Early and late results of operation after thrombolytic therapy for acute myocardial infarction

Recent reports have established the efficacy of thrombolytic therapy in limiting myocardial infarction. Between September 1981 and September 1984, 355 patients were treated with intracoronary (87) or intravenous (268) streptokinase within 6 hours of acute myocardial infarction. Thrombolysis was successful in 63% of patients receiving intracoronary streptokinase and 81% of those receiving intravenous streptokinase. Because residual critical stenosis is usually present and predisposes the patient to reinfarction, revascularization procedures were investigated as an extension of thrombolytic therapy. One hundred ninety-one patients aged 56 +/- 10 (25 to 77) years underwent early surgical revascularization 4.1 +/- 3.6 days after intracoronary or intravenous streptokinase for acute myocardial infarction. Results of this treatment were successful in 89% (170/191) of the patients. Thirteen patients (6.8%) underwent emergency coronary artery bypass grafting for failed percutaneous angioplasty. There were 3.2 +/- 1.4 grafts per patient and 3.8 +/- 2.9 units of blood were administered in the perioperative period. Operative mortality was 4.2% (8/191) with a 15.4% mortality (2/13) in the group in which angioplasty failed. Mean hospitalization time after operation was 10.9 +/- 6.8 days. Follow-up was 27 +/- 8 (12 to 48) months and was obtained on all patients. Late cardiac mortality was 1.0% (2/183). Ninety percent of the follow-up group was without angina and only 1.7% showed no improvement after operation. Reinfarction occurred in four patients (2.2%), with graft failure documented by coronary arteriography in two of these patients. This experience indicates that early revascularization after thrombolytic therapy may be performed with low operative mortality and morbidity and is associated with excellent late results.

Thrombolytic therapy followed by early revascularization for acute myocardial infarction

During a 24-month period, 192 patients with acute myocardial infarction were treated with intracoronary or intravenous streptokinase (SK). In 147 patients (77%) an open infarct artery was demonstrated by coronary angiography; 117 of these 147 patients were judged to have viable myocardium supplied by a critically narrowed coronary artery and underwent revascularization 3 +/- 2 days after SK therapy. In-hospital mortality was 6% (12 of 192). The mortality rate over the subsequent 20 +/- 7 months of follow-up was lower for those in whom SK therapy was successful (1 of 137, 0.7%) than in those in whom it was not (6 of 43, 14%) (p less than 0.001), and tended to be lower for those treated with intravenous (2 of 111, 2%) rather than intracoronary SK (5 of 69, 7%, p = 0.11). Reinfarction occurred in 3% of the 180 survivors of hospitalization, angina pectoris in 11% and congestive heart failure in 7%. Clinical outcome was similar for patients treated with intravenous and intracoronary SK and for patients treated in community hospitals and the referral center.

Prominence of the calcaneus: is operation justified?

Sixty-nine heels in 42 patients with prominence of the calcaneus sufficient to cause symptoms were operated upon after conservative treatment had failed. At review the overall results of operation were found to be poor.

Percutaneous transluminal coronary angioplasty as palliation for patients considered poor surgical candidates

Thirty-one patients with angina inadequately controlled by medical therapy, but who were poor surgical candidates because of advanced age and poor general condition, or because of depressed left ventricular function, had percutaneous transluminal coronary angioplasty (PTCA). These high-risk patients were identified prospectively, and coronary artery bypass surgery (CABS) was planned only in the event of arterial occlusion and chest pain. PTCA was successful in 11 of 17 (65%) high-risk geriatric patients, in 11 of 12 (92%) patients with left ventricular ejection fraction less than 40%, and in two additional patients having PTCA without surgical stand-by because of technically difficult vascular anatomy for CABS. There were no PTCA-related deaths; three of the 31 high-risk patients had emergency surgery because of arterial occlusion, and the remaining four patients with PTCA failure remain on medical therapy for angina. The clinical course of the 31 high-risk patients was similar to that of 155 patients having PTCA during the study period who were considered good candidates for either PTCA or CABS. PTCA may thus be considered an intermediate, palliative procedure for patients with inadequate control of ischemic symptoms who are poor surgical candidates.

Reliability of Q-wave formation and QRS score in predicting regional and global left ventricular performance in acute myocardial infarction with successful reperfusion

The frequency of electrocardiographic Q-wave formation and the relation of Q wave and QRS score to regional and global left ventricular (LV) performance were determined in 131 patients with acute myocardial infarction (AMI) receiving thrombolytic therapy. Thrombolytic therapy was successful in reperfusing the occluded infarct artery in 100 patients and was unsuccessful in 31. The number of patients who had 1 or more Q waves (88 vs 87%) and 2 or more Q waves (70 vs 74%) was similar. In contrast, normal wall motion was significantly more common in the infarct area in patients in whom reperfusion was successful (42 vs 15%, p less than 0.05). Total QRS scores were similar in patients in whom reperfusion was successful and in those in whom it was not (6.0 +/- 3.2 vs 6.4 +/- 4.2). Despite similar QRS scores, successfully treated patients had significantly higher LV ejection fraction (53 +/- 13% vs 46 +/- 15%, p less than 0.05). Thus, Q-wave formation after successful thrombolytic therapy for AMI is common but does not faithfully reflect regional or global LV performance. Electrocardiographic analysis alone is not a reliable method to assess efficacy of reperfusion therapy.

The role of the plaster bed after spinal fusion

Between 1974 and 1983, 40 patients underwent intertransverse lumbar fusion at the Royal Free Hospital, London. Nine of these were managed after operation on a plaster bed for 12 weeks and the rest were mobilized within 2 weeks. A satisfactory radiologic fusion rate of 75% was achieved in the first group and of 70% in the second group. There was no significant difference between these two groups, (chi 2 test). The results do not support the use of the plaster bed after lumbar fusion.

Toronto Alexithymia Scale: relationship with personality and psychopathology measures

The Toronto Alexithymia Scale (TAS) is a 26-item self-report measure of alexithymia with good internal consistency and test-retest reliability, and a factor structure congruent with the alexithymia construct. This study assesses the construct validity of the scale by examining its relationship with several personality and psychopathology measures. In a sample of 81 college students, the TAS correlated strongly and positively with a measure of hypochondriasis but negatively with measures of psychological mindedness and 'need for cognition'. There were low-magnitude correlations between the TAS and measures of self-depreciation, social introversion, persecutory ideation, and impulse expression, but no correlation with a measure of denial. These results indicate that the TAS is assessing adequately the theoretical domain relevant to its item and factor structure.

Ergonovine-induced coronary artery spasm and myocardial infarction after normal delivery

Reported is the first known case of postpartum myocardial infarction probably induced by ergonovine maleate, a drug known to provoke coronary artery spasm in susceptible patients.

Toward the development of a new self-report alexithymia scale

Addressing methodological problems in the development of existing scales for measuring alexithymia, this study reports the development of a new self-report scale. The Toronto Alexithymia Scale (TAS) was devised with concern for theoretical congruence with the alexithymia construct, independence of social desirability response bias, and internal consistency. Initially, 41 items were administered to 542 college students. Twenty-six items meeting preestablished psychometric guidelines were retained. Factor analysis yielded four interpretable factors, all consistent with the construct. The scale demonstrated adequate split-half and test-retest reliability, and scores were not significantly associated with age, education, and socioeconomic status. These preliminary results suggest that the TAS may be used as a clinical screening device with psychiatric and general medical patient populations.

Verbal measures of alexithymia: what do they measure

Previous studies have shown that measurement of verbal affective expression is influenced by the method used for obtaining speech samples, thereby supporting a situation-dependent, or state concept of alexithymia. In this study monadic speech samples obtained from 20 psychoneurotic and 20 psychosomatic patients, using selected thematic apperception test (TAT) cards, were examined using different methods of content analysis. Although no differences were found with the Gottschalk-Gleser anxiety, hostility outward and hope scales, the psychosomatic patients had a more limited emotional vocabulary than the psychoneurotic patients as measured by an 'affect vocabulary score' (AVS). In contrast to the Gottschalk-Gleser scores (GGS), the AVS correlated with measures of fantasizing ability and would appear to be a more valid method of measuring alexithymia. The findings also supported a trait concept rather than a state concept of alexithymia.

Early operative intervention after thrombolytic therapy for acute myocardial infarction

Thrombolytic therapy effectively interrupts acute myocardial infarction but does not correct the underlying plaque causing acute thrombosis. Early operation and treatment of the residual coronary artery disease has therefore been evaluated. Over 29 months, 184 patients with acute myocardial infarction of less than 6 hours duration were treated with intracoronary (IC) or intravenous (IV) streptokinase (SK). Angiography was performed early and thrombolysis found to be successful in 70% of the IC-SK group and 82% of the IV-SK group. One hundred six patients with successful thrombolysis had early revascularization surgery performed 3.3 +/- 2.1 days following SK treatment (range 0 to 11 days). These patients were compared with 110 consecutive patients who underwent coronary artery bypass grafting for standard indications. The SK group had an average of 3.0 +/- 1.4 grafts, 4.3 +/- 3.1 units of blood, and 10.8 +/- 5.3 days in the hospital postoperatively per patient and had an operative mortality rate of 2.7%. The control group averaged 3.6 +/- 1.3 grafts, 4.0 +/- 2.4 units of blood, and 9.6 +/- 3.5 days in the hospital postoperatively per patient with an operative mortality rate of 2.7%. This experience indicates that early operation following SK therapy can be performed with low operative risk and without prolonged hospitalization.

Comparative cost of myocardial revascularization: percutaneous transluminal angioplasty and coronary artery bypass surgery

A consecutive series of 78 patients having percutaneous transluminal coronary angioplasty for single vessel coronary artery disease and 85 patients having single vessel coronary artery bypass graft surgery were followed up prospectively for 1 year. Days in hospital and angiographic and revascularization procedures were counted in the two groups of patients and total cost of care for 12 months was calculated using current billing levels. Angioplasty was initially successful in 74% of patients; because of initial failure in 26% and late restenosis in 18%, bypass surgery was ultimately needed in 23 of 78 patients having coronary angioplasty. Nevertheless, total cost of care per patient was 43% lower for those having angioplasty as an initial procedure for single vessel coronary artery disease.

Intravenous versus intracoronary streptokinase therapy for acute myocardial infarction in community hospitals

A consecutive series of 184 patients with acute myocardial infarction (AMI) received thrombolytic therapy. The first 63 were treated in the catheterization laboratory with intracoronary streptokinase (IC-STK), and 44 (70%) had successful thrombolysis. One hundred twenty-one patients received intravenous (IV) STK immediately after diagnosis of AMI, and 99 (82%) were found to have an open infarct artery. Only 58% of patients (14 of 24) who required transfer from out-of-town hospitals for IC-STK treatment had successful thrombolysis; in contrast, IV-STK given in the local hospital resulted in an 85% (72 of 85) rate of thrombolysis (p = 0.005). IV-STK thus appears at least as effective as IC-STK for AMI and is more effective for patients treated in hospitals without catheterization facilities.

Alexithymia: concept, measurement, and implications for treatment

Alexithymia refers to a specific disturbance in psychic functioning characterized by difficulties in the capacity to verbalize affect and to elaborate fantasies. Although initially described in the context of psychosomatic illness, alexithymic characteristics may be observed in patients with a wide range of medical and psychiatric disorders. The author reviews the concept of alexithymia, including its historical background, clinical and demographic features, and possible etiology. He critically evaluates the different methods used to measure alexithymia and discusses the important implications it has for medical and psychiatric treatment.

Psychotherapy with the boring patient

Boredom is an unpleasant affective state which may be evoked by monotonous sensory input and reduction of an individual's internal instinctual and fantasy activity. Certain difficult patients have the capacity to evoke boredom in their psychotherapists and unless technical modifications are used, therapy quickly reaches an impasse and may be terminated on the grounds that the patient is 'not psychologically-minded.' Chronically boring patients have an impaired capacity for symbolization and can be identified by their non-symbolic communicative style. This reflects an inner struggle with primitive mental states due to fixation at, or regression to, the paranoid-schizoid developmental position. The patient may use projective identification to discharge unbearable psychic tension into the therapist whose boredom is partly a defense against this. Alternatively, the patient may create impenetrable barriers with language by making 'attacks on linking' which are tantamount to attacks on the therapist's peace of mind. The therapist should initially interpret the form and function of the patient's communications rather than the contents. In a manner comparable to a mother's interaction with her young child, the therapist can help the patient acquire a greater capacity for symbolization, including the ability to accurately label and verbalize different affective experiences. Careful analysis of the countertransference will identify the patient's projective identifications, provide valuable information about the patient's primitive mental life, and prevent anti-therapeutic projective counter-identifications. The patient will become less boring as he learns to use symbols and as his primitive anxieties are resolved.

Relation of therapeutic response to nifedipine to coronary anatomy and motion of S-T segment during unstable angina pectoris

Of 77 patients hospitalized for unstable angina pectoris and failure of oral, dermal, or intravenous nitrates and/or beta blockade, 81 percent with negligible or single-vessel disease and 55 percent with two- or three-vessel disease showed response (p less than 0.05) to nifedipine therapy. Patients with either S-T elevation or no change during pain responded better (31 of 45) than those with any S-T depression (16 of 32; p less than 0.05). Patients with negligible or single-vessel disease had a higher prevalence of S-T elevation (13 of 16) than patients with two- or three-vessel disease (15 of 31; p = 0.004). S-T motion did not predict response in patients with two- or three-vessel disease, but did predict response in patients with negligible or single-vessel disease. On follow-up study at 9 +/- 8 (range one to 33) months, 39 of 42 who had shown response were free from pain. Three died from infarction without unstable angina. (range one to 33) months, 39 of 42 who had shown response were free from pain. Three died from infarction without unstable angina. Five who showed response had elective bypass surgery. The addition of nifedipine abolished or reduced pain episodes by more than 50 percent in 61 percent of patients with refractory unstable angina pectoris. Patients with negligible or single-vessel disease with S-T elevation benefit most. In patients with two- or three-vessel disease, the type of S-T motion did not predict response. Follow-up of all those with response indicated sustained amelioration by nifedipine therapy. Failure of nifedipine therapy should not be accepted until a dose of 120 mg per day has been achieved, or until intolerable side effects appear.

Prospective assessment of regional myocardial perfusion before and after coronary revascularization surgery by quantitative thallium-201 scintigraphy

Because thallium-201 uptake relates directly to the amount of viable myocardium and nutrient blood flow, the potential for exercise scintigraphy to predict response to coronary revascularization surgery was investigated in 47 consecutive patients. All patients underwent thallium-201 scintigraphy and coronary angiography at a mean (+/- standard deviation) of 4.3 +/- 3.1 weeks before and 7.5 +/- 1.6 weeks after surgery. Thallium uptake and washout were computer-quantified and each of six segments was defined as normal, showing total or partial redistribution or a persistent defect. Persistent defects were further classified according to the percent reduction in regional thallium activity; PD25-50 denoted a 25 to 50% constant reduction in relative thallium activity and PD greater than 50 denoted a greater than 50% reduction. Of 82 segments with total redistribution before surgery, 76 (93%) showed normal thallium uptake and washout postoperatively, versus only 16 (73%) of 22 with partial redistribution (probability [p] = 0.01). Preoperative ventriculography revealed that 95% of the segments with total redistribution had preserved wall motion, versus only 74% of those with partial redistribution (p = 0.01). Of 42 persistent defects thought to represent myocardial scar before surgery, 19 (45%) demonstrated normal perfusion postoperatively. Of the persistent defects that showed improved thallium perfusion postoperatively, 75% had normal or hypokinetic wall motion before surgery, versus only 14% of those without improvement (p less than 0.001). Whereas 57% of the persistent defects that showed a 25 to 50% decrease in myocardial activity demonstrated normal thallium uptake and washout postoperatively, only 21% of the persistent defects with a decrease in myocardial activity greater than 50% demonstrated improved perfusion after surgery (p = 0.02). Thus, preoperative quantitative thallium-201 scintigraphy appears useful in predicting response to revascularization surgery, and some persistent defects may revert to normal thallium uptake after surgery. Importantly, the preoperative distinction between viable and nonviable myocardium can be reasonably established by quantitating the amount of persistent reduction in thallium uptake and correlating this with preoperative wall motion.

Traumatic pericardiocentesis: two-dimensional echocardiographic visualization of an unfortunate event

Two-dimensional echocardiography was performed simultaneously with pericardiocentesis in an attempt to visualize the pericardiocentesis needle. Rapid penetration of the right ventricular myocardium by the pericardiocentesis needle occurred and was only appreciated in a slow-motion analysis of the two-dimensional echocardiogram videotape. Development of an intrapericardial thrombus was clearly detected by the two-dimensional echocardiogram videotape. Development of an intrapericardial thrombus was clearly detected by the two-dimensional echocardiogram within 24 hours following this traumatic pericardiocentesis. While two-dimensional echocardiography may offer the possibility for seeing the pericardiocentesis needle, technical considerations may limit the easy visualization of the pericardiocentesis needle and accurate localization of its tip. However, two-dimensional echocardiography may be useful in identifying consequences of suspected or proved traumatic pericardiocentesis procedures.

Precordial ST-segment depression during acute inferior myocardial infarction: clinical, scintigraphic and angiographic correlations

The cause and associated pathophysiology of precordial ST-segment depression (ST decreases) during acute inferior myocardial infarction (IMI) are controversial. To investigate this problem, electrocardiographic findings in 48 consecutive patients with acute IMI were prospectively compared with results of coronary angiography, submaximal exercise thallium-201 (201TI) scintigraphy and multigated blood pool imaging, all obtained 2 weeks after IMI, and with clinical follow-up at 3 months. Patients were classified according to the admission ECG obtained 3.3 +/- 3.1 hours after the onset of chest pain. Twenty-one patients (group A) had no or less than 1.0 mm ST decreases, and 27 (group B) had greater than or equal to 1.0 mm ST decreases in two or more precordial (V1-6) leads. Patients in group B had more prolonged chest pain after admission to the coronary care unit than those in group A (2.8 +/- 3.0 vs 1.2 +/- 1.1 hours, p less than 0.03), greater summed ST-segment elevation in leads II, III, aVF (6.7 +/- 4.7 vs 3.3 +/- 4.5 mm, p less than 0.02), higher plasma peak creatine kinase levels (1133 +/- 781 vs 653 +/- 482 IU/l, p less than 0.01), a higher prevalence of "true posterior" infarction by ECG criteria (26% vs 5%, p less than 0.05), a lower radionuclide ejection fraction (46 +/- 9% vs 54 +/- 6%, p less than 0.001), more extensive infarct-related asynergy (p less than 0.001) and 201TI perfusion abnormalities (p less than 0.01), more complications during hospitalization (p less than 0.03), and more cardiac events at 3 months (p less than 0.02). There were no significant differences between group A and group B in the extent of underlying coronary disease, prevalence of left anterior descending coronary artery disease, exercise-induced ST decreases or angina, and 201TI defects or wall motion abnormalities in anterior or septal segments. Thus, patients with acute IMI who have associated precordial ST decreases have greater global and regional left ventricular dysfunction due to more extensive inferior or inferoposterior wall infarction, rather than concomitant anteroseptal ischemic injury.