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Doron Zahger

Publications and source records attributed to Doron Zahger.

At least 19 recordsLinked to original sources
PubMed2007

Trends in management, hospital and long-term outcomes of elderly patients with acute myocardial infarction.

PURPOSE: The number of elderly patients with acute myocardial infarction (AMI) is growing rapidly, and their early and postdischarge mortality is high. Several studies have reported a decline in mortality after myocardial infarction; however, the magnitude of the decline among the elderly has not been fully investigated. METHODS: We assessed trends in management, in-hospital, and long-term outcomes of 1475 elderly patients (aged > or =75 years, 42% women) hospitalized with AMI in all 25 operating coronary care units in Israel between 1992 and 2002, from our prospective nationwide biennial surveys. RESULTS: Between 1992 and 2002, a significant increase was observed in the use of acute reperfusion therapy (27%-48%), coronary angiography (6%-47%), percutaneous coronary intervention (3%-33%), coronary bypass (2%-8%), aspirin (53%-88%), beta-blockers (18%-65%), angiotensin-converting enzyme inhibitors (26%-63%), and lipid-lowering drugs (0%-43%). These changes were associated with a 42% reduction in 30-day mortality (27.6%-16.1%; adjusted odds ratio 0.57; 95% confidence interval [CI], 0.36-0.93). One-year cumulative mortality declined by 20% (37%-29%; adjusted odds ratio 0.74; 95% CI, 0.49-1.13). CONCLUSIONS: The management of elderly patients with AMI changed substantially during the last decade. This change was associated with a significant reduction in early mortality, whereas cumulative 1-year mortality improved only slightly. Better adherence to in-hospital management guidelines and better implementation of postdischarge health policy may further decrease mortality and morbidity in the elderly after AMI.

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PubMed2006

Benefit of direct ambulance to coronary care unit admission of acute myocardial infarction patients undergoing primary percutaneous intervention.

BACKGROUND: Early reperfusion therapy in ST-segment elevation myocardial infarction (STEMI) patients improves left ventricular (LV) function and survival. However, emergency room (ER) triage may unnecessarily delay this time-dependent treatment. We sought to determine whether direct admission of STEMI patients from the mobile intensive care units to the intensive coronary care unit (ICCU), bypassing the ER, can shorten the time intervals for primary PCI (PPCI) and improve prognosis. METHODS: All STEMI patients who underwent PPCI between Jan-2002 to Nov-2005 were included. Baseline, clinical and time interval parameters were compared between groups. Mortality rates were obtained through the population register. RESULTS: Of 533 admissions, 115 (21%) were admitted directly to the ICCU. These patients were younger (mean (+S.D.) age of 58+13 years) than patients admitted via the ER (62+/-13 years, P<0.01) and had a lower proportion of women (9% vs. 22%, P<0.01), hypertension (45% vs. 62%, P<0.01) and diabetes (15% vs. 27%, P=0.01). Directly admitted patients had a substantially shorter median pain-to-balloon time (210 vs. 247 min, P=0.02) as well as s significantly shorter door-to-balloon time (70 vs. 94 min, P<0.01), a difference that was particularly pronounced during daytime (55 min vs. 90 min, P<0.01). There were no significant differences in LV function at 24 h as assessed by echocardiography or infarct size as determined by peak creatine kinase levels. We observed a trend towards reduced 30-day (5.2% vs. 9.8%, P=0.12) and 1-year (11.1% vs. 16.1%, P=0.25) mortality in directly admitted patients. CONCLUSIONS: Directly admitted STEMI patients differ from patients admitted via the ER; Direct ICCU admission, based on a pre-hospital ECG, can substantially shorten time to treatment.

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PubMed2006

Influence of the new definition of acute myocardial infarction on coronary care unit admission, discharge diagnosis, management and outcome in patients with non-ST elevation acute coronary syndromes: a national survey.

BACKGROUND: Major changes occurred recently in the definition and recommended management of non-ST segment elevation acute coronary syndromes (NSTE ACS). The impact of these changes on the coronary care unit (CCU) is incompletely characterized. METHODS: ACSIS is a national survey gathering data every other year among all ACS patients in all CCUs in Israel. We compared case load, baseline variables, management, outcome and distribution of diagnoses among NSTE ACS patients admitted before (during 2000 [N = 729]) and after (during 2002 [N = 970]) the widespread introduction of troponin and the new AMI definition. RESULTS: The number of NSTE ACS patients in 2002 increased by 33% compared to 2000, with no change in the number of beds, while the number of ST elevation ACS patients remained unchanged. The rate of AMI rose by 16% and hospital stay decreased by 1 day (p = 0.005). The availability of troponin values increased from 20% in 2000 to 60% in 2002; The proportion of patients given the diagnosis of NSTE AMI rose significantly more in centers with high utilization of troponin (p = 0.023). During 2002 significant increases occurred in the utilization of guideline-recommended medications, as in the use of coronary angiography and intervention. Mortality at 30 days decreased by 35%. CONCLUSIONS: This is the first large registry of ACS to describe the significant actual changes which occurred in the CCU following the introduction of troponin and the new AMI definition. We observed a substantial increase in the burden of NSTE ACS coupled with a shortened length of stay. These changes may impact significantly upon patient care and resource utilization.

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PubMed2006

Intracoronary nitroprusside for the prevention of the no-reflow phenomenon after primary percutaneous coronary intervention in acute myocardial infarction. A randomized, double-blind, placebo-controlled clinical trial.

BACKGROUND: The aim of this study was to test whether nitroprusside (NTP) injected intracoronary immediately before primary angioplasty for acute ST-elevation acute myocardial infarction (STEMI) prevents no-reflow and improves vessel flow and myocardial perfusion. METHODS: Ninety-eight patients presenting with STEMI were evenly randomized to receive either NTP (60 microg) or placebo. The drug was selectively injected into the infarct-related artery, distal to the occlusion, in a double-blind manner. The primary end points were postintervention angiographic corrected thrombolysis in myocardial infarction frame count and the proportion of patients with complete (>70%) ST-segment elevation resolution. Secondary end points included myocardial blush score and clinical outcome at 6 months follow-up. RESULTS: Mean (+/-SD) age was 62 (+/-12) years, and 87% were men. Baseline characteristics (excluding sex) did not differ between groups. The corrected thrombolysis in myocardial infarction frame count after angioplasty was 20.8 (+/-18.6) and 20.3 (+/-21.3) in patients given NTP and placebo, respectively (P = .78). Complete ST-segment resolution was achieved in 61.7% and 61.2% of NTP and placebo subjects, respectively (P = .96). The distribution of myocardial blush score did not differ between groups. At 6 months, the rate of target lesion revascularization, myocardial infarction, or death occurred in 6.3% of the NTP group and 20.0% of the placebo group (P = .05). CONCLUSIONS: In patients with STEMI, selective intracoronary administration of a fixed dose of NTP failed to improve coronary flow and myocardial tissue reperfusion but improved clinical outcomes at 6 months.

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PubMed2006

Prior heart failure among patients with acute coronary syndromes is associated with a higher incidence of in-hospital heart failure.

BACKGROUND: There are few data regarding the impact of prior heart failure (P-HF) on the presentation, course and outcomes of acute coronary syndromes (ACS). METHODS AND RESULTS: We prospectively analyzed all ACS patients admitted in all cardiology wards in Israel during February and March, 2004. Of the 2098 patients, 156(7.4%) had P-HF. These patients were older (75 [66.5-81] versus 63 [53-74] years, (P<0.001)) and more often female (38.5% versus 25.0%, P<0.001)), with a higher prevalence of coronary artery disease risk factors, prior cardiac disease and procedures, and other co-morbidities. They more often presented with atypical angina and heart failure and less with ST-elevation (18.6% versus 51.3%, p<0.0001). In-hospital heart failure developed more frequently (15.4% versus 6.1%, p = 0.00001), including cardiogenic shock (7.1% versus 2.9%, p = 0.005), as did persistent atrial fibrillation (6.4% versus 0.7%, p<0.001), but not ischemic complications. After adjustment for differences, P-HF was not independently associated with 30 day or six-month mortality, but at one-year follow-up, it was (OR 1.16, 95% CI 1.0-2.5). P-HF was also independently associated with increased incidence of heart failure upon admission or thereafter in-hospital (OR = 4.3, 95% CI 2.8-6.6). CONCLUSIONS: P-HF ACS patients had high-risk features, lower incidence of ST-elevation, and higher one-year adjusted mortality. P-HF was also independently associated with in-hospital heart failure, suggesting they should be monitored vigilantly.

Age Factors↗
PubMed2006

Plasma level of N terminal pro-brain natriuretic peptide as a prognostic marker in critically ill patients.

We studied whether N-terminal pro brain natriuretic peptide (NT-pro BNP) measured at intensive care unit admission is an independent predictor of mortality in critically ill patients. We conducted a prospective observational cohort study enrolling 78 patients with APACHE II scores more than 12. Serum NT-pro BNP and cardiac troponin T were measured at admission, and echocardiography was performed within 24 h. The primary end-point was 30-day mortality. The median NT-pro BNP levels of the 22 (28.2%) patients who died were significantly more frequent than that of those who survived (8328 versus 1016 pg/mL; P = 0.001). Patients with NT-pro BNP levels more than 1900 pg/mL had significantly more frequent mortality (47.2% versus 11.9%; P = 0.03). This group also had more frequent moderate to severe left ventricular dysfunction (30.6% versus 9.5%; P = 0.02) and abnormal cardiac troponin T levels (33.3% versus 14.3%; P = 0.05). Multivariate analyses adjusted for APACHE-II revealed that a NT-pro BNP level more than 1900 pg/mL is an independent predictor of mortality.

APACHE↗
PubMed2006

[Trends in management, morbidity and mortality of patients with acute myocardial infarction hospitalized in the last decade].

BACKGROUND: The diagnosis and management of acute myocardial infarction (AMI) has undergone major changes during the last decade. These changes reflect the results of numerous controlled clinical trials that established the basis for evidence-based guidelines. AIMS: The aims of this study were to examine the trends in the characteristics, management and outcome of patients with AMI, hospitalized in all 25 Intensive Care Units (ICCU) operating in Israel during the last decade (1994-2004). METHODS: Data were derived from the biannual two-month national AMI/Acute Coronary Syndrome Israeli Surveys (ACSIS) performed in Israel. During the last decade, there was a continuous increase in the number of AMI patients admitted to the ICCU's operating in Israel - 999 AMI patients in 1994 and 1,534 in 2004. This increase was possibly due to shortening of hospital stay of AMI patients. RESULTS: The mean age of patients (64 years) did not change significantly in the last decade. The ICCU population has been characterized by an increasing number of octogenarians (7% in 1994 and 13% in 2004) and higher numbers of patients with past history of PCI, CABG, CVA and other comorbidities. There have been increases in the use of evidence-based medications during hospital stays and at discharge, reflecting greater adherence to guidelines. The "primary reperfusion" rate increased in the last decade from 60% in 1998 to 64% in 2004. The mode of reperfusion has changed in favor of primary PCI in 2004. In 1998, 88% of STEMI patients who underwent primary reperfusion were treated with thrombolysis and 12% by primary PCI while in 2004, 33% were treated with thrombolysis and 67% by primary PCI. The hospital course of patients with AMI in the last decade is characterized by better outcomes with reductions in rates of reischemia and reinfarction, cardiogenic shock, atrial fibrillation, VT/VF, and AV Block 2 degrees - 3 degrees. The most striking change in the last decade is the significant reduction in short- and long-term mortality with 45% reduction in 7-day mortality and 33% reduction in one-year mortality. CONCLUSIONS: This trend of better clinical outcomes and lower mortality in the last decade most probably relates to the use of evidence-based treatment and to better adherence to guidelines in the operating ICCUs in Israel.

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PubMed2006

[Diabetics with normal coronary arteries: clinical features and prognosis].

BACKGROUND: Diabetic patients comprise a large proportion of patients referred for coronary angiography. Only a minority of these patients will be found to have normal coronary arteries. AIM: To characterize diabetic patients who have angiographically normal coronary arteries. METHODS: Case-control study based on a computerized database. RESULTS: Using our computerized database, 13,342 consecutive patients referred for coronary angiography were identified. Diabetes mellitus was diagnosed in 24% of cases. Angiographically normal coronary arteries were found in 151 (5%) and 1228 (12%) of diabetic and non-diabetic patients, respectively (p<0.01). Diabetic patients with angiographically normal coronary arteries were matched with 155 diabetic patients who were catheterized on the same day but were found to have coronary artery disease. The median follow-up period was 1,774 days. The age of the diabetic patients with normal coronary arteries and diabetic patients with coronary artery disease was 5710 and 6410 years old respectively (p<0.01). A total of 39% and 60% of diabetic patients with normal coronary arteries and with coronary artery disease respectively were males, (p<0.01). Dyslipidemia was diagnosed in 66 (43%) of the diabetic patients with normal coronary arteries and 87 (57%) of the diabetic patients with coronary artery disease (P<0.01). After controlling for age and sex, the finding of normal coronary arteries was associated with decreased mortality (OR: 0.47, 95% CI 0.23 to 0.95). CONCLUSIONS: In diabetic patients referred for angiography it is unusual to find angiogrtaphically normal arteries. These patients have a relatively benign prognosis, as opposed to diabetic patients with evident coronary disease.

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PubMed2005

Aspirin, warfarin and a thienopyridine for acute coronary syndromes.

BACKGROUND: Although clopidogrel and aspirin (dual therapy, DT) are used for acute coronary syndrome (ACS), sometimes treatment with warfarin (triple therapy, TT) is required. AIM: To determine the incidence, complications, and outcomes of TT. METHODS: We analyzed Israeli surveys of ACS from 2000 to 2004. RESULTS: In these surveys, 5,706 (96%) were discharged alive from hospital. Post-ACS TT and DT were 76 patients (1.3%) and 2,661 patients (46.7%), respectively. The TT group was older with more prior cardiac disease. During hospitalization, the TT patients received more intravenous anticoagulant and antithrombotic agents, and had more heart failure, arrhythmias, ischemia, and major bleeding (2.6 vs. 0.6%, p=0.03). There were no differences in adjusted 30-day and 6-month mortality between the 2 groups. CONCLUSION: TT is feasible among ACS patients who require concomitant warfarin treatment.

Aspirin↗
PubMed2005

Clinical characteristics and prognostic factors in patients with complicated acute coronary syndromes requiring prolonged mechanical ventilation.

Patients with acute coronary syndromes (ACSs) may develop serious multiorgan complications and require prolonged intensive care. Our aim was to characterize and identify factors that are associated with outcomes in these patients. We retrospectively identified 267 consecutive patients admitted to the coronary care unit for an ACS who required >3 days of mechanical ventilation. Multiple clinical and laboratory variables were correlated with mortality. Patients' ages were 68.3 +/- 10.9 years (mean +/- SD) and 165 (62%) were men. Seventy-six patients (29%) died within 30 days of admission, and the 1 year mortality was 46%. Moderate or severe left ventricular systolic dysfunction was found in 72% of the patients. Eighty-nine patients (33.3%) required vasopressors, of whom 64 (72%) did not survive 30 days. Among 127 patients who required antibiotics (48.3%), 30-day mortality was 53% compared with 4% among patients who did not require antibiotics (p <0.001). The 30-day mortality among patients who received both antibiotics and vasopressors was 64 of 87 patients (74%), and the 1-year mortality in this subgroup was 86.2%. Parameters found to be independent predictors of 30-day mortality were (in descending order): vasopressor requirement, use of antibiotics, peripheral vascular disease, ST-elevation myocardial infarction, renal failure, obesity and Killip class on admission. In conclusion, mortality among patients who require prolonged mechanical ventilation after an ACS is substantial. The main independent predictors of with mortality are the severity of heart failure and the presence of co-morbidities.

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PubMed2005

Grade 3 ischemia on admission and absence of prior beta-blockade predict failure of ST resolution following thrombolysis for anterior myocardial infarction.

BACKGROUND: ST segment resolution (STR) is a strong predictor of outcome following thrombolysis. If failure of STR could be predicted on admission, better selection of treatment may be possible. Among patients given reperfusion, those with terminal QRS distortion (grade 3 ischemia) have larger infarcts, but the mechanism underlying this association is unclear. Whether grade 3 ischemia on admission can predict STR is unknown. METHODS: We studied 180 consecutive patients given thrombolysis for a first anterior acute myocardial infarction (AMI). Multiple variables available on admission were analyzed as predictors of STR at 1, 2, and 24 h and as predictors of the need for rescue percutaneous coronary intervention (PCI). RESULTS: Multivariate predictors of failure of STR were: for 1 h: extent of ST elevation (OR: 1.09 [1.01-1.18]); for 2 h: no previous use of beta-blockers (OR: 4.71 [1.56-13.98]) and grade 3 ischemia (OR: 6.77 [3.27-13.95]); for 24 h: previous use of aspirin (OR: 6.70 [1.31-34.01]) and grade 3 ischemia (OR: 29.44 [7.30-118.1]). Grade 3 ischemia had a strong positive predictive value for failure of STR at 1 and 2 h and was the strongest predictor of the need for rescue PCI. CONCLUSIONS: Grade 3 ischemia on admission is the strongest independent predictor of failure to achieve myocardial reperfusion after thrombolysis. This association may underlie the larger infarcts associated with grade 3 ischemia. Other predictors of reperfusion failure are the extent of ST segment elevation, prior use of aspirin and no prior use of beta-blockers.

Adrenergic beta-Antagonists↗
PubMed2005

Increased long term rates of stent thrombosis and mortality in patients given clopidogrel as compared to ticlopidine following coronary stent implantation.

BACKGROUND: Clopidogrel has largely replaced ticlopidine following coronary stent implantation. Recently, concern has been raised regarding the possibility of excess long term mortality in patients given clopidogrel rather than ticlopidine following coronary stenting. METHODS: We studied 1519 consecutive patients who underwent 2020 stent implantations and were discharged on dual antiplatelet regimens of either aspirin and ticlopidine or aspirin and clopidogrel given for up to 4 weeks. Thrombotic stent occlusion (TSO) was defined as ST elevation myocardial infarction in the stented artery territory associated with angiographic demonstration of complete stent occlusion. Mortality follow up was obtained for all patients by linkage to the Population Register. Follow up duration was 12 months. RESULTS: TSO occurred in 37 stents at a median of 29 days post procedure. Of these cases, six occurred in the ticlopidine group (0.7%) and 31 in the clopidogrel group (2.8%) (p<0.01). The median time to TSO was 34 days and 28 days in ticlopidine and clopidogrel treated patients, respectively (p<0.01). After controlling for multiple demographic, clinical and angiographic variables clopidogrel (vs. ticlopidine) treatment remained the sole predictor of TSO (OR: 5.4, 95% CI=1.2-24.1, p=0.028). Of even more concern, clopidogrel treatment was associated with an increased risk of 1 year mortality (OR: 1.8, 95% CI=1.2-2.8). CONCLUSIONS: Long term follow up after stent implantation in patients receiving the traditional 2-4 weeks course of dual antiplatelet therapy reveals increased rates of TSO and mortality in patients given clopidogrel as opposed to ticlopidine. Whether longer treatment with clopidogrel will change these observations deserves further study.

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PubMed2004

What have the new definition of acute myocardial infarction and the introduction of troponin measurement done to the coronary care unit? Impacts on admission rate, length of stay, case mix and mortality.

OBJECTIVE: To assess the impact of the new American College of Cardiology/European Society of Cardiology definition of acute myocardial infarction (AMI) and the introduction of troponin measurement on the coronary care unit (CCU). METHODS: This was a retrospective cohort study performed in a tertiary care university hospital. All admissions to the CCU during the year before (period 1, year 2000, n = 1,134) and the year after (period 2, year 2002, n = 1,360) the introduction of troponin measurement and the new AMI definition were studied. We studied baseline characteristics, case load, distribution of admission diagnoses, management and outcome of patients in the two periods. RESULTS: There was a 20% increase in the number of CCU admissions, driven solely by a 141% increase in the burden of non-ST elevation AMI (NSTEMI) (p < 0.01). This increase was not a mere reflection of a change in diagnostic criteria, as the overall burden of non-ST elevation acute coronary syndromes (ACS) (NSTEMI + unstable angina) increased by 46%, suggesting referral of many more patients to the CCU. Despite a 42% increase in the number of angiograms performed, the proportion of ACS patients who had an angiogram declined. AMI patients in period 2 were older and had higher rates of coronary risk factors but had a higher chance of receiving a guideline-based therapy. Length of CCU stay decreased by a whole day for all ACS patients. 30-day mortality for AMI patients did not change significantly. CONCLUSIONS: The new AMI definition had a dramatic impact on the CCU case load, case mix and length of stay and on the ability to provide early coronary angiography.

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PubMed2004

Can enoxaparin safely replace unfractionated heparin during coronary intervention in acute coronary syndromes?

BACKGROUND: Enoxaparin has gained wide acceptance in patients with acute coronary syndromes. However, there is uncertainty regarding management of patients who require coronary intervention while on enoxaparin. Some physicians withhold the morning dose of enoxaparin prior to coronary intervention while others switch patients to unfractionated heparin. Both methods do not provide optimal anticoagulation in the hours preceding intervention. There are no published controlled data to assess the safety of coronary intervention using enoxaparin alone in patients with acute coronary syndromes. METHODS: We prospectively compared enoxaparin to unfractionated heparin during coronary angiography and intervention. Sixty four patients admitted to the coronary care unit (CCU) were given enoxaparin twice daily, including on the morning of procedure. Coronary angiography and intervention were performed without additional unfractionated heparin. The control group comprised of 52 patients admitted to Internal Medicine for an acute coronary syndrome. These were also given enoxaparin but the morning dose was withheld and unfractionated heparin was used during procedure. RESULTS: Patients in both groups had similar baseline characteristics. No significant differences were observed between the two groups in procedural success rate, complications or bleeding. One year follow up showed similar rates of hospitalization and mortality. CONCLUSION: Enoxaparin seems to offer safe and effective procedural anticoagulation in patients undergoing percutaneous intervention for acute coronary syndromes. Patients given enoxaparin can probably have coronary intervention without interruption of enoxaparin treatment and without additional procedural anticoagulation. These findings require confirmation in larger, randomized trials.

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PubMed2004

[A new definition for acute myocardial infarction].

The recently introduced cardiac troponins are highly sensitive and specific markers for myocardial cell necrosis. The availability of these markers required a change in the classical definition of acute myocardial infarction. This definition of acute myocardial infarction, issued in 2000 by the American College of Cardiology and the European Society of Cardiology, requires elevation of cardiac biomarkers (preferably troponins). The new definition has multiple medical, epidemiological, social, occupational and other implications. As many as 30% of patients previously diagnosed with unstable angina now receive the diagnosis of myocardial infarction. These additional patients change the epidemiology of acute myocardial infarction. New approaches to issues of insurance and employment following myocardial infarction are necessary following the introduction of the new definition. A few aspects of the new definition of myocardial infarction remain controversial, especially those regarding mild myocardial damage following percutaneous coronary intervention. The Israel Heart Society has recently joined other such Societies in the world and endorsed the new definition. While some further refinement of the definition is probably required, we believe it is the best tool available today for the working diagnosis of myocardial infarction and call upon physicians to learn it and use it on a routine basis.

Acute Disease↗