Prognosis during one year of follow-up after acute myocardial infarction with emphasis on morbidity

Return to Work After Acute Myocardial Infarction: Comparison Between Young Women and Men

BACKGROUND

Return to work after acute myocardial infarction (AMI) is an important outcome and is particularly relevant to young patients. Women may be at a greater risk for not returning to work given evidence of their worse recovery after AMI than similarly aged men. However, sex differences in return to work after AMI has not been studied extensively in a young population (≤ 55 years).

METHODS AND RESULTS

We analyzed data from 1680 patients with AMI aged 18 to 55 years (57% women) participating in the Variation in Recovery: Role of Gender on Outcomes of Young AMI Patients (VIRGO) study who were working full time (≥ 35 hours) before the event. Data were obtained by medical record abstraction and patient interviews. We conducted multivariable regression analyses to examine sex differences in return to work at 12 months after AMI, and the association of patient characteristics with return to work. When compared with young men, young women were less likely to return to work (89% versus 85%; 85% versus 89%, P=0.02); however, this sex difference was not significant after adjusting for patient sociodemographic characteristics, psychosocial factors, and health measures. Being married, engaging in a professional or clerical type of work, having more favorable physical health, and having no previous coronary disease or hypertension were significantly associated with a higher likelihood of return to work at 12 months.

CONCLUSIONS

Among a young population, women are less likely to return to work after AMI than men. This disadvantage is explained by differences in demographic, occupational, and health characteristics.

Work Resumption after Newly Diagnosed Coronary Heart Disease: Findings on the Importance of Paid Leave

OBJECTIVES

Studies have demonstrated the health benefits of work resumption for adults experiencing health problems, but there are important gaps in the research examining the factors that would help these individuals return to work. This study examines if working conditions predict whether women who experience angina or a myocardial infarction (MI) return to work.

METHODS

A sample of 289 employed women from the Nurses' Health Study was analyzed. Bivariate chi-square and logistic regression analyses were conducted to examine the relationship between working conditions and the likelihood of returning to work after experiencing an MI or angina.

RESULTS

Seventy-nine percent of women returned to work after experiencing an MI or angina. Women who had paid leave were substantially more likely to return to work after an MI or angina episode than women without this benefit (adjusted odds ratio [OR] 2.7, p = 0.04).

CONCLUSIONS

Public and corporate policies to promote paid leave for female workers who experience a serious health condition are likely to help these workers return to their jobs, thereby providing important health and economic benefits for both workers and society.

Valvular Heart Disease

Aortic regurgitation (AR) is characterized by diastolic reflux of blood from the aorta into the left ventricle (LV). Acute AR typically causes severe pulmonary edema and hypotension and is a surgical emergency. Chronic severe AR causes combined LV volume and pressure overload. It is accompanied by systolic hypertension and wide pulse pressure, which account for peripheral physical findings, such as bounding pulses. The afterload excess caused by systolic hypertension leads to progressive LV dilation and systolic dysfunction. The most important diagnostic test for AR is echocardiography. It provides the ability to determine the cause of AR and to assess the severity of AR and its effect on LV size, function, and hemodynamics. Many patients with chronic severe AR may remain clinically compensated for years with normal LV function and no symptoms. These patients do not require surgery but can be followed carefully for the onset of symptoms or LV dilation/dysfunction. Surgery should be considered before the LV ejection fraction falls below 55% or the LV end-diastolic dimension reaches 55 mm. Symptomatic patients should undergo surgery unless there are excessive comorbidities or other contraindications. The primary role of medical therapy with vasodilators is to delay the need for surgery in asymptomatic patients with normal LV function or to treat patients in whom surgery is not an option. The goal of vasodilator therapy is to achieve a significant decrease in systolic arterial pressure. Future therapies may focus on molecular mechanisms to prevent adverse LV remodeling and fibrosis.

Diagnosis, treatment, and long-term management of Kawasaki disease: a statement for health professionals from the Committee on Rheumatic Fever, Endocarditis and Kawasaki Disease, Council on Cardiovascular Disease in the Young, American Heart Association

BACKGROUND

Kawasaki disease is an acute self-limited vasculitis of childhood that is characterized by fever, bilateral nonexudative conjunctivitis, erythema of the lips and oral mucosa, changes in the extremities, rash, and cervical lymphadenopathy. Coronary artery aneurysms or ectasia develop in approximately 15% to 25% of untreated children and may lead to ischemic heart disease or sudden death.

METHODS AND RESULTS

A multidisciplinary committee of experts was convened to revise the American Heart Association recommendations for diagnosis, treatment, and long-term management of Kawasaki disease. The writing group proposes a new algorithm to aid clinicians in deciding which children with fever for > or =5 days and < or =4 classic criteria should undergo echocardiography, receive intravenous gamma globulin (IVIG) treatment, or both for Kawasaki disease. The writing group reviews the available data regarding the initial treatment for children with acute Kawasaki disease, as well for those who have persistent or recrudescent fever despite initial therapy with IVIG, including IVIG retreatment and treatment with corticosteroids, tumor necrosis factor-alpha antagonists, and abciximab. Long-term management of patients with Kawasaki disease is tailored to the degree of coronary involvement; recommendations regarding antiplatelet and anticoagulant therapy, physical activity, follow-up assessment, and the appropriate diagnostic procedures to evaluate cardiac disease are classified according to risk strata.

CONCLUSIONS

Recommendations for the initial evaluation, treatment in the acute phase, and long-term management of patients with Kawasaki disease are intended to assist physicians in understanding the range of acceptable approaches for caring for patients with Kawasaki disease. The ultimate decisions for case management must be made by physicians in light of the particular conditions presented by individual patients.

Swedish Council on Technology Assessment in Health Care (SBU). Chapter 8. Sick leave due to coronary artery disease or stroke

The assessment of the literature on sick-leave with cardiovascular diseases include only studies with sufficient scientific quality. These studies describe sick leave following stroke, myocardial infarction, coronary artery bypass grafting (CABG), or percutaneous coronary intervention (PCI). We found limited scientific evidence for the following results: After stroke, more than half of the patients of working age returned to work (RTW) during the first year following onset (higher rate for the younger patients). The consequences of brain damage, e.g. impaired ADL ability or cognitive capacity, play an important role in this respect. Also after myocardial infarction most patients RTW. PCI is a milder coronary artery intervention than CABG and RTW is more rapid. However, in the long run there are no differences in sick leave. People at higher ages or with physically demanding jobs return to work to a lesser degree. An international comparison shows that the duration of sick leave due to these conditions in Sweden is longer than in other countries although there is no scientific evidence to support this practice. It appears that the interest in research on sick leave in patients with cardiovascular diseases has waned in recent years. Developments in acute cardiological care should inspire renewed scientific involvement in this area of research.

Effect of anemia on 1-year mortality in patients with acute myocardial infarction

BACKGROUND

Limited data are available on the effect of anemia on mortality in patients with acute myocardial infarction (MI).

METHODS

We examined the association of anemia with mortality at 1 year among 30,341 patients hospitalized with acute MI in 1986 (prethrombolytic era, n = 15,584) and 1996 (thrombolytic era, n = 14,757). The records were obtained from the Myocardial Infarction Data Acquisition System, a database of all patients with MI admitted to nonfederal hospitals in New Jersey.

RESULTS

Anemia was present in 996 patients (6.4%) in 1986 and 1510 patients (10.2%, P <.0001) in 1996. In both years, patients with anemia were older, more frequently female and nonwhite, and more likely to have left ventricular dysfunction, non-Q MI and coronary artery bypass graft. In addition, in 1996, patients with anemia were more likely to undergo percutaneous transluminal coronary angioplasty and less likely to have a history of MI. One-year mortality was lower overall in 1996 compared with 1986 (1996 23.6%, 95% CI 22.9-24.3 vs 1986 24.9%, 95% CI 24.2-25.6, P =.0001). In both years, patients with anemia had significantly higher unadjusted risk for 1-year mortality (RR = 1.40, P =.0001 in both years). However, after controlling for demographics, left ventricular dysfunction, arrhythmias, Q versus non-Q MI, comorbid conditions, and revascularization procedures in a multivariable regression model, 1-year mortality in the anemia group was similar to the nonanemia group in both years.

CONCLUSION

In the Myocardial Infarction Data Acquisition System database, anemia appears to have no significant direct effect on 1-year mortality. The higher unadjusted mortality observed among patients with acute MI and anemia is probably the result of older age, higher comorbidity, and more left ventricular dysfunction.

Referral to occupational medicine clinics and resumption of employment after myocardial infarction

Rehabilitation after acute myocardial infarction (AMI) consists of education, exercise, and an encouragement to return to work (RTW). This study attempts to (1) determine whether the time interval between AMI and the visit at occupational medicine (OM) clinics predicts resumption of full employment, and (2) estimate the incidence of work-related recurrent AMI after RTW. We followed 216 consecutive AMI patients at a single OM clinic. The independent variables were clinical and personal data, physical workload and time between AMI, and first visit to the OM clinic. The outcome variables were full employment 24 months after the acute event and recurrent AMI during this period. Of all patients, 168 attempted RTW. Of these, 18 stopped working subsequently. Of the remaining 150 patients, 54 returned to part-time work and 96 were employed full-time after 2 years. Logistic regression indicated that a failure to resume full employment was independently associated with diabetes, older age, Q wave AMI, angina before AMI, heavy work, and a late visit to the OM clinic. For each month's delay in referral to the OM clinic, there was a 30% decrease in the chance for full employment 24 months after AMI. Six (4%) of the 150 patients who resumed employment sustained a recurrent AMI, two of them while at work. A delayed referral to the OM clinic was associated with work disability after AMI. Late referrals to OM clinics should receive a more intensive and sustained rehabilitation than early referrals. Whether an earlier referral to OM clinics will result in increased RTW rates is unknown. Patients who attempted to resume employment had a 1.2% risk of a recurrent ischemic event at their workplace.

Contribution of stenting to the results of rescue PTCA

Failed thrombolysis in acute myocardial infarction (AMI) is associated with increased mortality. Controversial benefit of rescue percutaneous transluminal coronary angioplasty (PTCA) in these setting has been published. The feasibility, safety, and contribution of stenting to the outcome of AMI patients treated with this strategy is unknown. We studied the angiographic result and clinical outcome of 33 patients with failed thrombolysis referred for rescue angioplasty. Twenty-three patients had stenting and 10 patients did not have stenting. Both groups had similar clinical and angiographic characteristics. Stent indications were nonoptimal result, 40%; bailout, 40%; elective, 20%. Angiographic success was 100% with stent vs. 91% with balloon alone (P < 0.8). Postprocedure residual stenosis was 1.5% (0%-10%) with stent vs. 18.05% (0%-30%) with balloon alone (P < 0.01). Thirty-day outcome with and without stent was mortality, 0% vs. 13% (P < 1.0); reinfarction, 10% vs. 0% (P < 0.30); target vessel revascularization, 0% vs. 21% (P < 0.21). The 6-month mortality was 0% with stent vs. 14% (P < 0.5). We conclude that stenting during rescue angioplasty is feasible, safe, and is associated with better immediate angiographic results. Although no obvious clinical benefit was found, a potential decrease in the revascularization rate was suggested.

Clinical epidemiology of acute myocardial infarction

In the United States by mid-century, cardiovascular disease accounted for more than half of all deaths. In the second half of this century, 85% of reduction in age-adjusted mortality rates from all causes can be ascribed to the decline in death from cardiovascular disease and stroke. Approximately half of such dramatic decline in mortality rates from ischemic heart disease (IHD) can be explained by primary and secondary prevention and half by therapeutic improvements. Epidemiology of therapeutic regimens in acute myocardial infarction (AMI) indicates substantial increases in the use of thrombolytic therapy, aspirin, beta-blockers and, in some countries, coronary angioplasty. The long-term results of several thrombolytic trials have shown the persistence of early benefit until 10 years after AMI. However, approximately half of the patients with AMI are admitted to the hospital too late to fully benefit from thrombolytic therapy, and one fourth of eligible patients do not receive any form of reperfusion. Primary angioplasty is advocated by some as the treatment of choice in AMI. The present results are not convincing enough to induce the enormously complex and costly reorganization of the health system, allowing the immediate access to coronary angiography for all or most patients with AMI. However, stenting the infarct coronary artery at the site of previous occlusion appears to improve the immediate and medium-term results of coronary revascularization procedures. Approximately half of the AMI survivors are rehospitalized within 1 year after the index event, and postinfarction mortality rate remains exceedingly high. After AMI, prognostic and therapeutic procedures have been introduced in the absence of evidence from controlled trials of their effectiveness profile. Outcome research is needed to standardize effective post-AMI policies. Moreover, new strategies are needed to reduce the incidence and mortality rates of acute ischemic events. A number of new candidate risk factors for IHD are emerging; they are associated with endothelial dysfunction, thrombogenic state, and inflammatory state. It is hoped that advances in molecular approach to cardiovascular disease, molecular genetics and transgenic techniques will allow better understanding and more effective therapeutic strategies to prevent and control IHD.

[The effect of myocardial infarct on the employment situation of patients]

INTRODUCTION AND OBJECTIVES

The impact of acute myocardial infarction in labour activity changes from one country to another as well as patients' characteristics. Our purpose was aimed to learn the main demographic, professional, clinical and therapeutic variables which might affect the return to work after suffering a myocardial infarction in our environment.

METHODS

584 patients treated consecutively in our Coronary Unit for 4 years, aged under 65, were studied. The following aspects were analyzed: age, sex, previous ischaemic heart disease, previous working condition, professional level, economical area of labour activity, main therapeutic procedures and complications, number of days of sick leave, posterior labour status and date of invalidity or death, should it occur. The minimum follow up period was two years.

RESULTS

65.3% of patients were regularly working before suffering the myocardial infarction. Mean length of sick leave after myocardial infarction was 243.9 days although it changed according to age and economical areas. 56.6% of the patients returned to work according to age (odds ratio = 0.92), high professional status (odds ratio = 2.14), economical area of services (odds ratio = 2.03), and the presence of previous anginal attacks (odds ratio = 1.73).

CONCLUSIONS

In our environment, patients less likely to resume their work after suffering a myocardial infarction are older, working in agricultural and industrial areas, with a lower professional level and without known ischemic heart disease antecedents.

Myocardial Perfusion Abnormalities by Intravenous Administration of the Contrast Agent NC100100 in an Experimental Model of Coronary Artery Thrombosis and Reperfusion

The aim of this study was to evaluate a second-generation echo contrast agent (NC100100) for the study of myocardial perfusion. In eight anesthetized open-chest dogs, this agent was injected intravenously under baseline conditions, during acute coronary thrombosis, and after reperfusion, using both fundamental (FI) and harmonic (HI) imaging, both continuous and intermittent imaging, and both ultrasound (US) and integrated backscatter (IBS) imaging. Contrast injections did not modify the hemodynamic parameters. With all imaging modalities, myocardial contrast enhancement (MCE) was higher with intermittent than with continuous imaging (134 vs 82 gray level/pixel using FI, P = 0.02; 62 vs 32 acoustic units using US HI, P = 0.02; and 52 vs 12 dB using IBS, P = 0.05). MCE equally increased using either US or IBS imaging. The accuracy of MCE in detecting perfusion defects during coronary occlusion and myocardial reperfusion after thrombolysis was very good (sensitivity and specificity = 93% and 95% and 89% and 93%, respectively). The extent of myocardial perfusion defects by echo contrast showed a closer correlation with microspheres using HI (r = 0.82) than FI (r = 0.53). Thus, the intravenous administration of NC100100 during intermittent HI allows myocardial perfusion abnormalities to be accurately detected during acute myocardial infarction.

Factors associated with rehospitalization in patients with acute myocardial infarction

Rehospitalization of patients surviving acute myocardial infarction is common, but why it occurs is not well documented. In Seattle area hospitals, rehospitalization was frequent, particularly for women and those with extensive cardiac histories.