Medical history of hypercholesterolaemia adversely affects the outcome of out-of-hospital cardiopulmonary resuscitation; the 'Shahal' experience in Israel.

AIMS: To evaluate the impact selected risk factors for cardiac death may have on the success rate in a large cohort of subscribers to 'SHAHAL' who were resuscitated from out-of-hospital cardiac arrest. METHODS AND RESULTS: In this medical facility currently serving 50 000 subscribers, data were prospectively gathered from between 1987-1998. The information retrieved from the patients' medical records included a medical history of hypertension, diabetes, hypercholesterolaemia (>220.mg. dl(-1)) smoking, angina, previous myocardial infarction, and congestive heart failure. A total of 998 patients aged 74+/-12 years (mean+/-1 SD) were included. Death was announced at the scene for 659 (66%) victims, while 339 (34%) patients were taken to hospital. Of these 140 (14% of the total cohort) survived and were discharged from the hospital. A comparison of various selected parameters between survivors and non-survivors of resuscitation revealed that survivors were younger, had a higher rate of pulseless ventricular tachycardia/ventricular fibrillation, more were among the arrests witnessed by the 'SHAHAL' team, and that more had a shorter time lag to initiation of cardiopulmonary resuscitation than non-survivors. None of the studied risk factors predicted the outcome of cardiopulmonary resuscitation, with the exception of hypercholesterolaemia, which carried a significantly worse prognosis for cardiopulmonary resuscitation (P=0.009). CONCLUSIONS: A medical history of hypercholesterolaemia appears to be an important risk factor which adversely affects the outcome of cardiopulmonary resuscitation.

Usefulness of self-administration of intramuscular lidocaine in the prehospital setting for ventricular tachyarrhythmias unassociated with acute myocardial infarction (the "Shahal" experience in Israel).

We report on the experience accumulated by the subscribers of SHAHAL cardiac services who self-injected intramuscular lidocaine (using an automatic injector "LidoPen") for documented ventricular tachyarrhythmias which were not associated with an acute myocardial infarction. SHAHAL provides professional care to its subscribers who telephone a monitor center and describe their symptoms, whereupon therapeutic measures are decided upon. Patient data are stored in a central computer, and the center can dispatch mobile intensive care units. All subscribers carry a portable transtelephonic electrocardiographic transmitter and are provided with the LidoPen. Indications for self-injection were: transmission of a wide-QRS tachycardia (rate > 100 beats/min), symptomatic multiple or complex ventricular premature complexes in association with chest discomfort, and when the time of arrival of a medical team to the patient was estimated to be at least 8 to 10 minutes. Successful usage of the LidoPen was reported in 137 cases (123 patients). An additional 11 patients failed to use the injector properly. There was a success rate in abolishing rapid sustained ventricular tachycardia (27 of 76 patients) and nonsustained ventricular tachycardia and/or multiple and complex ventricular ectopic activity (8 of 30 patients) of 33% (total 35 of 106 patients). In another 9%, those arrhythmias were slowed markedly. The remaining 31 cases were eventually interpreted as being of supraventricular origin. No complications attributed to the use of the injector were reported and its use was found to be both feasible and effective in the prehospital setting.

[Impact of Shahal (Cardiac Emergency Services) on daily life of subscribers].

SHAHAL (Cardiac Emergency Services) provides professional 24-hour mobile emergency medical service monitored by intensive care nurses via a central computerized operations unit. All subscribers carry a "cardiobeeper" for transtelephonic transmission of a 3-lead electrocardiogram, and an automatic intramuscular self-injector containing 300 mg lidocaine. In this retrospective study we assessed the impact of SHAHAL on subscribers' mental stress, self-confidence and ultimately, quality of life. Answers to a written questionnaire (n = 1034) and a personal interview (n = 55) were analyzed. It was shown that SHAHAL is effective in decreasing mental stress and improving self-confidence in the majority of subscribers. It was especially beneficial in women, the elderly, those of lower socioeconomic status, pessimists and chronic worriers, and the ill more than the healthy. Those whose functional capacities were very limited benefited less, but for them SHAHAL's function as a life-saving and rescue system is more valuable. Lastly, subscription to SHAHAL also improved the self-confidence of the subscriber's family.

From swirling to a mobile, pedunculated mass--the evolution of left ventricular thrombus despite full anticoagulation. Echocardiographic demonstration.

We describe the unusual evolution of a left ventricular thrombus following acute anterior myocardial infarction despite adequate anticoagulation. Serial echocardiographic examinations demonstrated the evolution from swirling in the left ventricle through a solid apical mass gradually dislodging into a mobile, pedunculated mass that was removed surgically to prevent embolization. This report emphasizes the need to follow echocardiographically left ventricular thrombi during treatment with anticoagulants, and to identify morphologic changes that may predict embolization. This case suggests that left ventricular thrombectomy should be considered in selected patients in whom a very high-risk thrombus morphology is detected.

Utilization of an automated ECG interpretation system in an ambulatory health service.

A computerized ECG interpretation system was incorporated into a large ambulatory health care service. The central unit has several terminals located at various regional cardiological clinics. In each clinic 80--120 ECG's are taken daily, of which 56% are interpreted as normal tracings. The interpretation system is currently utilized to separate automatically normal from abnormal tracings. Normal tracings are not re-checked by a cardiologist and the report is delivered directly to the family physician. In order to evaluate the reliability of the computer interpretation of normal ECG's (i.e., the percent of false-negative readings), 500 tracings interpreted by the program as normal were selected at random and read independently by three cardiologists. It was found that in 4.6% of the cases additional remarks were supplemented to the computer statement by at least one of the cardiologists. Most of the computer-cardiologist disagreements were of limited clinical importance. It was concluded that this system could be used as an effective tool for simultaneously processing ECG's from several remote locations, serving large ambulatory populations. By using the assistance of the computer system, marked reduction in cardiologists' time and cost could be achieved.