education in nursing schools, education of nurses in other departments in the care of the cardiac patient, and CV nursing education in the community. The CV nurse takes a large role in the total care of the cardiac patient, which includes rehabilitation within the hospital and in the ambulatory setting and coordination of nursing in national and international multicenter clinical trials. In collaboration with the Ministry of Health Nursing Division, Israeli CV nurses participate in national and international projects to: develop and upgrade nursing education; train new CV nurses; develop, review, and revise nursing protocols and guidelines; and establish new, more advanced ICCUs in underdeveloped areas within Israel and around the world. Our vision for the future development of CV nursing in Israel includes coordination and management roles in the hospital setting, and the establishment and management of home-care programs., (Copyright 2003 CHF, Inc.)

Background: Cerebrovascular accidents (CVAs), transient ischemic attacks (TIAs), and peripheral arterial disease (PAD) frequently coexist with coronary artery disease (CAD) and were previously reported to adversely affect the prognosis of patients with chronic CAD., Methods: We examined the effect of prior CVA/TIA or PAD (extra-cardiac vascular disease [EVD]) on the outcome of 10,281 patients with acute coronary syndromes enrolled in the Orbofiban in Patients with Unstable Coronary Syndromes-Thrombolysis in Myocardial Infarction (OPUS-TIMI) 16 trial of the oral glycoprotein IIb/IIIa antagonist orbofiban plus aspirin versus aspirin alone. We evaluated mortality, recurrent cardiac events, and stroke and used multivariate analysis to control for differences in baseline characteristics., Results: Patients with EVD were older, had more coronary risk factors, had a history of CAD, and received more intensive medical treatment at baseline. The acute event in these patients was more often unstable angina pectoris and less commonly Q-wave myocardial infarction. With coronary angiography, patients with prior EVD more often had multivessel disease. During the 10 months of follow-up, the presence of EVD was predictive of an increased hazard of death, reinfarction, recurrent ischemia, stroke, and a composite of these events. Despite the increased severity of the CAD and increased risk of events, patients with EVD were treated less frequently with beta-blockers and more frequently with calcium blockers. Despite patients with EVD having a 45% higher incidence of hypercholesterolemia, lipid-lowering agents were prescribed in a similar percentage of patients as patients without EVD., Conclusion: In patients with acute coronary syndromes, the presence of prior CVA, TIA, or PAD is associated with more extensive CAD and worse outcome. These patients appear to receive less aggressive treatment, which may explain, at least in part, their worse outcome.

The offspring of coronary heart disease (CHD) patients are at particularly high risk for developing CHD. Endothelial dysfunction is present in the majority of CHD and atherosclerosis patients. Fish oil, rich in n-3 fatty acids has been shown to augment endothelium-dependent vasodilatation in human peripheral and coronary arteries. The aims of this study are to investigate presence of endothelial dysfunction determined by the brachial flow-mediated diameter, nitric oxide, plasma lipids and fibrinogen, and the effect of high doses of fish oil on these parameters. Twenty-four healthy offspring of CHD patients (study group) were supplemented with 9 g/day Alsepa fish oil (each gram containing 180 mg EPA and 120 mg DHA), for a period of two weeks. Plasma nitric oxide, urine nitric oxide, fibrinogens and flow-mediated vasodilatation (FMD) were determined prior to fish oil therapy, two weeks into therapy and four weeks after the end of therapy with fish oil. Twelve healthy subjects (control group) with no family history of heart disease were studied as controls (day one only). The offspring had a lower increase in FMD and lower nitric oxide production, compared with the control group. No other parameters varied between the two groups. The administration of fish oil did not result in any changes in the studied parameters. In healthy offspring of CHD patients, early endothelial dysfunction was documented before evidence of atherosclerosis. Ingestion of fish oil over a 13-day period did not improve endothelial dysfunction.

Background: Noninvasive ventilatory support (NIVS) is intended to provide ventilatory assistance for a wide range of respiratory disturbances. The use of NIVS for treatment of respiratory distress may be applicable in the emergency department (ED). It may prevent endotracheal intubation and, likewise, may favorably influence the course of the patient's hospitalization, depending on the primary disease or ventilatory disturbance., Objective: To evaluate the efficacy of bilevel positive airway pressure (BiPAP) ventilation in patients with acute respiratory distress presenting in the ED., Methods: A prospective, uncontrolled, nonrandomized, nonblind study enrolled 30 patients. They were cooperative and hemodynamically stable, aged over 18 years, and presented with acute respiratory distress as defined by predetermined criteria. They were connected to a BiPAP machine through a face mask, using an initial pressure of 8/3 cm H(2)O, which was gradually raised to 12/7 cm H(2)O inspiratory positive airway pressure/expiratory positive airway pressure. Standard drugs, inhalation and oxygen therapies were administered as needed. The BiPAP was disconnected either upon relief of respiratory distress or on deterioration of the patient's condition., Results: Of the 30 patients in the study, 19 had cardiogenic pulmonary edema, four had acute asthma, three had exacerbation of COPD, three had pneumonia and one had malignant pleural effusion. BiPAP was instituted subsequent to failure of standard therapies. Twenty-six patients were classified as responders to the BiPAP ventilation and four as nonresponders (three patients were intubated after 1 hour and one patient 24 hours, post BiPAP). The total length of stay (LOS) in the ED was 3-5 hours and the mean LOS in hospital was 4.1 +/- 1.5 days, versus 6.5 +/- 1.2 days in LOS reports of similar patients in the same hospital during 1999, who did not undergo BiPAP ventilation. No other complications were observed., Conclusions: We found BiPAP ventilation simple, safe, effective and well tolerated by patients in respiratory distress. The rate of endotracheal intubation after successful BiPAP ventilation was low. In carefully selected patients with respiratory distress, BiPAP ventilation may successfully replace endotracheal intubation.

Background: Endothelin-1, a potent vasoconstrictor, is elevated in congestive heart failure and is postulated to play a major role in the pathogenesis of the disease. Endothelin receptor antagonism may be a specific therapeutic approach. This study was designed to determine the effective dosage range, hemodynamic effects, and tolerability of tezosentan, an intravenous dual endothelin receptor antagonist, in patients with advanced heart failure., Methods: This randomized, double-blind, placebo-controlled multicenter trial enrolled 38 patients with symptomatic stable heart failure (New York Heart Association class III, left ventricular ejection fraction <35%) undergoing right heart catheterization. Patients were equally randomized to a 4-hour intravenous infusion of placebo or tezosentan in ascending doses (5, 20, 50, and 100 mg over 1 hour each). Angiotensin-converting enzyme inhibitors and diuretics were withheld 24hours before the study. Hemodynamics were measured during and for 4 hours after the infusion., Results: Compared with placebo, tezosentan treatment produced a significant increase in cardiac index (treatment difference 0.59 L/min/m(2), P =.0001) and decreases in pulmonary and systemic vascular resistances (P

Objective: This study investigated the effect of tezosentan (an intravenous endothelin-1 receptor antagonist) on vascular resistance and cardiac function and determined the dose response in patients with stable congestive heart failure (CHF) due to left ventricular systolic dysfunction., Methods: In a double-blind fashion, tezosentan or placebo were administered in ascending doses (5, 20, 50, 100 mg h(-1)) to 38 CHF (NYHA class III) patients with ejection fraction or=15 mmHg. Systemic vascular resistance index (SVRi) was estimated as mean arterial blood pressure [(MAP-right atrial pressure)/cardiac index (CI)]. Cardiac function was assessed as cardiac power index (Cpi), calculated as pressure x flow (MAP x CI), where MAP represents pressure and CI represents cardiovascular flow., Results and Discussion: Compared to the placebo, tezosentan induced a dose-dependent decrease in SVRi (-32%), an increase in Cpi (+20%) and a small decrease in MAP (-9%). By contrast, patients treated with nitrate vasodilators or nesiritide (a natriuretic peptide) showed a decrease in SVRi not accompanied by a significant increase in Cpi leading to a steep decrease in MAP., Conclusions: The use of Cpi in the assessment of the hemodynamic effects of tezosentan, provides a useful alternative characterization of the complex influences of vasodilators on cardiac function in patients with CHF.

Myocardial ischemia during daily life can be induced by increased demand and by increased coronary tone. The purpose of this study was to assess the mechanism of action of mibefradil, a new T-channel calcium blocker that is a vasodilator with negative chronotropic properties. Included in this study were 114 patients with chronic stable angina pectoris and ischemic episodes during baseline 48-hour ambulatory ECG monitoring (AEM). After a placebo run-in period patients received 50 mg, 100 mg, or 150 mg of mibefradil per day and repeat 48 hours AEM was performed. Ischemic episodes were divided into 2 categories: Type I is those in which an increase in heart rate > 10% preceded the development of 1 mm ST depression; Type II is those with < or = 10% increase in heart rate. Of the 625 ischemic episodes recorded at baseline, 83% were Type I and 17% were Type II. At 50 mg mibefradil dose, there was a significant decrease in the number of Type I ischemic episodes but not of Type II. At doses of 100 mg and 150 mg/day, there was a significant decrease in frequency of both types of ischemic episodes. At a low dose of 50 mg/day, mibefradil reduces ischemia predominantly by preventing an increase in heart rate, while at higher doses of 100 mg and 150 mg/day, it also acted as a vasodilator suppressing episodes associated with increased coronary tone.

Blood pressure (BP) reduction of 5-6 mm Hg reduces the relative risk of stroke by 30-40%. This effect does not appear to depend on the antihypertensive agent used to bring about the required reduction in BP. Patients with acute ischaemic stroke often exhibit an elevated BP. These patients, who previously suffered from hypertension, have significantly higher levels of BP readings on admission with increased incidence of stroke immediately after arising. The aim of this study was to compare antihypertensive agents, especially short and long acting drugs with the measurement of BP on admission, the time of the ischaemic stroke and its clinical severity. This was studied retrospectively in 109 patients (55 females and 54 males). The mean age was 69.7 +/- 10.4 years. All the patients admitted between 1 July 1996 and 30 June 1997 for ischaemic stroke as established by brain CT scan, were studied. Of the stroke subjects not treated or treated with short acting calcium blockers, 40.8% and 44.4% of them respectively appeared to have an ischaemic stroke in the early morning hours in contrast to 20% of those treated with long acting calcium blockers (P < 0.05). The last group of patients also experienced less clinical severity. These results emphasise the need for proper 24-h control of BP and by comparison to other antihypertensive agents, the long acting calcium blockers with these subjects may prevent a sudden early morning rise in BP, which is instrumental in stroke prevention.

Ischemic heart disease (IHD) is women is characterized by a higher morbidity and mortality in the peri-infarction and coronary bypass peri-operative periods. These epidemiological data strengthen our impression that the health system unintentionally "ignores" the high proportion of females with IHD. The process of investigating chest pain, diagnosing IHD, and the subsequent treatment and rehabilitation, seem to differ between the genders. Time elapsed from beginning of chest pain to diagnosis of IHD seems to be longer in women than in men. Personal, educational and social factors are contributory. Although time elapsed between diagnosis and rehabilitation is usually similar in the genders, peri-operative morbidity and mortality are higher in women. It may be that the higher rates in women are caused by delay in diagnosis and treatment, which allows worsening of the disease in women before treatment. This delay can occur during the time needed for evaluation of chest pain, from the door of the physician to diagnosis and treatment. In our retrospective study we determined the difference in referral of men and women with chest pain to the emergency department (ED) and the attitude of physicians in the ED and medical department to chest pain in men and in women, including final diagnosis on discharge. 615 patients over 18 years referred to the ED for chest pain during 3 randomly chosen, consecutive months were studied. We found that women constituted only 39.5% of the referred patients, but the proportion hospitalized was similar to that in men. Hospitalized women were older (57.7 +/- 18.4 versus 49.7 +/- 17.8 years in men), and had more risk factors (4 versus 2 in men). Proportions of specific diagnoses on discharge from hospital were equal in the genders. To bridge the differences and to implement education in prevention, investigation and treatment of IHD in women, we established the "Female Heart" clinic. The objective of this clinic is to reduce differences in the first step, in the process of evaluating chest pain in women, by educating and encouraging them to present early to their physicians, and by changing physicians' attitudes in the investigation of chest pain in women. We plan to determine in a prospective study if these goals are reached.

Background: Patients with a history of stroke presenting with acute myocardial infarction (MI) are often excluded from thrombolytic therapy owing to fear of intracranial hemorrhage. Few data, however, are available on the risks vs the benefits of thrombolysis in patients with an acute MI and a prior cerebrovascular event (PCE)., Methods: Data were derived from 2 nationwide surveys of 2012 consecutive patients with acute MI admitted to all 25 coronary care units in Israel during 1992 and 1994. Thrombolytic therapy was given to patients with a PCE at the discretion of the treating physicians. Outcomes were compared between patients with an acute MI with and without a PCE and between patients with a PCE treated with or excluded from thrombolysis., Results: Patients with a PCE (n = 115 [6%]) were older, with higher rates of atherosclerotic risk factors and in-hospital complications than their counterparts without a prior event (n = 1897). They were treated less often with thrombolysis or mechanical reperfusion. The 1-year mortality rates were higher among patients with a PCE (28% vs 19%, P<.01), but not after multivariate adjustments for clinical characteristics (adjusted hazard ratio, 1.08; 95% confidence interval, 0.75-1.55). Patients with an acute MI and a PCE who were treated with thrombolysis (n = 29 [25%]) were compared with 46 patients found ineligible for thrombolysis primarily because of their PCE. The timing of the PCE was comparable in both groups (one fifth in the preceding year), while prior transient ischemic attacks were more prevalent among patients who had undergone thrombolysis. The patients who were treated with thrombolysis (n = 29) were older, had a higher rate of anterior infarction, and, while in the hospital, received aspirin, anticoagulants, and beta-blockers more often than their counterparts (n= 46). In-hospital intracranial hemorrhage did not occur in either group. The 1-year mortality rates were 2-fold higher among patients who had not undergone thrombolysis compared with those who had (33% vs 18%; adjusted hazard ratio, 2.44; 95% confidence interval, 0.78-7.64)., Conclusions: These findings, derived from 2 nationwide surveys of consecutive patients with acute MI, suggest that patients with PCEs have an adverse outcome attributed to their older age and less favorable risk profile. Thrombolytic therapy, however, based on our preliminary data, may be beneficial in selected patients with an acute MI with a nonrecent PCE.

Objective: The objective of this study was to evaluate the efficacy, tolerability, and safety of mibefradil, a new selective T-type calcium channel blocker, in patients with chronic stable angina pectoris receiving concomitant beta-blocker therapy., Design: This was a multicenter, double-blind, placebo-controlled study., Methods: Ninety-five patients receiving a stable dose of beta-blockers, which was not changed for the purpose of the study, were administered either 50 mg mibefradil once daily for 2 weeks, then 100 mg once daily for 2 weeks, or matching placebo. Efficacy was evaluated by treadmill exercise tolerance testing 24 hours after dose and by diary registration of anginal episodes and nitroglycerin consumption., Results: Two weeks of treatment with 50 mg mibefradil resulted in a significant increase in symptom-limited exercise duration and a significant delay in the onset of persistent 1 mm ST-segment depression (placebo-corrected treatment effect: 23.2 and 51.7 seconds, respectively). Treatment with the 100 mg dose for 2 additional weeks resulted in a larger improvement in treadmill exercise tolerance testing duration and onset of ischemia (placebo-corrected treatment effect: 52.7 and 75.8 seconds, respectively). In addition, a significant decrease in weekly anginal episodes was observed with the 100 mg dose of mibefradil compared with the effect in the placebo group (-53% vs - 12%, p = 0.037)., Conclusions: The combined treatment of mibefradil and beta-blockers was well tolerated, and the overall incidence of adverse events was no different from that with beta-blockers alone. The results indicate that adding mibefradil to chronic beta-blocker treatment is associated with significant improvement in efficacy, which is not achieved at the expense of tolerability.

Twenty patients with acute myocardial infarction (AMI) treated with streptokinase (SK) and 11 patients with AMI not treated with SK were clinically and echocardiographically evaluated in the intensive coronary care unit (ICCU). Blood samples, in which complement components C4d, C5b-9, and Bb were measured, were taken immediately after arrival of the patient at the ICCU, 1 hour after SK infusion, and 24 hours later from the SK group, and similar time-matched samples were taken from the control group. The classic, alternative, and common complement pathways were found to be activated in AMI, but this activation was statistically significant only in the SK-treated group. Activation was not related to the site of the AMI nor to the extent of its damage, as assessed by Killip class and ejection fraction. However, in the SK-treated group and even more so in non-SK group, the C5b-9 increment was significantly higher in patients diagnosed with reperfusion, based on ST-segment recovery of > or =50% reduction from the peak ST-segment level. There was little change in complement levels when reperfusion did not occur. Detection of reperfusion without coronary angiography would have important practical clinical implications, and complement activation may predict its occurrence. However, more studies of this phenomenon are needed.

Prostaglandin E ( 1 ) (PGE ( 1 ) ), the active ingredient of the drug alprostadil-alpha-cyclodextrin, has been effective in mitigating the clinical manifestations of peripheral arterial occlusive disease (PAOD). PGE ( 1 ) often is administered to patients with the potential for developing serious arrhythmias, presenting potential safety hazards if the drug caused or potentiated arrhythmias. However, PGE ( 1 ) has antiadrenergic properties and, theoretically, might have an antiarrhythmic action. Therefore, the effect of PGE ( 1 ) on frequency and severity of atrial and ventricular arrhythmias was evaluated from 48-hour electrocardiographic recordings in patients receiving PGE ( 1 ) therapy for severe PAOD. No significant effects on arrhythmia frequency or severity, and no evidence of proarrhythmia, was apparent after PGE ( 1 ) administration.

Objectives: To confirm the safety of prostaglandin E ( 1 ) (PGE ( 1 ) ) when administered in 100 mL normal saline to patients with severe peripheral occlusive disease (PAOD; Fontaine class III or IV) and concomitant compensated chronic congestive heart failure (CHF) and to explore possible hemodynamic benefits of PGE ( 1 ) in CHF., Background: PGE ( 1 ) has been found to be effective in the treatment of severe PAOD. The agent may beneficially affect left ventricular performance or hemodynamics in patients with CHF. However, it must be administered intravenously (in saline diluent, adding potential hazard in patients with volume CHF)., Methods: In a randomized, double-blinded protocol, 50 patients received intravenous (i.v.) infusion of either 60 microg PGE ( 1 ) or placebo, each dissolved in 100 mL saline solution administered over 2 hours each day for 14 days. During the succeeding 14 days, i.v. PGE ( 1 ) was administered to all patients in open-label fashion. Safety was assessed by clinical evaluation of symptoms and signs of CHF or other adverse events, by catheter-based and echocardiographic search for objective cardiac functional influences, and by echocardiogram monitoring for cardiac rhythm. PAOD status also was defined., Results: No evidence of clinical or objective cardiac functional influence was detected. With the usual dosage approved in PAOD, no significant influence on cardiac performance was observed., Conclusion: PGE ( 1 ) is safe for treatment of PAOD in patients with concomitant chronic, compensated CHF.

This study assesses the impact of infarct location on immediate (in-hospital) and 1- and 5-year mortality among patients with reinfarction during the year following discharge from the initial episode of myocardial infarction. The analysis included 192 patients with a second myocardial infarction who were compared in four infarction location groups. The in-hospital mortality associated with reinfarction was higher in patients with a second anterior (32%) than with a second inferior (18%) location, irrespective of the first infarction location (p = 0.03). At 5 years of follow-up, the mortality (65%) tended to be higher in patients with a first anterior-second anterior infarction as compared with patients with all other combinations of location.

We evaluated the early and long-term prognosis of patients with a first non-Q-wave acute myocardial infarction (AMI) in relation to infarct site. Among 4,314 patients with a first AMI, 610 (14%) had a non-Q-wave AMI. Of them, 248 patients with anterior wall AMI were compared with 327 patients with inferior/lateral AMI. Baseline clinical characteristics were similar in both groups except for higher mean age in the anterior wall group. In-hospital complications were more common among patients with anterior wall AMI than in the inferior/lateral group. Patients with anterior wall AMI also had higher rates of in-hospital (15%), 1-year (12%), and 5-year (36%) postdischarge mortality compared with the inferior/lateral infarction group (10%, 6%, and 22%, respectively). The 1-year cardiac event rate (recurrent AMI and cardiac death) was significantly higher among the anterior wall AMI group than the inferior/lateral AMI group (14.2% and 4.8% respectively, p = 0.001). After adjustment for age, gender, systemic hypertension, diabetes mellitus, prior angina, and treatment with various medications, an increased risk for 1-year (odds ratio 1.31, 95% confidence interval [CI] 0.62 to 2.78) and 5-year mortality (relative risk 1.29, 95% CI 0.90 to 1.85) was observed, but it did not reach statistical significance. Anterior wall AMI location emerged as a predictor for higher 1-year cardiac event rate (odds ratio 3.15, 95% CI 1.59 to 6.78). These findings suggest that AMI location is an important prognostic variable for risk stratification of patients with a first non-Q-wave AMI.

Unlabelled: OBJECTIVE, DESIGN AND PATIENTS: Between August 1981 and July 1983, 5839 consecutive myocardial infarction patients were hospitalized in 13 coronary care units in Israel. The present study examines 10 year survival among 4037 consecutive patients with a first myocardial infarction with either Q or non-Q waves. Demographic and medical data were collected from hospital records, and 1 year clinical follow-up was complete for 99% of hospital survivors. Mortality follow-up was extended to June 1992 (mean 10 years of follow-up)., Results: Five hundred and eighty patients (14%) had first myocardial infarctions of the non-Q wave type and 3457 of the Q wave type. Hospital mortality was significantly higher in patients with a Q wave (10%) than those with a non-Q wave myocardial infarction (7%) (P < 0.05). One year post-discharge, non-fatal reinfarction and mortality rates were comparable in patients with Q wave (4% and 7%) and non-Q wave myocardial infarctions (4% and 7% respectively). Similarly, 5 to 10 year post-discharge mortality rates were equally high in patients with a non-Q wave (26% and 44%) as in those with a first episode of a Q wave myocardial infarction (22% and 40% respectively)., Conclusions: Patients with a first non-Q wave acute myocardial infarction exhibited relatively better in-hospital survival than counterparts with a first Q wave infarction, but the advantage did not persist after discharge. Patients with a non-Q wave infarction deserve particular attention as their post-discharge mortality risk is similar to counterparts with a first Q wave myocardial infarction.

The association between fibrinogen measured in healthy individuals and subsequent development of ischemic heart disease is well established, but studies reporting fibrinogen levels in coronary heart disease patients are scarce. Plasma fibrinogen was determined for 5729 men and 728 women (aged 45 to 74) with established coronary heart disease, screened for participation in the Bezafibrate Infarction Prevention study, with the following lipid profile at the time of the first screening visit: total serum cholesterol < or = 270 mg/dl, high density lipoprotein cholesterol < or = 45 mg/dl and triglyceride < or = 300 mg/dl. Increased age was associated with augmented plasma fibrinogen values. Age-adjusted fibrinogen levels were higher in women than in men. A direct association was found between mean fibrinogen levels and low density lipoprotein cholesterol. On the other hand, the correlation with high density lipoprotein cholesterol was inverse. Fibrinogen was also associated with body mass index, behavioral variables and severity of coronary heart disease. In a multivariable linear regression analysis performed, risk factors considered explained merely 6 and 4% of fibrinogen variation for men and women, respectively. Therefore, most of the fibrinogen level variability in coronary heart disease patients is accounted for by factors that remain to be established by further research.

Objective: To characterize the 24-h arterial pressure (AP) profile and the left ventricular (LV) structures and functions in women with pregnancy-associated hypertension., Methods: Twenty nulliparous pregnant women after 20 weeks' gestation, 10 normotensive and 10 hypertensive women matched for gestational age, were hemodynamically investigated using 24-h AP monitoring and Doppler echocardiography to determine LV structures and functions, both systolic and diastolic., Results: The hypertensive women had significantly higher AP determinations throughout the 24 h, with no change in diurnal variation, i.e. nocturnal decline and early morning peaks. Their LV mass was greater and it was accompanied by a slight reduction in contractility and a significant reduction in LV relaxation. The increased AP was due to peripheral vasoconstriction, while cardiac output was preserved., Conclusions: It appears that pregnancy-associated hypertension is caused mainly by arterial vasoconstriction and not by higher cardiac output. The hypertension increases the LV mass, which is associated with a fall in LV relaxation.

We present herein a case of cough-induced nonsustained ventricular tachycardia for which we found no definitive explanation. It could be an anomaly, but this so far unreported clinical fact is worth noting. Notwithstanding this interesting case, we believe that cough can be recommended as a safe and efficacious technique for overcoming hypotensive cardiac arrhythmias.

Unlabelled: 214 patients with angina pectoris were randomized to placebo or isosorbide-5-mononitrate (ISMN) rapid release 5, 10 or 20 mg b.i.d. at 8 a.m. and 3 p.m. Exercise tests were performed between 8 a.m. and 10 p.m., before and 2 and 7 h after each dose on days 2 and 14 and before and 2 h after the morning dose on days 7 and 21. All doses of ISMN increased exercise duration significantly more than placebo, and this effect lasted throughout most of the day. It was maximal (73 s; 24%) 2 h after the morning dose, slightly attenuated but still significant at 7 h, increased 2 h after the second dose and attenuated but still greater than with placebo at 7 h. The increase was even greater at 3 weeks (99 s; 29%), perhaps due to a training effect. Similar improvement was observed in other exercise parameters. There was no significant dose response. There were 100% more anginal attacks in the placebo than in the 20-mg treatment group. No rebound (assessed by comparing exercise duration before the morning dose between the groups) was observed., Conclusion: ISMN b.i.d. eccentrically has an antianginal effect throughout most of the day, peaking at 2 h. This effect is sustained during chronic therapy, without tolerance or rebound.

Ventricular fibrillation in humans is generally sustained (SVF), but it can be also transient (TVF), reverting spontaneously to sinus rhythm. In previous studies we have shown that: a) TVF appears in all young mammals and varies according to age and species; b) it requires synchronization of myocardial cell activity; c) infusion of certain drugs may change the type of ventricular fibrillation from sustained into transient. We hypothesize that the synchronization required for TVF depends on the electrical conductivity of intercellular structures. These intercellular couplings differ among species and decrease with age. Comparison between the inter- and intra-specific variations of intercellular connective structure described in the literature with the type of ventricular fibrillation found in our previous studies on various animals of different ages showed a clear relationship between these histological variations and the changes in the type of ventricular fibrillation. In this study we examined intercellular connective structures ultrastructurally in 3 groups of cats: a. control, untreated cats exhibiting sustained ventricular fibrillation; b. untreated cats exhibiting transient ventricular fibrillation; c. treated cats exhibiting sustained ventricular fibrillation before infusion of a defibrillating drug and transient ventricular fibrillation thereafter. It was found that the intercellular connective structure in cats exhibiting sustained ventricular fibrillation differs significantly from that in cats exhibiting transient fibrillation. In hearts exhibiting sustained ventricular fibrillation, many intercellular connective structures are widened and the degree of widening is pronounced, forming a continuous line, while in hearts exhibiting transient ventricular fibrillation the widened junctions are rare and isolated and the widening is relatively small. These preliminary results strongly support our above-mentioned hypothesis, providing an explanation for the origin of transient ventricular fibrillation and a tool for the development of new defibrillating drugs.

The files of 172 consecutive hypertensive patients who received captopril or enalapril have been reviewed and the patients questioned on the development of chronic dry cough, persisting for at least two months. Forty patients had cough that was attributed to the drugs. Thirteen of them discontinued the drugs because of this adverse effect. In 15 of the 27 patients (55%) who continued receiving ACE inhibitors (7 males, 8 females, aged 65.4 +/- 9.9 years) the cough had spontaneously disappeared after 3.9 +/- 1.9 months of continued unaltered administration of these drugs and without any treatment aimed against this symptom. All patients were followed for at least four months after disappearance of cough, without recurrences. This finding may discourage withdrawal of ACE inhibitors from many patients who develop cough. Continuation of ACE inhibitors for at least several months, despite cough, (if the cough is not too severe) is probably justifiable.

The safety of pregnancy after myocardial infarction remains a significant dilemma for both the obstetrician and the cardiologist. Only 20 cases of pregnancy after myocardial infarction have been reported. To clarify this problem, we add our experience of four such cases in which conception occurred 9 months to 9 years after myocardial infarction with no previous consultation. Each woman had an uneventful pregnancy with no cardiac or obstetric complications related to the myocardial infarction. All patients were under the strict supervision of an obstetrician and a cardiologist during pregnancy in our conjoined antepartum-cardiologic clinic. The mode of delivery in all patients was related to the obstetric indications. Our experience and the accumulated experience in the literature demonstrate good prognosis for patients who conceive after myocardial infarction.

Myocardial infarction during pregnancy is rare. This report presents a 28-year-old parturient with no risk factors for coronary heart disease, in whom an acute anterior myocardial infarction occurred in the 34th gestational week. A cesarean section was performed at term due to an obstetrical cause and under hemodynamic monitoring without complications. Coronary angiography performed 4 months after delivery revealed the presence of normal coronary arteries and mild regional left ventricular dysfunction.

All antianginal drugs except nitrates are also first-line antihypertensive drugs. Their antianginal efficacy has not been evaluated in relation to pretreatment blood pressure. They may aggravate ischemia due to excessive reduction in blood pressure. Until the results of direct comparative studies are available, it is advisable to start treatment of angina pectoris in normotensive and hypotensive patients with other drugs that do not primarily decrease blood pressure. Nitrates are a reasonable choice.

An iatrogenic burn is an unexpected burn that results from a diagnostic or therapeutic procedure. Modern therapy and research, while achieving new standards of cure rate, likewise has the potential for causing serious and, at times, hazardous complications. This report describes an illustrative case of an unusual iatrogenic burn.

Variant angina with two or more electrocardiographic or angiographic localizations has seldom been reported [1-4]. We present a case of variant angina pectoris and normal coronary arteries with three different and independent electrocardiographic localizations.