Age-associated neovasculopathy with recurrent bleeding.

We hypothesize the existence of an age-associated neovasculopathy with recurrent bleeding. It could be the result of age-related defects in the regulation of the angiogenetic process creating pathologic small vessels with a bleeding tendency. Conditions like subdural hematoma, ocular angiopathies, intestinal angiodysplasia, coronary atherosclerotic plaques and others, may be the clinical expression of such a neovasculopathy.

Preliminary evaluation of a convalescence cardiac unit for older patients as a model of "transitional facility" from hospital to home.

OBJECTIVES: The increasing number of older cardiac patients combined with the tendency to reduce hospital stays created the need for a Convalescence Cardiac Unit (Con.CU). It functions as a transitional facility for elderly patients discharged from hospitals after cardiac events, and was established within a geriatric medical center using existing infrastructure and staff. METHODS: Patients from 5 neighboring general hospitals (including 23 internal medicine wards and 3 departments of cardiac surgery) were offered the option of one week stay in the Con.CU after discharge. During the stay in the unit they received medical supervision as well as counsel on matters of nutrition and physical activity. RESULTS: 78 patients were admitted during the first 14 months. Forty patients were after coronary artery bypass grafts (CABG) (51%)30 after acute myocardial infarction (MI) (38%). The average age was 75 +/- 2.5 (SD). Medical complications developed in 57%. Most of these patients were treated by the local staff. Five cases had to be readmitted to the hospital they came from. Elderly cardiac patients that chose the option of Con.CU and their families expressed high appreciation regarding this experience and its contribution in facilitating return home. CONCLUSION: This innovative model is aimed to improve continuity of care for elderly cardiac patients and provide them with a new service in this era of "early discharge" from hospitalization. Geriatric settings striving to diversify their services, and medical directors required to contribute to policy development may learn from this experience.

Usefulness of losartan, captopril, and furosemide in preventing nitrate tolerance and improving control of unstable angina pectoris.

Sixty consecutive normotensive patients with unstable angina pectoris, who were on continuous intravenous isosorbide dinitrate (ISDN) treatment and had not previously received angiotensin II receptor antagonists, angiotensin-converting enzyme (ACE) inhibitors, or diuretics were randomly assigned to treatment groups receiving intravenous ISDN for 72 hours. No additional treatment was given to group A (n = 15). Captopril, in a test dose of 6.25 mg, and followed by 12.5 mg 3 times daily for 24 hours and 25 mg 3 times daily for the next 24 hours, was given to group B (n = 15). The same dose of captopril plus 40 mg of furosemide in the morning were given to group C (n = 15). Losartan, in a single dose of 25 mg/day and increased to 50 mg after 24 hours was given to group D (n = 15). Nitrate tolerance was evaluated at 24-hour intervals at trough levels of each of the drugs by administering intravenous ISDN (1 mg bolus dose every 4 minutes) and recording the total ISDN test dose required to decrease the mean arterial blood pressure by > or =10%. Treatment with continuous ISDN only (group A) induced nitrate tolerance. The ISDN (mean +/- SD) test dose was 3.5 +/- 1.8 mg at baseline, increasing to 4.9 +/- 2.4 mg at 24 hours, and 8.0 +/- 3.0 mg at 48 hours. The addition of increasing doses of captopril to the continuous ISDN treatment (group B) completely prevented nitrate tolerance. Losartan, however, did not attenuate nitrate tolerance at 24 hours and attenuated it only partially at 48 hours. The addition of furosemide to captopril had no further effect on nitrate tolerance. Of 15 patients in group A (ISDN only), 4 (27%) experienced recurrent ischemic events requiring urgent coronary catheterization. No such events were recorded in group B (captopril), but did occur in 1 patient in each of group C (captopril plus furosemide) and D (losartan) (p = 0.083). Thus, the addition of captopril to the ISDN treatment regimen prevented tolerance to nitrates and improved angina control with apparent safety. Losartan also decreased nitrate tolerance, although to a lesser extent, and also improved angina control. The addition of furosemide to captopril conferred no further benefit.