Improved Outcome of Elderly Patients (≥75 Years of Age) With Acute Myocardial Infarction From 1981-1983 to 1992-1994 in Israel
Background The number of elderly patients experiencing acute myocardial infarction (AMI) is growing rapidly, and their hospital mortality rate remains high, although mortality after AMI declined in the 1990s with the introduction of new therapeutic modalities.
Methods and Results We compared the management, in-hospital complications, and 30-day and 1-year mortality rates in two cohorts of elderly (≥75 years of age) AMI patients in the coronary care units in Israel before and after the reperfusion era. The first cohort of 789 consecutive patients was from the Secondary Prevention Reinfarction Israel Nifedipine Trial registry in 1981-1983; the second 366 patients came from two prospective nationwide surveys in 1992 and 1994. Reperfusion therapies were not used in 1981-1983 but were used in 1992-1994. The 30-day mortality rate declined from 38% in 1981-1983 to 27% in 1992-1994 (odds ratio, 0.49; 95% confidence interval [CI], 0.34 to 0.71), and the cumulative 1-year mortality rate declined from 52% to 38% (hazard ratio [HR], 0.62; 95% CI, 0.50 to 0.76). In the 1992-1994 cohort, the decline in mortality was most marked in patients reperfused by thrombolysis and/or percutaneous transluminal coronary angioplasty or coronary artery bypass graft surgery but was also evident in nonreperfused patients: cumulative 1-year mortality rate was 29% in the former (HR, 0.45; 95% CI, 0.31 to 0.67) and 42% in the latter (HR, 0.60; 95% CI, 0.46 to 0.78).
Conclusions During the last decade, elderly (≥75 years) AMI patients experienced fewer in-hospital complications and lower 30-day and 1-year mortality rates, which declined ≈30%, most markedly in reperfused patients. The favorable outcome in 1992-1994 was related to changes in patient management. Reperfusion therapy is therefore also advocated in elderly AMI patients, unless specific contraindications are present.
During the last decade, new, important therapies for the management of AMI patients—thrombolysis, PTCA, and CABG—have been introduced. The beneficial effects on short- and long-term mortality rates of early reperfusion of AMI patients with thrombolytic therapy are now well established.1 2 3 4 5 6
A significant decrease in the in-hospital mortality rate from AMI has been shown during the last 3 decades,7 8 9 10 11 particularly in elderly patients,9 10 11 but no change has been seen in postdischarge survival.7 8 12
The number of elderly (≥75 years of age) patients with AMI is growing rapidly.13 Their hospital mortality rate remains high,14 15 16 although age alone is no longer a contraindication to thrombolysis.3 5 17 In fact, thrombolytic therapy may exert its greatest effect in elderly patients, because the overall number of lives saved is greater in the elderly than in their younger counterparts.3 17 18 19 More than 60% of trials of specific pharmacotherapies used in the treatment of AMI published during the last 30 years excluded patients >75 years of age.20 Thus, little is known about the clinical course and the outcome of elderly patients with AMI in the thrombolytic era.
The purpose of the present study was to compare the characteristics, management, in-hospital complications, and 30-day and first-year prognosis in two cohorts of elderly (≥75 years of age) patients: one cohort admitted for AMI in the CCUs in Israel during 1981-1983 (prethrombolytic era); the other admitted during 1992-1994 (thrombolytic era).
Between August 1981 and July 1983, 5839 consecutive patients with confirmed AMI were hospitalized in 13 of the 21 CCUs operating at that time in Israel and were screened for inclusion in the SPRINT registry. Of these, 789 patients (14%) were ≥75 years of age and therefore ineligible for the SPRINT study. The detailed methods and results of the SPRINT registry have been published elsewhere.21
Demographic and medical data, including history, in-hospital course, and complications, were recorded for all patients. Diagnosis of AMI was based on the presence of any two of the following: typical chest pain lasting ≥30 minutes, unequivocal new ECG changes (Q/QS and/or ST-segment and T-wave changes), or an increase in at least two of the three serum cardiac enzymes (creatine kinase, aspartate aminotransferase, or lactate dehydrogenase) to more than 1.5 times the upper limit or a concomitant increase in creatine kinase and MB isoenzyme. The location of AMI was determined by the Minnesota Code as follows: anterior (V1 through V5), inferior (L2, L3, or aVF), lateral (L1, aVL, or V6), or undetermined if conduction disturbances concealed the site of infarction.22 One-year mortality follow-up was completed for 99% of the hospital survivors.
A second cohort of 1940 consecutive patients with AMI was derived from two prospective national surveys conducted during 2-month periods (January and February) in 1992 and 1994 in all 25 CCUs operating in Israel (including the 13 centers from 1981-1983 cohort). Of these, 366 patients (19%) were ≥75 years of age. Criteria used for diagnosis and determination of infarct site were identical in both cohorts. In 1992, all CCUs participated in the international GUSTO study23 and followed uniform guidelines for thrombolytic treatment. Patients ineligible for the Gusto study who nevertheless received thrombolytic treatment at the discretion of the treating physician and patients who underwent mechanical reperfusion (PTCA or CABG) were also included in this analysis. The patients were followed for 1 year after hospital discharge.24 In 1994, none of the CCUs participated in a thrombolytic or reperfusion randomized study, and thrombolytic therapy and invasive procedures (coronary angiography, PTCA, or CABG) were used at the discretion of each center. The baseline characteristics of the patients in 1992 and 1994 were similar. During the 1992-1994 survey period, a “conservative strategy” of “watchful waiting” with coronary arteriography followed by coronary mechanical reperfusion was used only for patients with spontaneous or provocative ischemia.25
In-hospital complications were compared between the two periods: asystole (pause >3 seconds), ventricular tachycardia (≥3 beats in a row at a heart rate of >120 bpm) or ventricular fibrillation, paroxysmal atrial fibrillation, second- or third-degree AV block, congestive heart failure (signs or symptoms of congestion: rales greater than bibasilar, dyspnea, pulmonary edema, or low cardiac output secondary to cardiac dysfunction), cardiogenic shock (systolic blood pressure <90 mm Hg, not responsive to fluid resuscitation alone, associated with signs of hypoperfusion), recurrent ischemia (typical symptoms or ECG changes), recurrent MI (two of the following: recurrent ischemic symptoms, new ST-T wave changes or new Q waves, second cardiac enzymes elevation), acute mitral regurgitation (new onset, clinically significant), and cerebrovascular accident (acute new neurological deficit resulting in death or lasting >24 hours).
Mortality rates at 30 days and 1 year in both study periods were assessed from medical charts and by matching the identification numbers of the patients with the Israeli National Population Register.
Statistical analysis was performed by use of SAS statistical software.26 χ2 and t tests were used to determine the significance of the differences between proportions and means, respectively, when appropriate. Results of continuous variables are reported as mean±SD. Two-sided probability values are reported.
The overall effect of changes in management between the two periods on all hospital complications in the two cohorts was assessed by MANOVA (SAS GLM procedure with MANOVA statement).
Survival curves were estimated by use of the Kaplan-Meier method. The significance of the difference between the survival curves was assessed by the log rank test (SAS LIFETEST procedure).
To compare 30-day mortality rates in the two periods (1992-1994 versus 1981-1983), in terms of OR with 95% CI, logistic regression analyses (SAS CATMOD procedure) were performed, with adjustments for age, sex, hypertension, diabetes mellitus, prior infarction, prior angina, anterior Q wave during the index infarction congestive heart failure, “period” (when the 1981-1983 cohort was the reference group, OR=1), and “center” (when the 13 CCUs that participated in both cohorts in 1981-1983 and in 1992-1994 were the reference group, OR=1). The variable “period” was introduced because the current study was too small to separately assess the role of reperfusion therapy (thrombolysis, PTCA, or CABG) and other new therapeutic modalities thought to be associated with improved survival. Stepwise Cox proportional hazard regression models (SAS PHREG procedure) with adjustments for the same variables were used to compare first-year mortality in 30-day survivors and cumulative first-year mortality in 1992-1994 versus 1981-1983 in terms of HR (95% CI). A variable was allowed to enter into the model if it made a significant contribution at the P=.10 level and was removed if, after subsequent addition of other variables, it no longer made a contribution at the P=.15 level. An alternative analytic approach was performed with adjustments for the same variables and the variable “reperfusion therapy” to determine separately the adjusted decline in mortality rates of reperfused and nonreperfused patients in 1992-1994 versus patients in 1981-1983.
The proportion of elderly patients included in the current study who were hospitalized in the CCUs in the two periods increased from 14% to 19%. The clinical characteristics of the two cohorts of elderly patients in 1981-1983 (n=789) and 1992-1994 (n=366) were comparable (Table 1⇓). The cohort of patients in 1992-1994 was slightly older, with a lower prevalence of a history of angina but with a higher prevalence of a history of hypertension and diabetes. The type of the index infarction and its location differed slightly between the two cohorts; the 1992-1994 cohort had more non–Q-wave and inferior Q-wave infarctions.
In the 1992-1994 cohort, 119 elderly patients (33%) received reperfusion therapy (thrombolysis, PTCA, or CABG), and 247 did not. The former included a higher percentage of men, more patients with Q-wave infarction and anterior Q-wave location, and a better Killip class on admission but less frequently included patients with prior infarction.
The baseline characteristics of the 247 nonreperfused patients in the 1992-1994 cohort were slightly worse than those of the 789 patients in 1981-1983.
Elderly patients in 1992-1994 had fewer in-hospital complications than 10 years earlier (P<.0001 by MANOVA; Table 2⇓). The following complications were significantly less frequent in 1992-1994: asystole, ventricular tachycardia or ventricular fibrillation, second- or third-degree AV block, congestive heart failure, and recurrent MI. The frequency of cardiogenic shock, recurrent ischemia, and acute mitral regurgitation was similar in the two periods. In 1992-1994, nonreperfused elderly patients experienced a higher complication rate of asystole and paroxysmal atrial fibrillation compared with reperfused patients. Recurrent MI was more frequent in reperfused patients. Stroke and other complications were similarly frequent in the two groups. The complication rate of nonreperfused patients in 1992-1994 was lower than in 1981-1983, although being ineligible for reperfusion therapy suggests that this group is at increased risk.
Temporary pacemaker and Swan-Ganz catheter insertions (left to the discretion of the treating physicians in each center) were performed less often in 1992-1994 (Table 3⇓). Coronary angiography was performed in 0.4% (3 patients) in 1981-1983 versus 10% (35 patients) in 1992-1994 (6% in 1992 and 13% in 1994), of whom 5% (19 patients) underwent PTCA or CABG (4% in 1992 and 6% in 1994). Primary PTCA, without antecedent thrombolysis, was not performed in 1992, whereas in 1994 it was performed in only 2 of our elderly patients.
Among the 119 reperfused patients in 1992-1994, thrombolytic treatment was used in 105, of whom 5 also underwent PTCA or CABG. Another 14 patients underwent PTCA or CABG without antecedent thrombolysis. Thrombolysis use among elderly increased from 23% in 1992 to 34% in 1994. The reasons for exclusion from thrombolytic therapy in 1992-1994 were contraindications to thrombolytic therapy (history of stroke, active bleeding, recent trauma or major operation, noncompressible vascular puncture, and recent traumatic cardiopulmonary resuscitation), 27%; unqualifying ECG changes, 31%; late arrival (>6 hours or >12 hours from onset of symptoms in 1992 and 1994, respectively), 27%; advanced age (defined by the treating physician), 11%; and other reasons, 4%. The reasons for exclusion from thrombolytic therapy differed slightly in men and women. Whereas late arrival was more frequent in women (30% versus 25%, respectively), contraindication to thrombolytic therapy was more frequent in men (31% versus 23%, respectively), differences that were statistically not significant (P=.35). The main reason for exclusion from thrombolytic therapy was late arrival in 1992 (32% of the excluded patients) and unqualifying ECG changes in 1994 (38% of the excluded patients).
In 1992-1994, pacemaker and Swan-Ganz catheter insertions were similarly performed in reperfused and nonreperfused patients (Table 3⇑). Coronary angiography was more frequently performed in reperfused than in nonreperfused elderly patients (22% versus 4%, P<.0001; Table 3⇑), but its use among thrombolysed and nonthrombolysed patients was similar (11% versus 9%, respectively). Elderly women received reperfusion therapy less often than men (26% versus 37%, P<.04). This observation may be explained only partly by the worse baseline characteristics of women; they had a higher prevalence of hypertension (60% versus 41%, P<.01), cardiogenic shock (25% versus 13%, P<.01), and high-grade AV block (13% versus 6%, P=.01) during the hospitalization period. However, after multivariate adjustment, this finding persisted (OR, 0.64; 95% CI, 0.40 to 1.02).
In-hospital medications in 1981-1983 were not recorded. In 1992-1994, 72% received nitrates, 24% received β-blockers, 22% were given calcium antagonists, 17% received digitalis, 59% were given heparin, 63% were given aspirin, and 36% received ACE inhibitors. Reperfused patients in 1992-1994 received heparin (92% versus 43%), aspirin (92% versus 49%), and β-blockers (35% versus 19%) more frequently (P<.001 for all) than their nonreperfused counterparts. Administration of other medications was comparable.
Medications at discharge were compared between 1981-1983 and 1992 (in 1994, discharge medications were not recorded). In 1992, patients were discharged more often while on nitrates (70% versus 57%, P<.01), β-blockers (19% versus 7%, P<.0001), calcium antagonists (24% versus 16%, P<.05), oral anticoagulants (6% versus 0.8%, P<.0001) and antiplatelets (45% versus 17%) and less often while on digitalis (13% versus 22%, P<.01). ACE inhibitors, not available in 1981-1983, were given to 33% of the patients discharged in 1992.
The 30-day, 30-day to 1-year, and cumulative 1-year mortality rates were significantly lower in 1992-1994 than in 1981-1983 (Table 4⇓ and Fig 1⇓). The relative declines in 30-day, 30-day to 1-year, and cumulative 1-year mortality rates were ≈29%, ≈35%, and ≈27%, respectively. The corresponding adjusted mortality declined by 51% (OR, 0.49), 41% (HR, 0.59), and 38% (HR, 0.62), respectively. This favorable outcome in 1-year survival during the last decade was also noted in various subgroups, ie, men, women, first infarctions, prior infarctions, anterior location during the index infarction, and other infarct locations (Fig 2⇓).
Among the 1992-1994 cohort, the decline in mortality was most marked in reperfused patients (n=119; Table 4⇑ and Figs 1B, 2, and 3⇑⇑⇓). The relative declines in 30-day, 30-day to 1-year, and the cumulative 1-year mortality rates were ≈45%, ≈52%, and ≈44%, respectively. The corresponding adjusted mortality declined by 59% (OR, 0.41), 54% (HR, 0.46), and 55% (HR, 0.45), respectively.
A milder decline in the 1-year cumulative mortality rate was also evident in nonreperfused patients in 1992-1994 compared with patients in 1981-1983 (from 52% to 42%; adjusted HR, 0.60) mainly as the result of the decline in 30-day mortality rate (from 38% to 29%; adjusted OR, 0.53; Table 4⇑ and Figs 1B and 3⇑⇑). This favorable outcome of nonreperfused patients was also noted in various subgroups (Fig 2⇑).
The present study demonstrates that in the 1990s compared with the early 1980s, elderly (≥75 years of age) AMI patients hospitalized in the CCUs in Israel exhibited fewer in-hospital complications and lower early and 1-year mortality rates that declined ≈30%, most markedly in reperfused patients. Reperfusion therapy after an AMI should therefore not be restricted to younger patients but also advocated in the elderly.
Magnitude of the Problem
In the western world, the proportion of elderly subjects is growing rapidly. Among persons ≥75 years of age, AMI occurs twice as frequently as in younger persons.8 27 The risk of in-hospital death for AMI patients >75 years of age ranges from 20% to 30%, far exceeding that of younger patients.14 15 27 28 29 In our study, the proportions of elderly patients (≥75 years of age) hospitalized in the CCUs with AMI in the 1981-1983 and 1992-1994 cohorts were 14% and 19%, respectively, yet they accounted for 27% and 36% of in-hospital deaths.28 A similar shift in the proportion of elderly hospitalized AMI patients through the decade was noted in Canada10 and England.30 However, because in the early 1980s fewer CCU beds were available, elderly patients hospitalized in non-CCU beds may have been missed.
Baseline Characteristics and In-Hospital Complications
Elderly patients hospitalized with AMI had more frequent comorbidities than their younger counterparts.15 16 29 31 32 These comorbidities contributed to the high complication rate of heart failure (26%) and cardiogenic shock (18%) during the hospitalization course, which remained high even in 1992-1994. Elderly patients in our study experienced fewer in-hospital complications in 1992-1994 than in 1981-1983. The comparability of baseline characteristics in both periods suggests that these changes were probably related to the alterations in medical practice, the use of thrombolytic therapy, and new therapeutic modalities introduced during the last decade.
Increasing age is associated with a high mortality rate after AMI.14 15 16 27 31 The reasons for increased mortality in elderly AMI patients are multifactorial, including a high prevalence of adverse baseline risk factors,15 16 27 29 31 32 more diffuse triple-vessel disease,15 29 33 more hypertrophy with reduced compliance of the left ventricle,34 and greater risk of cardiac rupture.1 4 31 35 Elderly patients also are often treated differently during the AMI than younger patients,36 including being given insufficient β-blockers37 38 and aspirin.39
Data comparing the outcome of elderly patients with AMI before and after the advent of the reperfusion era are scarce. In our study, 30-day mortality declined by 30% (from 38% to 27%) in about 10 years. The mortality declined in both sexes, was independent of the type or site of AMI (Fig 2⇑) and other pertinent variables, and probably reflected changes in patient management. Changes in medical management (ie, increased use of heparin, aspirin, β-blockers, and ACE inhibitors) and the use of thrombolytic therapy with adjuvant mechanical revascularization procedures may have contributed to the better outcome of patients hospitalized with AMI in the 1990s. Similar trends in declining early mortality were reported in other countries in Europe9 and in North America,10 11 40 41 42 and were attributed to changes in patient management.9 10 11 40
Despite the impressive decline in 30-day mortality in our 1992-1994 reperfused patients, mortality remained high (21%) and is comparable to the figures (15% to 28%) observed among elderly patients in recent thrombolysis mega-trials.4 24 31 43 44
Recent meta-analyses incorporating the ISIS-2 and GISSI-1 studies,18 the Fibrinolytic Therapy Trialists' Collaborative Group,4 and others17 have shown that the overall number of lives saved, a more meaningful measure than percent reduction, is larger in the elderly; the older the age, the larger the benefit in absolute terms.17 19 In our population, the number of lives saved during the first 30 days after an AMI in reperfused compared with nonreperfused patients was 8 per 100 patients (21% versus 29%, respectively).
In the present study, the main improvement in survival between the two periods was achieved early after the AMI and was followed by further improvement during the first postinfarction year, an improvement that was more noticeable in reperfused than in nonreperfused patients (Figs 1 and 2⇑⇑). This finding suggests an extra benefit in elderly reperfused patients after 30 days, although in large-scale studies postdischarge survival of thrombolysed and control AMI patients was similar.12
Although exclusion from reperfusion therapy may have placed our nonreperfused patients in 1992-1994 at increased risk, their improved prognosis compared with those patients hospitalized in 1981-1983 suggests a beneficial effect of other new therapeutic modalities introduced since the early 1980s or alterations in their use. In the current study, in-hospital use of β-blockers, heparin, and aspirin among nonreperfused patients in 1992-1994 was relatively low (19%, 43%, and 49%, respectively) but still higher than in the early 1980s. Similar trends were reported in other studies.9 10 11 40 45 Underutilization of aspirin and β-blockers has been recently addressed in elderly Medicare beneficiaries with AMI.39 The reason for the low rate of usage of these medications in the elderly is not clear and may be related to the higher prevalence of other comorbidities, congestive heart failure, or conduction disturbances. ACE inhibitors were not in use in 1981-1983, but by 1992-1994 they were given to 36% of our elderly patients. Their beneficial effect in death reduction from all causes after AMI was more marked in older patients than in younger counterparts in the Survival and Ventricular Enlargement46 and GISSI-343 studies but not in the ISIS-4 trial.44
Trends in the Use of Thrombolytic Therapy and Invasive Procedures
Despite the capacity of thrombolytic therapy to decrease mortality from AMI,1 2 3 4 5 6 17 few elderly patients have been treated with these agents.17 36 Most early thrombolytic trials excluded patients >75 years of age.1 2 3 4 47 Currently, between 10% and 27% of patients presenting with AMI are excluded from thrombolytic therapy because of advanced age.6 47 In our study, 11% of patients ≥75 years of age were excluded for this reason, similar to current practice in the United States.6 The progressive rise in the incidence of major hemorrhagic complications with increasing age formed the rationale for this exclusion.32 48 In our study, nonfatal stroke occurred in only one nonthrombolysed patient in the 1992-1994 cohort. This low incidence of stroke may be explained by the admission of sicker and moribund patients to non-CCU beds.
In 1992-1994, thrombolysis was used in 29% (24% in 1992 and 35% in 1994) of our elderly (≥75 years of age) patients, more than reported in other studies4 6 16 17 30 36 38 40 in which it ranged from 5% to 20%. Recent US data40 indicate that from 1988 through 1992, the use of thrombolysis increased proportionally more in older than in younger patients, which concurs with the view that physicians are becoming more comfortable using thrombolytic therapy in elderly patients. Our observation that elderly reperfused patients exhibited the greatest decline in mortality during the last decade is in accordance with prior studies4 18 and strongly suggests that elderly patients without contraindications should be reperfused.
In 1992-1994, 10% (8% in 1992 and 12% in 1994) of our elderly patients underwent coronary angiography (5% had PTCA or CABG) compared with 0.4% of the patients in 1981-1983. Data from the US National Hospital Discharge Survey from 1980 through 1990 show a marked increase in cardiac catheterizations and CABG in all ages41 and a more pronounced increase in patients ≥65 years of age. The number of PTCA procedures also increased since 1985, and by 1990 it was equal to the number of bypass procedures.41 Similar trends were observed in Medicare patients ≥65 years of age between 1987 and 1990.42 In the present study, coronary angiography during the index hospitalization was performed similarly in thrombolysed and nonthrombolysed elderly patients (11% versus 9%, respectively) in contrast to other studies.36 42 49 Although the efficacy of primary PTCA in the elderly has been demonstrated,50 only two of our elderly patients in the present study underwent this procedure in 1994.
The patients in the 1992-1994 cohort were derived from a prospective nationwide survey. The decision whether to treat patients with thrombolytic therapy was left to the discretion of the treating physicians in each center, was not randomized, and thus might have been influenced by a physician bias, resulting in the selection of less severely ill patients. Major difficulties in recruiting elderly patients (≥75 years of age) have previously hampered such a randomized trial.51
The present study included 13 CCUs operating in Israel in 1981-1983 and all 25 units operating in 1992-1994. To eliminate the potential of center bias, a comparison of the same 13 units operating in both periods with the other 12 units was performed. Overall, there was a remarkable similarity between these two groups, as published previously.52 In the multivariate analyses, “center” was entered as one of the variables adjusted for in the models (see “Methods”) and turned out to be not statistically significant. This lends credence to the appropriateness of a comparison of the original 13 centers in 1981-1983 and the 25 centers in 1992-1994.
The present study includes data on in-hospital complications and first-year mortality but not morbidity data such as recurrent infraction, hospitalization for unstable angina, heart failure, and need for PTCA or CABG during the 1-year after discharge. We cannot exclude the possibility that even though the mortality was lower in the 1992-1994 cohort, especially in reperfused patients, their postdischarge morbidity may not have differed from those of 1981-1983.
During the last decade, elderly (≥75 years of age) AMI patients hospitalized in the CCUs in Israel experienced fewer in-hospital complications and lower early and 1-year mortality rates, which declined ≈30%, most markedly in reperfused patients. The main improvement in survival was achieved early after the AMI, with further improvement during the first postinfarction year. The present study suggests that the use of thrombolytic therapy and, to a lesser degree, mechanical procedures, as well as changes in therapeutic management (heparin, aspirin, β-blockers, ACE inhibitors, etc), may have contributed to the improved outcome. Thus, reperfusion therapy should not be restricted to younger patients but also advocated in elderly patients with AMI, unless specific contraindications are present.
Selected Abbreviations and Acronyms
|AMI||=||acute myocardial infarction|
|CABG||=||coronary bypass graft surgery|
|CCU||=||coronary care unit|
|GISSI||=||Gruppo Italiano per lo Studio della Streptochinasi nell'Infarto Miocardico|
|GUSTO||=||Global Utilization of Streptokinase and Tissue Plasminogen Activator for Occluded Coronary Arteries|
|ISIS||=||International Study of Infarct Survival|
|PTCA||=||percutaneous transluminal coronary angioplasty|
|SAVE||=||Survival and Ventricular Enlargement|
|SPRINT||=||Secondary Prevention Reinfarction Israeli Nifedipine Trial|
Participating Centers, Directors of the Cardiac Departments, and Responsible Physicians of the Thrombolytic Survey
Assaf Harofeh, Zerifin: Zwi Schlesinger, MD, and Hady Faibel, MD.
Barzilai Medical Center, Ashkelon: Leonardo Reisin, MD, and Jamal Jafari, MD.
Beilinson Medical Center, Petach-Tikvah: Samuel Sclarovsky, MD; Eldad Rehavia, MD; and Boris Strasberg, MD.
Bikur Cholim Hospital, Jerusalem: Shlomo Stern, MD; Andre Keren, MD; and Shmuel Gottlieb, MD.
Bnei Zion Medical Center, Haifa: Edward Abinader, MD, and Ehud Goldhammer, MD.
Carmel Hospital, Haifa: Basil S. Lewis, MD; Nabil Mahul, MD; David Hallon, MD; and Moshe Flugelman, MD.
Carmel Hospital and “Lin” Medical Clinic, Haifa: Abraham Palant, MD, and Chen Shapira, MD.
Central Emek Hospital, Afula: Tiberiu Rosenfeld, MD, and Nahum A. Friedberg, MD.
Hadassah, Ein-Kerem, Medical Center, Jerusalem: Mervyn S. Gotsman, MD; Yonatan Hasin, MD; and Chaim Lotan, MD.
Hadassah, Mount Scopus, Jerusalem: Teddy A. Weiss, MD, and Shimon Rosenheck, MD.
Hasharon Hospital, Petach-Tikvah: Izhar Zahavi, MD, and Menachem Kanetti, MD.
Hillel Yaffe Hospital, Hadera: Benyamin Pelled, MD, MSc; Fatchy Daka, MD; and Magdalah Rashmi, MD.
Ichilov Hospital, Sourasky Medical Center, Tel Aviv: Shlomo Laniado, MD, and Arie Roth, MD.
Josephtal Medical Center, Eilat: Alen Gelvan, MD.
Kaplan Hospital, Rehovot: Abraham Caspi, MD; Oskar H. Kracoff, MD; and M. Michael Oettinger, MD.
Laniado Hospital, Netanya: Eddy Barasch, MD, and Ron Leor, MD.
Meir Hospital, Kfar-Saba: Daniel David, MD, and Hana Pauzner, MD.
Poriah Hospital, Tiberius: Leonid Rudnik, MD, and Shai Reifler, MD.
Rambam Medical Center, Haifa: Walter Markiewicz, MD; Boaz Benari, MD; and Haim Hammerman, MD.
Rebecca Sieff Medical Center, Safed: Alon T. Marmor, MD, and David Blondheim, MD.
Shaare Zedek Medical Center, Jerusalem: Dan Tzivoni, MD; Mark Klutstein, MD; and Jonathan Balkin, MD.
Sheba Medical Center, Tel Hashomer: Elieser Kaplinsky, MD, and Hanoch Hod, MD.
Soroka Medical Center, Beer-Sheva: Natalio Cristal, MD; Amos Katz, MD; Alexander Battler, MD; and Arie Gilutz, MD.
Western Galilee Hospital, Naharia: Nathan Roguin, MD.
Wolfson Medical Center, Holon: Yehezkiel Kishon, MD; Ron Narisky, MD (deceased); and Michael Kriwiski, MD.
Coordinating Center of the National Israeli Thrombolytic Survey, Neufeld Cardiac Research Institute, Sheba Medical Center, Tel Hashomer, Israel: Solomon Behar, MD (director), and Shmuel Gottlieb, MD.
We are indebted to all physicians and nurses who participated in the SPRINT study and the Israeli Thrombolytic Survey in 1992-1994. We are grateful to Dalia Ben-David and Yemima Nahum for data collection, Mark Goldberg for computer programming, and Hanna Sebag for assistance in preparing this manuscript.
See the “Appendix” for a complete list of participants.
Presented in part at the 67th Scientific Sessions of the American Heart Association, Dallas, Tex, November 14-17, 1994.
- Received March 5, 1996.
- Revision received August 28, 1996.
- Accepted September 9, 1996.
- Copyright © 1997 by American Heart Association
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