[Worsening of heart failure during hospital course in myocardial infarction is a factor of poor prognosis. Apropos of a prospective cohort study of 2,507 patients hospitalized with myocardial infarction: the PRIMA study]

BACKGROUND

Worsening of heart failure in patients with myocardial infarction is seldom studied, elderly patients often are not included, and multivariate analysis is uncommon.

AIMS

The prospective PRIMA study (Prise en charge de l'Infarctus du Myocarde Aigu; management of acute myocardial infarction) sought to determine the incidence of heart failure worsening, its risk factors, and its prognostic importance in patients with myocardial infarction, regardless of age and hospital facilities, in the "real world" in a region in France, using multivariate analysis.

METHODS

Data were prospectively collected in all patients with myocardial infarction admitted in all hospitals in three departments in the Rhône-Alpes region in France between September 1, 1993 and January 31, 1995.

RESULTS

Among 2,507 patients, 33% were in Killip classes II-IV at admission. Four hundred and sixteen patients (17%) had worsening of Killip class during the first five days. In-hospital mortality (overall: 14%) increased dramatically with Killip class at admission (9% in class I; 62% in class IV) and with worsening of Killip class during the first five days (36% vs 8% if no worsening). In multivariate analysis, older age, diabetes mellitus and anterior Q-wave myocardial infarction were significant predictors of Killip class at admission and of its worsening. The significant predictors of in-hospital mortality were older age, Killip class III at admission and worsening of Killip class during the first five days.

CONCLUSION

This large, unselected cohort revealed that among patients with myocardial infarction, heart failure and its worsening are frequent, especially in the elderly, and dramatically worsen the in-hospital mortality.

Three-year follow-up after intracoronary gamma radiation therapy for in-stent restenosis. Original WRIST. Washington Radiation for In-Stent Restenosis Trial

BACKGROUND

The Washington Radiation for In-Stent Restenosis Trial (WRIST) is a double-blinded randomized study evaluating the effects of intracoronary radiation therapy (IRT) in patients with in-stent restenosis (ISR).

METHODS

One hundred and thirty patients with ISR (100 native coronary and 30 vein grafts) underwent PTCA, laser ablation, rotational atherectomy, and/or additional stenting (36% of lesions). Patients were randomized to either Iridium-192 IRT or placebo, with a prescribed dose of 15 Gy to a 2-mm radial distance from the center of the source.

RESULTS

Angiographic restenosis (27% vs. 56%, P=.002) and target vessel revascularization (TVR; 26% vs. 66%, P<.001) were dramatically reduced at 6 months in IRT patients. Between 6 and 36 months, IRT compared to placebo patients had more target lesion revascularization (TLR; IRT=17% vs. placebo=2%, P=.002) and TVR (IRT=17% vs. placebo=3%, P=.009). At 3 years, the major adverse cardiac event (MACE) rate was significantly reduced with IRT (39% vs. 65%, P=.003).

CONCLUSIONS

In WRIST, patients with ISR treated with IRT using 192Ir had a marked reduction in the need for repeat target lesion and vessel revascularization at 6 months, with the clinical benefit maintained at 3 years.

Thrombolysis in myocardial infarction in a prospective cohort of 2,515 consecutive patients: older age and longer delays lead to a lower thrombolysis rate

OBJECTIVE

This prospective study sought to determine the rate of thrombolysis in myocardial infarction and the factors that influenced it in everyday practice.

METHODS AND RESULTS

Data were prospectively collected in all patients admitted in all (48) university, community, and private hospitals in three departments in the Rhĵne-Alpes region in France between September 1, 1993 and January 31, 1995. Data from 2,515 patients were included. Overall, 36% of the patients received thrombolysis. The decrease of the thrombolysis rate with age was very regular. The difference between men and women disappeared almost completely when age was taken into account in a bivariate analysis. Among 19 variables introduced in the logistic regression, only the following ones were significant predictors (odds ratio < 1 means less thrombolysis): age (odds ratio: 0.60 per decade), administrative department, type of hospital (community/tertiary: 0.74; private/tertiary: 0.58), history of myocardial infarction or of angina pectoris (0.67), location of myocardial infarction (Q wave non anterior/Q wave anterior: 0.75; non Q wave/Q wave anterior: 0.18), delay between symptoms onset and first medical intervention (0.06), history of cancer (0.47), and history of psychiatric disorder (0.38).

CONCLUSIONS

In France as in other countries, the rate of thrombolysis is low. In order to increase this rate, we have to find ways to be more "aggressive" in older patients, and to precisely describe the health care pathways in order to shorten delays.

[Study of blood pressure, hemodynamic, ventilatory and metabolic responses to isometric exercise performed during dynamic exercise in health subjects]

The object of this study was to study the blood pressure, haemodynamic, ventilatory and metabolic changes on isometric exercise during a dynamic effort in healthy subjects. Twelve healthy subjects underwent isometric exercise by manual prehension at 40% maximal capacity under these conditions: isolated (A), five minutes after the onset of rectangular dynamic exercise on a cycle at 60% of ventilatory threshold (B) and at the fourth minute of the recovery phase of dynamic exercise (C). The blood pressure, heart rate, stroke volume and cardiac index measured by Doppler echocardiography, systemic arterial resistances, respiratory flow and respiratory rate, were measured before and after each isometric exercise. The results showed blood pressure and heart rate to increase in a similar manner during isometric exercise under all conditions. The cardiac index increased by 29.5% +/- 8.3% (p < 0.01) under condition A and by 38.1% +/- 10% (p < 0.01) under conditions C but did not change significantly under conditions B. On the other hand, the systemic arterial resistances increased by 15.5% +/- 6.5% (p < 0.05) under conditions B, decreased by 8.8% +/- 3.9% (p < 0.05) under conditions C but did not change significantly under conditions A. The respiratory flow increased under all three conditions although the respiratory rate was only increased under conditions B. The authors conclude that, in healthy subjects, the increase in blood pressure during isometric and dynamic exercise is the result of an increase in systemic resistances whereas, during isometric exercise, it is flow-dependant.

Are women with acute myocardial infarction managed as well as men? Does it have consequences on in-hospital mortality? Analysis of an unselected cohort of 801 women and 1,718 men

OBJECTIVE

This study sought to compare characteristics and management of myocardial infarction in men and women, and whether a difference in management would translate into a difference in in-hospital mortality.

METHODS AND RESULTS

Data were prospectively collected in 2,519 patients (801 women) admitted in all hospitals in three departments in the Rhĵne-Alpes region in France between September 1, 1993 and January 31, 1995. Women were older than men (76 vs. 64 years). The interval between symptom onset and initial medical intervention was longer in women than in men (median: 180 vs. 135 minutes), as was the interval between symptom onset and hospital admission (median: 315 vs. 255 minutes). After age-adjustment, women were less often smokers, and more often hypertensive or diabetic than men, location of infarction was more often anterior in women, as congestive heart failure at admission. In multivariate analysis, thrombolysis rate was not significantly different in both sexes, whereas noninvasive tests, coronary arteriography, percutaneous transluminal coronary angioplasty, and coronary artery bypass grafting were significantly less often performed in women than in men. Although in-hospital mortality was higher in women than in men (21% vs. 11%), this difference disappeared after age-adjustment (relative risk = 0.99). In multivariate analysis, gender was not an independent predictor of survival.

CONCLUSIONS

Although in-hospital mortality after myocardial infarction was similar in both sexes, rates of diagnostic and therapeutic procedures were lower in women than in men. This raises the question of whether mortality would decrease in women if management were similar in both sexes.

Worsening of heart failure during hospital course of an unselected cohort of 2507 patients with myocardial infarction is a factor of poor prognosis: the PRIMA study. Prise en charge de l'Infarctus du Myocarde Aigu

Worsening of heart failure in patients with myocardial infarction is seldom studied, elderly patients often are not included, and multivariate analysis is uncommon. The prospective PRIMA study (Prise en charge de l'Infarctus du Myocarde Aigu; management of acute myocardial infarction) sought to determine the incidence of worsening heart failure, its risk factors, and its prognostic importance in patients with myocardial infarction, regardless of age and hospital facilities, in the 'real world' in a region in France, using multivariate analysis. Data were prospectively collected in all patients with myocardial infarction admitted in all hospitals in three departments in the Rhône--Alpes region in France between 1 September 1993 and 31 January 1995. Among the 2507 patients included, 33% were in Killip classes II--IV at admission. After exclusion of patients with admission Killip class IV, 416 patients (17% of the cohort, 24% of women and 14% of men) had worsening of Killip class during the first 5 days. In-hospital mortality (overall, 14%) increased dramatically with Killip class at admission (9% in class I, 62% in class IV) and with worsening of Killip class during the first 5 days (36.5 vs. 8.5% if no worsening). In multivariate analysis, older age, diabetes mellitus and anterior Q-wave myocardial infarction were significant predictors of Killip class at admission and of its worsening; Killip class >I at admission was a significant predictor of Killip-class worsening. The significant predictors of in-hospital mortality were older age, Killip class III at admission and worsening of Killip class during the first 5 days. This large, unselected cohort revealed that, among patients with myocardial infarction, heart failure and its worsening are frequent, especially in the elderly, and dramatically worsen the in-hospital mortality.

Treatment at discharge after myocardial infarction in 2,102 patients. The PRIMA study. Prise en charge de l'Infarctus du Myocarde Aigu

OBJECTIVE

This study sought to examine the use of treatments at discharge in patients hospitalized for myocardial infarction in a French region.

METHODS AND RESULTS

Data from 2,102 patients discharged after myocardial infarction were prospectively collected at 48 university, community, and private hospitals in three departments in the Rh ne-Alpes region between September 1, 1993 and January 31, 1995. Beta-blockers were prescribed in 59% of the patients, calcium channel blockers in 22%, nitrates in 59%, antiplatelet agents in 82%, anticoagulants in 26%, angiotensin-converting enzyme inhibitors in 36%, diuretics in 33%. Beta-blockers were prescribed less often in older patients, and in patients with higher Killip classes or a history of pulmonary disease. Calcium channel blockers were prescribed more often in older patients, and in patients with a history of diabetes, pulmonary disease, or non-Q wave myocardial infarction. Nitrates were prescribed more often in older patients. Angiotensin-converting enzyme inhibitors were prescribed more often in patients with a history of diabetes, hypertension, or anterior myocardial infarction, and less often in patients with a history of renal failure. Diuretics were prescribed more often in older patients, and in patients with a history of renal failure, diabetes, hypertension, or higher Killip classes.

CONCLUSIONS

There is still underuse of beneficial treatments, particularly in elderly patients.

Characteristics, management, and in-hospital mortality of acute myocardial infarction in the "real world" in France--data from a large unselected cohort of 2,519 consecutive patients in a French region

OBJECTIVE

The prospective PRIMA study (Prise en charge de l'Infarctus du Myocarde Aigu; management of acute MI) sought to determine characteristics, management, and in-hospital mortality of myocardial infarction (MI), regardless of age and hospital facilities, in the "real world" in a region in France.

METHODS AND RESULTS

Data were prospectively collected in all patients with MI admitted in all hospitals in three departments in the Rh ne-Alpes region between September 1, 1993 and January 31, 1995. 2,519 patients (68% men; mean +/- SD: 68 +/- 14 years) were included. Time from onset of symptoms to admission was < 6 h in 56% of the patients (median: 4 h 30 min). MI was non-Q wave in 12%. Among Q wave MI, location was anterior in 44%. At admission, Killip class was > 1 in 33%. The overall rate of thrombolysis was 36%. It was significantly higher in men than in women, in younger patients than in older patients, in lower Killip classes, in Q wave MI, and when the delay before initial medical intervention was < 6 hours. After age-adjustment, there was no difference between men and women for thrombolysis rate (odds ratio women/men: 0.92; p = 0.10). During the first 5 days, Killip class worsened in 17%. In-hospital mortality rate was 14%. Multivariate analysis identified age, anterior location, presence of Q waves, and higher Killip classes as significant predictors of in-hospital mortality.

CONCLUSIONS

This large unselected cohort revealed that among patients with MI in a French region, there was a high proportion of elderly patients, a low rate of thrombolysis, and a high in-hospital mortality.

[Epidemiology and economic impact of heart failure in France]

There are little epidemiological data available about heart failure in France, despite its considerable impact on the system of health care and the fact that this problem will become even more acute in the future. Here are some important statistics: in France, there are about 500,000 people suffering from heart failure with about 120,000 new cases every year. The incidence increases from 4% in men and 3% in women of 55 to 64 years of age to 50% in men and 85% in women of 85 to 94 years of age. The average age of diagnosis is 73.5 years: two thirds of patients are over 70 years of age. There are about 3.5 million consultations and 150,000 hospital admissions for heart failure per year. The average length of hospital stay is 11 days. There are more than 32,000 deaths per year from heart failure. The cost of treating heart failure represents more than 1% of total medical expenses. Heart failure is a major problem of public health which is on the increase. This should incite physicians to provide optimal treatment for those affected and to place greater emphasis on preventive measures.