Did prognosis after acute myocardial infarction change during the past 30 years? A meta-analysis

Emerging opportunities to target inflammation: myocardial infarction and type 2 diabetes

After myocardial infarction (MI), patients with type 2 diabetes have an increased rate of adverse outcomes, compared to patients without. Diabetes confers a 1.5-2-fold increase in early mortality and, importantly, this discrepancy has been consistent over recent decades, despite advances in treatment and overall survival. Certain assumptions have emerged to explain this increased risk, such as differences in infarct size or coronary artery disease severity. Here, we re-evaluate that evidence and show how contemporary analyses using state-of-the-art characterization tools suggest that the received wisdom tells an incomplete story. Simultaneously, epidemiological and mechanistic biological data suggest additional factors relating to processes of diabetes-related inflammation might play a prominent role. Inflammatory processes after MI mediate injury and repair and are thus a potential therapeutic target. Recent studies have shown how diabetes affects immune cell numbers and drives changes in the bone marrow, leading to pro-inflammatory gene expression and functional suppression of healing and repair. Here, we review and re-evaluate the evidence around adverse prognosis in patients with diabetes after MI, with emphasis on how targeting processes of inflammation presents unexplored, yet valuable opportunities to improve cardiovascular outcomes in this vulnerable patient group.

Prognostic Factors of In-Hospital Mortality in Patients with Acute Myocardial Infarction Complicated by Cardiogenic Shock

Among patients with acute myocardial infarction (MI) complicated by cardiogenic shock (CS), in-hospital mortality remains high. In the present study, we aimed to identify factors associated with clinical outcomes of acute MI patients with CS in a contemporary setting. A total of 1102 patients with acute MI undergoing primary percutaneous coronary intervention were included, among whom 196 (17.8%) were complicated by CS. The primary outcome was all-cause death during hospitalization, and factors associated with in-hospital mortality were explored in patients with acute MI and CS. Of the 196 patients with acute MI complicated by CS, 77 (39.3%) died during hospitalization. The rates of non-ST-segment elevation MI (NSTEMI) (33.8% vs. 19.3%, p = 0.02) and culprit lesion in the left main or left anterior descending coronary artery (68.8% vs. 47.9%, p = 0.004) were higher, while left ventricular ejection fraction (LVEF) was lower (24.4 ± 11.7% vs. 39.7 ± 13.8%, p < 0.001) in non-survivors than in survivors. Multivariable analysis identified NSTEMI presentation and lower LVEF as independent predictors of in-hospital death. In conclusion, NSTEMI and low LVEF were identified as factors associated with higher in-hospital mortality. The identification of even higher-risk subsets and targeted therapeutic strategies may be warranted to improve survival of patients with acute MI and CS.

Development of a complete blood count with differential-based prediction model for in-hospital mortality among patients with acute myocardial infarction in the coronary care unit

Purpose

In recent years, the complete blood count with differential (CBC w/diff) test has drawn strong interest because of its prognostic value in cardiovascular diseases. We aimed to develop a CBC w/diff-based prediction model for in-hospital mortality among patients with severe acute myocardial infarction (AMI) in the coronary care unit (CCU).

Materials and methods

This single-center retrospective study used data from a public database. The neural network method was applied. The performance of the model was assessed by discrimination and calibration. The discrimination performance of our model was compared to that of seven other classical machine learning models and five well-studied CBC w/diff clinical indicators. Finally, a permutation test was applied to evaluate the importance rank of the predictor variables.

Results

A total of 2,231 patient medical records were included. With a mean area under the curve (AUC) of 0.788 [95% confidence interval (CI), 0.736-0.838], our model outperformed all other models and indices. Furthermore, it performed well in calibration. Finally, the top three predictors were white blood cell count (WBC), red blood cell distribution width-coefficient of variation (RDW-CV), and neutrophil percentage. Surprisingly, after dropping seven variables with poor prediction values, the AUC of our model increased to 0.812 (95% CI, 0.762-0.859) (P < 0.05).

Conclusion

We used a neural network method to develop a risk prediction model for in-hospital mortality among patients with AMI in the CCU based on the CBC w/diff test, which performed well and would aid in early clinical decision-making. The top three important predictors were WBC, RDW-CV and neutrophil percentage.

S100A9 and SOCS3 as diagnostic biomarkers of acute myocardial infarction and their association with immune infiltration

Acute myocardial infarction (AMI) is one of the leading causes of death globally, with a mortality rate of over 20%. However, the diagnostic biomarkers frequently used in current clinical practice have limitations in both sensitivity and specificity, likely resulting in delayed diagnosis. This study aimed to identify potential diagnostic biomarkers for AMI and explored the possible mechanisms involved. Datasets were retrieved from the Gene Expression Omnibus. First, we identified differentially expressed genes (DEGs) and preserved modules, from which we identified candidate genes by LASSO (least absolute shrinkage and selection operator) regression and the SVM-RFE (support vector machine-recursive feature elimination) algorithm. Subsequently, we used ROC (receiver operating characteristic) analysis to evaluate the diagnostic accuracy of the candidate genes. Thereafter, functional enrichment analysis and an analysis of immune infiltration were implemented. Finally, we assessed the association between biomarkers and biological processes, infiltrated cells, clinical traits, tissues and time points. We identified nine preserved modules containing 1,016 DEGs and managed to construct a diagnostic model with high accuracy (GSE48060: AUC = 0.923; GSE66360: AUC = 0.973) incorporating two genes named S100A9 and SOCS3. Functional analysis revealed the pivotal role of inflammation; immune infiltration analysis indicated that eight cell types (monocytes, epithelial cells, neutrophils, CD8+ T cells, Th2 cells, NK cells, NKT cells and platelets) were likely involved in AMI. Furthermore, we observed that S100A9 and SOCS3 were correlated with inflammation, variably infiltrated cells, clinical traits of patients, sampling tissues and sampling time points. In conclusion, we suggested S100A9 and SOCS3 as diagnostic biomarkers of AMI and discovered their association with inflammation, infiltrated immune cells and other factors.

Association of blood pressure in the first-week of hospitalization and long-term mortality in patients with acute left ventricular myocardial infarction

BACKGROUND

Previous studies have shown that optimal blood pressure (BP) control is necessary to outcomes in patients with acute myocardial infarction (AMI). Acute left ventricular MI is a prevalent type of AMI with poor prognosis. We aimed to analyze the associations between BP control in the first 7 days of hospitalization and long-term mortality specific to patients with isolated left ventricular MI.

METHODS

A total of 3108 acute left ventricular MI patients were included in this analysis. The average BP on the first seven days of hospitalization was categorized into 10-mmHg increments. The primary and secondary outcomes were all-cause death and cardiac death, respectively. Cox models were used to assess the association of outcomes with BP during hospitalization.

RESULTS

The median length-of-stay was 7 (IQR 6-10) days. The relationship between systolic BP (SBP) or diastolic BP (DBP) followed a U-shaped curve association with outcomes. All-cause mortality was higher in patients with lower SBP (≤90 mmHg) (adjusted hazard ratios (HRs) 7.12, 95% confidence interval (CI) 3.13-16.19; p < 0.001) and DBP (<60 mmHg) (HR 1.76, 95% CI 1.14-2.71; p = 0.011) [reference: 110 < SBP ≤120 mmHg; 70 < DBP ≤ 80 mmHg], respectively. Furthermore, primary outcome was higher in patients with higher SBP (>130 mmHg) (HR 1.51, 95% CI 1.12-2.03; p = 0.007) and DBP (>80 mmHg) (HR 1.61, 95% CI 1.20-2.18; p = 0.002), respectively.

CONCLUSION

Maintaining a SBP from 90 to 130 mmHg and a DBP from 60 to 80 mmHg may be beneficial to patients with acute left ventricular MI in the long run.

Modernizing the World Health Organization List of Essential Medicines for Preventing and Controlling Cardiovascular Diseases

The World Health Organization (WHO) Model List of Essential Medicines (EML) is a key tool for improving global access to medicines for all conditions, including cardiovascular diseases (CVDs). The WHO EML is used by member states to determine their national essential medicine lists and policies and to guide procurement of medicines in the public sector. Here, we describe our efforts to modernize the EML for global CVD prevention and control. We review the recent history of applications to add, delete, and change indications for CVD medicines, with the aim of aligning the list with contemporary clinical practice guidelines. We have identified 4 issues that affect decisions for the EML and may strengthen future applications: 1) cost and cost-effectiveness; 2) presence in clinical practice guidelines; 3) feedback loops; and 4) community engagement. We share our lessons to stimulate others in the global CVD community to embark on similar efforts.

[Predictors of Progressive Course of Multifocal Atherosclerosis in Patients With Myocardial Infarction]

PURPOSE

Determination of clinical and instrumental predictors of progressive course of multifocal atherosclerosis (MFA) in patients one year after myocardial infarction (MI), initially having hemodynamically insignificant stenoses of carotid arteries.

MATERIALS AND METHODS

From database of patients with acute coronary syndrome treated in the Kemerovo Regional Clinical Cardiac Dispensary in 2009-2010 we selected for this study 141 patients with verified diagnosis of MI and hemodynamically insignificant lesions in the internal carotid artery (ICA) (stenosis up ≤ 55 %). All patients had coronary atherosclerosis verified on coronary angiography at admission because of MI. A multivariate analysis of possible predictors of the progressive course of multifocal atherosclerosis was made based on assessment of the development of cardiovascular complications (CVC) (death, MI, stroke and transient cerebral circulatory attacks [TIA]), as well as revascularizations and negative dynamics of parameters of color duplex scanning (CDS) of ICA during one year after MI.

RESULTS

One year after MI the overall incidence of CVC was 16.3 % (n=23). Structure of registered events was as follows: death from MI 7.1 % (n=10), deaths from stroke 2.1 % (n=3) and other causes 2.1 % (n=3), non-fatal MI 5.0 % (n=7), non-fatal stroke / TIA 2.1 % (n=3), carotid revascularization 2.8 % (n=4), coronary revascularization 14.9 % (n=21). CDC of ICAs was repeated in 125 patients. There were 17 (13.6 %) cases of progression of carotid atherosclerosis in the form of de novo bilateral stenoses in 14 (11.2 %) patients, stenoses in the left and right ICA 1 patient and 2 patients, respectively. The following predictors of progression of atherosclerosis of cerebral arteries were identified: family history of cardiovascular diseases (CVD),ICA stenosis ≥45 %, baseline circular atherosclerotic plaque (ASP). Predictors of high risk of stroke were family history of CVD, history of stroke,ICA stenosis ≥45 %, heterogeneous hypoechoic ASP. As predictors of lethal outcome, we identified history of MI, high functional class of angina preceding the index MI, severe coronary vascular bed involvement (SYNTAX score &gt;23), presence of any bilateral atherosclerotic lesion in ICAs, and heterogeneous hypoechoic ASP. Assessment of the contribution of adherence to therapy in the prognosis 1 year after hospital discharge was fulfilled in 125 alive patients. It allowed to conclude that patients with progression of atherosclerosis and nonfatal CVC were characterized by insufficient adherence to standard therapy.

CONCLUSION

Predictors of the progressive course of multifocal atherosclerosis during one year after MI were identified in this study. It is necessary to strengthen therapeutic and preventive measures aimed at minimization of the impact of these factors in this category of patients.

German contribution to development and innovations in the management of acute myocardial infarction and cardiogenic shock

Treatment of acute coronary syndromes has evolved over time leading to a significantly reduced mortality. Multiple major trials have been performed in Germany leading to new treatment strategies in acute coronary syndromes including cardiogenic shock. This review article will summarize major trials and their impact on guideline recommendations in acute myocardial infarction highlighting reperfusion strategies, antiplatelet regimens, prognosis assessment and also mechanical circulatory support in stable infarction patients and in cardiogenic shock.

Cardiac repair by epicardial EMT: Current targets and a potential role for the primary cilium

Despite therapeutic advances that have prolonged life, myocardial infarction (MI) remains a leading cause of death worldwide and imparts a significant economic burden. The advancement of treatments to improve cardiac repair post-MI requires the discovery of new targeted treatment strategies. Recent studies have highlighted the importance of the epicardial covering of the heart in both cardiac development and lower vertebrate cardiac regeneration. The epicardium serves as a source of cardiac cells including smooth muscle cells, endothelial cells and cardiac fibroblasts. Mammalian adult epicardial cells are typically quiescent. However, the fetal genetic program is reactivated post-MI, and epicardial epithelial-to-mesenchymal transition (EMT) occurs as an inherent mechanism to support neovascularization and cardiac healing. Unfortunately, endogenous EMT is not enough to encourage sufficient repair. Recent developments in our understanding of the mechanisms supporting the EMT process has led to a number of studies directed at augmenting epicardial EMT post-MI. With a focus on the role of the primary cilium, this review outlines the newly demonstrated mechanisms supporting EMT, the role of epicardial EMT in cardiac development, and promising advances in augmenting epicardial EMT as potential therapeutics to support cardiac repair post-MI.

Predicting In-Hospital Mortality in Patients With Acute Myocardial Infarction

BACKGROUND

As a foundation for quality improvement, assessing clinical outcomes across hospitals requires appropriate risk adjustment to account for differences in patient case mix, including presentation after cardiac arrest.

OBJECTIVES

The aim of this study was to develop and validate a parsimonious patient-level clinical risk model of in-hospital mortality for contemporary patients with acute myocardial infarction.

METHODS

Patient characteristics at the time of presentation in the ACTION (Acute Coronary Treatment and Intervention Outcomes Network) Registry-GWTG (Get With the Guidelines) database from January 2012 through December 2013 were used to develop a multivariate hierarchical logistic regression model predicting in-hospital mortality. The population (243,440 patients from 655 hospitals) was divided into a 60% sample for model derivation, with the remaining 40% used for model validation. A simplified risk score was created to enable prospective risk stratification in clinical care.

RESULTS

The in-hospital mortality rate was 4.6%. Age, heart rate, systolic blood pressure, presentation after cardiac arrest, presentation in cardiogenic shock, presentation in heart failure, presentation with ST-segment elevation myocardial infarction, creatinine clearance, and troponin ratio were all independently associated with in-hospital mortality. The C statistic was 0.88, with good calibration. The model performed well in subgroups based on age; sex; race; transfer status; and the presence of diabetes mellitus, renal dysfunction, cardiac arrest, cardiogenic shock, and ST-segment elevation myocardial infarction. Observed mortality rates varied substantially across risk groups, ranging from 0.4% in the lowest risk group (score <30) to 49.5% in the highest risk group (score >59).

CONCLUSIONS

This parsimonious risk model for in-hospital mortality is a valid instrument for risk adjustment and risk stratification in contemporary patients with acute myocardial infarction.

Pre-hospital acute coronary syndrome care in Kerala, India: A qualitative analysis

OBJECTIVE

Ischemic heart disease is the leading cause of death in India. Many of these deaths are due to acute coronary syndromes (ACS), which require prompt symptom recognition, care-seeking behavior, and transport to a treatment facility in the critical pre-hospital period. In India, little is known about pre-hospital management of individuals with ACS. We aim to understand the facilitators, barriers, and context of optimal pre-hospital ACS care to provide opportunities to reduce pre-hospital delays and improve acute cardiovascular care.

METHODS AND RESULTS

We conducted a qualitative study using in-depth interviews and focus group discussions with 27 ACS providers in Kerala, India to understand facilitators, barriers, and context to pre-hospital ACS care. Six themes emerged from these interviews and discussions: (1) individuals with ACS misperceive their symptoms as non-cardiac in origin; (2) emergency medical services are infrequently used; (3) insufficient pre-hospital healthcare infrastructure contributes to pre-hospital delay; (4) multiple stops are made before arriving at a facility that can provide definitive diagnosis and treatment; (5) relatively high costs of treatment and lack of widespread health insurance coverage limits care delivery; and (6) novel mobile technologies may allow for faster diagnosis and initiation of treatment in the pre-hospital setting.

CONCLUSIONS

Individualized patient-based factors (general knowledge of ACS symptoms, socioeconomic position) and broader systems-based factors (ambulance networks, coordination of transport) affect pre-hospital ACS care in Kerala. Improving public awareness of ACS symptoms, increasing appropriate use of emergency medical services, and building a infrastructure for rapid and coordinated transport may improve pre-hospital ACS care.

Pre-hospital policies for the care of patients with acute coronary syndromes in India: A policy document analysis

Background and objective

Ischemic heart disease is the leading cause of death in India. In high-income countries, pre-hospital systems of care have been developed to manage acute manifestations of ischemic heart disease, such as acute coronary syndrome (ACS). However, it is unknown whether guidelines, policies, regulations, or laws exist to guide pre-hospital ACS care in India. We undertook a nation-wide document analysis to address this gap in knowledge.

Methods and results

From November 2014 to May 2016, we searched for publicly available emergency care guidelines and legislation addressing pre-hospital ACS care in all 29 Indian states and 7 Union Territories via Internet search and direct correspondence. We found two documents addressing pre-hospital ACS care.

Conclusion

Though India has legislation mandating acute care for emergencies such as trauma, regulations or laws to guide pre-hospital ACS care are largely absent. Policy makers urgently need to develop comprehensive, multi-stakeholder policies for pre-hospital emergency cardiovascular care in India.

Late Consequences of Acute Coronary Syndromes: Global Registry of Acute Coronary Events (GRACE) Follow-up

PURPOSE

Short-term outcomes have been well characterized in acute coronary syndromes; however, longer-term follow-up for the entire spectrum of these patients, including ST-segment-elevation myocardial infarction, non-ST-segment-elevation myocardial infarction, and unstable angina, is more limited. Therefore, we describe the longer-term outcomes, procedures, and medication use in Global Registry of Acute Coronary Events (GRACE) hospital survivors undergoing 6-month and 2-year follow-up, and the performance of the discharge GRACE risk score in predicting 2-year mortality.

METHODS

Between 1999 and 2007, 70,395 patients with a suspected acute coronary syndrome were enrolled. In 2004, 2-year prospective follow-up was undertaken in those with a discharge acute coronary syndrome diagnosis in 57 sites.

RESULTS

From 2004 to 2007, 19,122 (87.2%) patients underwent follow-up; by 2 years postdischarge, 14.3% underwent angiography, 8.7% percutaneous coronary intervention, 2.0% coronary bypass surgery, and 24.2% were re-hospitalized. In patients with 2-year follow-up, acetylsalicylic acid (88.7%), beta-blocker (80.4%), renin-angiotensin system inhibitor (69.8%), and statin (80.2%) therapy was used. Heart failure occurred in 6.3%, (re)infarction in 4.4%, and death in 7.1%. Discharge-to-6-month GRACE risk score was highly predictive of all-cause mortality at 2 years (c-statistic 0.80).

CONCLUSION

In this large multinational cohort of acute coronary syndrome patients, there were important later adverse consequences, including frequent morbidity and mortality. These findings were seen in the context of additional coronary procedures and despite continued use of evidence-based therapies in a high proportion of patients. The discriminative accuracy of the GRACE risk score in hospital survivors for predicting longer-term mortality was maintained.

Ischaemic Heart Disease at the University Hospital of the West Indies: Trends in Hospital Admissions and Inpatient Mortality Rates 2005-2010

OBJECTIVES

This study aimed to estimate hospital admission rates and inpatient mortality rates for ischaemic heart disease (IHD) and its subtypes at the University Hospital of the West Indies (UHWI) for the years 2005─2010, and to identify factors associated with inpatient mortality.

METHODS

Data from electronic discharge summaries for patients diagnosed with acute myocardial infarction (A-MI), unstable angina (UA) or other IHD were obtained from the Patient Information Management Systems database of the Medical Records Department of the UHWI. Data were entered into an electronic database and analysed using Stata 10.1. Random effects logistic regression was used to identify factors associated with inpatient mortality.

RESULTS

Analysis included 3794 admissions (2821 persons: 1415 males, 1406 females; mean age 63.9 ± 13.5 years). Overall admission rates for IHD were 12.1% (95% CI 11.7, 12.5) for medical admissions and 4.02% (95% CI 3.89, 4.15) for non-paediatric admissions. Admission rates were higher among males compared to females. There was a statistically significant trend for an overall increase in the rates for IHD admissions over the study period. Inpatient mortality rate was 18.9% for A-MI, 1.6% for UA and 7.8% for other IHD. In multivariable models, adjusted for age and gender, A-MI was associated with higher mortality compared to other IHD (OR 3.38, p < 0.001).

CONCLUSIONS

Ischaemic heart disease admission rate is increasing at the UHWI and accounts for approximately one of every eight medical admissions. Inpatient mortality for acute myocardial infarction is approximately 19%. Further studies are required to determine the factors associated with inpatient mortality and to inform strategies for improving outcomes.

The association of myocardial infarction process of care measures and in-hospital mortality: a report from the NCDR®

BACKGROUND

The Center for Medicare and Medicaid Services (CMS) publicly reports "core process of care measures" along with 30-day mortality rates for patients with acute myocardial infarction; the American College of Cardiology/American Heart Association has a similar but expanded set of performance measures.

METHODS

We sought to determine whether hospital-level adherence with these process performance measures was associated with risk-adjusted in-hospital mortality among 96,340 ST-segment elevation myocardial infarction (STEMI) and 145,832 non-STEMI (NSTEMI) patients in the National Cardiovascular Data Registry® ACTION Registry-Get With the Guidelines™ admitted from January 2007 to March 2011 from 372 US sites. Hospitals were grouped based on risk-adjusted in-hospital mortality: low (20%), middle (60%), and high mortality (20%).

RESULTS

The mean (SD) mortality from low to high hospital mortality groups for STEMI was 4.9% (0.9%), 5.8% (0.3%), and 7.0% (0.5%); and that for NSTEMI was 3.3% (0.2%), 4.0% (0.2%), and 4.9% (0.3%). Adherence to individual process measures was high, with composite measure adherences exceeding 88%. Composite adherence for both CMS and American College of Cardiology/American Heart Association performance measures was inversely associated with risk-adjusted hospital mortality. However, the association was low for STEMI hospitals and not significant for NSTEMI hospitals. Variation tended to be higher for CMS measures for higher-mortality hospitals.

CONCLUSIONS

Although process performance was associated with hospital mortality, the association was low for STEMI and nonsignificant for NSTEMI hospitals, thus supporting the need to measure complementary metrics of acute myocardial infarction quality of care.

Adjunctive therapy after reperfusion therapy in acute myocardial infarction

The current era has witnessed dramatic improvement in the treatment of acute myocardial infarction, due in large part to the more widespread use of thrombolytic therapy aimed at quickly restoring perfusion in the infarct-related artery. This review addresses the role of adjunctive pharmacologic therapy in the thrombolytic era, recognizing that much of the available clinical trial data supporting the role of adjunctive pharmacologic treatment strategies was conducted in patient populations not widely exposed to reperfusion therapy. This review, therefore, explores the data supporting the incremental benefit of therapy with beta blockers, nitrates, angiotensin-converting enzyme inhibitors, or magnesium in addition to thrombolytic therapy. Heparin and aspirin will not be discussed.

Highly Purified Omega-3 Fatty Acids for Secondary Prevention of Sudden Cardiac Death After Myocardial Infarction—Aims and Methods of the OMEGA-Study

INTRODUCTION

During the last decades a large body of data has been accumulated indicating omega-3 fatty acids to exert beneficial effects on the prognosis of patients with cardiovascular disease. Especially, omega-3 fatty acids are regarded to be effective in reducing the risk of sudden cardiac death after acute myocardial infarction. However, treatment of acute myocardial infarction and secondary prevention considerably have been improved within the past years including early revascularization by PCI, the routine use of beta-blockers, statins and ACE-inhibitors as well as cardiac rehabilitation for improving life style measures. To date, there exists no controlled randomized trial testing the prognostic effect of omega-3 fatty acids after acute myocardial infarction in a double blind regimen under the conditions of modern treatment of myocardial infarction.

MATERIALS AND METHODS

The present study therefore evaluates the effect of highly purified omega-3 fatty acid ethylesters (omega-3-acid ethyl esters 90=Zodin) on the rate of sudden cardiac death within 1 year after acute myocardial infarction. Secondary endpoints are total mortality, non-fatal cardiovascular events, rhythm abnormalities in holter monitoring and depression score.

RESULT AND CONCLUSION

The recruitment-period started in October 2003 and is expected to last until December 2006. The results of the study are therefore expected for the beginning of 2008, when all patients will have completed the 12-months follow up-period.

Trends in five-year survival of patients discharged after acute myocardial infarction

BACKGROUND

It has previously been shown that the increased use of therapeutic intervention may not reduce patient fatality if there is a simultaneous increase in case severity. The present study was designed to extend the relationship between case severity and therapeutic interventions to long-term survival in the same study population.

OBJECTIVE

To compare five-year survival of patients discharged after acute myocardial infarction from 1984 to 1988 and from 1989 to 1993, and to evaluate possible reasons for survival differences.

METHODS

The present study was population-based. Survival time was determined by record linkage into the Canadian Mortality Database. Association of five-year survival with patient characteristics, in-hospital treatment and discharge medications was assessed by logistical regression analysis. Case severity was calculated as the probability of death within five years, given the patient profile and excluding any interventions.

RESULTS

Between the two study periods, most patient characteristics and treatment intensity changed, but case severity for the study population remained constant. Five-year survival improved from 74.8% to 79.2% (P(chi2)=0.001). The improvement was adequately described by the combination of changes in patient profile and treatment without residual period effect (P(goodness-of-fit)=0.752). The treatments significantly associated with five-year survival were coronary artery bypass graft surgery (OR 2.74; 95% CI 1.86 to 4.05), percutaneous coronary intervention (OR 2.63; 95% CI 1.67 to 4.14) and thrombolysis (OR 1.98; 95% CI 1.50 to 2.62) during admission, as well as acetylsalicylic acid (OR 1.39; 95% CI 1.15 to 1.68) or beta-blocker (OR 1.60; 95% CI 1.34 to 1.92) prescription at discharge.

CONCLUSIONS

Changes in patient profile did not affect long-term prognosis; instead, treatment modalities accounted for the observed improvement in five-year survival.

Clinical outcome of older patients with acute coronary syndrome over the last three decades

OBJECTIVE

To Evaluate the clinical outcome of patients with acute coronary syndrome (ACS) in the Coronary Care Unit (CCU) over three decades in Dunedin, New Zealand.

DESIGN

Registry study.

SETTING AND PATIENTS

all consecutive patients (n = 3,013) with ACS admitted to the CCU from 1979 to 1981 (n = 966) and from 1989 to 1991 (n = 1470) were included prospectively. Data on ACS patients managed in the CCU in 2001-2002 (n = 577) were obtained via medical chart review.

RESULTS

There was a rising proportion of older (> or = 75 years of age) patients with ACS (3.8% in 1979-1981, 15.2% in 1989-1991 and 25.6% in 2001-2002, P < 0.0005). However, we observed a progressive reduction of in-hospital mortality for ACS (10.7, 7.3 and 5.0%, P < 0.005) and for ST-elevation myocardial infarction (STEMI) (18.4, 16.1 and 6.6%, P < 0.005). The progressive fall in mortality rate was also observed amongst older patients, both for ACS (27, 19.2 and 11.5%, P = 0.011) and for STEMI (34.8, 30.9 and 15.4%, P < 0.005). Of concern, only 10% of patients presented within 1 h of symptom onset and 50% within 5 h, and this has not changed over three decades. The variables associated with < 5 h from symptom onset to presentation were men [odds ratio (OR) 1.25, 95% confidence interval (CI) 1.10-1.42, P = 0.001], a history of ischaemic heart disease (OR 1.25, 95% CI 1.09-1.43, P = 0.002) and STEMI (OR 1.41, 95% CI 1.18-1.67, P < 0.0001). Advanced age was not a predictor for late presentation.

CONCLUSIONS

Over the past three decades, more old patients were treated in the CCU. However, there was a decline in hospital mortality, particularly for STEMI. Further efforts are required to decrease the time to presentation.

Six-month outcomes in a multinational registry of patients hospitalized with an acute coronary syndrome (the Global Registry of Acute Coronary Events [GRACE])

Relatively limited data are available, particularly from the perspective of a multinational registry, about the post-discharge outcomes and management practices of patients with an acute coronary syndrome (ACS). The objectives of this longitudinal study were to examine 6-month outcomes in a large multinational sample of patients hospitalized with an ACS. A total of 5,476 patients with ST-segment elevation acute myocardial infarction (STEAMI), 5,209 patients with non-ST-segment elevation acute myocardial infarction (NSTEAMI), and 6,149 patients with unstable angina pectoris discharged from 90 hospitals in 14 countries comprised the study population. The study sample was recruited from 18 cluster sites in 14 countries that are currently collaborating in the Global Registry of Acute Coronary Events (GRACE) study. The 6-month post-discharge death rates were 4.8% in patients with STEAMI, 6.2% in patients with NSTEAMI, and 3.6% in patients with unstable angina pectoris. Approximately 1 in 5 of each of our comparison groups were rehospitalized for heart disease during the 6-month follow-up, and approximately 15% of each of the respective study cohorts underwent coronary revascularization during follow-up. Demographic and clinical characteristics of post-discharge decedents were identified according to type of ACS. Our results suggest that a considerable proportion of patients who were discharged from the hospital after an ACS, with some differences noted according to type of ACS, remain at increased risk for adverse outcomes during the relatively brief post-discharge period. These data suggest the need for better long-term medical management and more intense follow-up of patients with an ACS to improve their long-term outlook.

Mortalidad del infarto de miocardio en el registro PRIMVAC. Factores pronósticos

BACKGROUND AND OBJECTIVE

The aim of this study was to determine the mortality due to acute myocardial infarction in the coronary units from Comunidad Valenciana (Spain) and the prognostic factors associated with a higher mortality.

PATIENTS AND METHOD

Demographic characteristics, coronary risk factors, electrocardiographic ischemic signs, complications and mortality of patients with acute myocardial infarction admitted in the coronary units were collected. The study period comprised January 1995-December 1999. Death incidence was measured during coronary unit's stay. Factors associated with poor prognosis were analyzed.

RESULTS

10.213 patients entered into the study. Mean age at admission was 65 12 years. 23.8% were females (76.2% males). Global mortality in coronary units was 13.3%. Independent variables associated with higher mortality were (p < 0.05): advanced age (OR=1.06 [1.05-1.06]), female sex (OR=1.45 [1.26-1.66]), diabetes mellitus (OR=1.53 [1.35-1.74]), previous myocardial infarction (OR=1.46 [1.23-1.70]), previous angor pectoris (OR=1.29 [1.13-1.49]) and Q-wave infarction (OR=1.23 [1.03-1.43]). Factors associated with lower mortality were: hypercholesterolemia (OR=0.76 [0.66-0.78]), smoking (OR=0.65 [0.57-0.74]) and thrombolysis (OR=0.85 [0.78-0.92]).

CONCLUSIONS

At present, in the reperfusion therapy era, acute myocardial infarction has a high mortality after coronary unit admission. Several clinical factors are associated with a worse prognosis.

The prevalence of atrial fibrillation in incident stroke cases and matched population controls in Rochester, Minnesota: changes over three decades

OBJECTIVES

We sought evidence of a change in the prevalence of atrial fibrillation (AF) over a 30-year period among residents of Rochester, Minnesota.

BACKGROUND

Atrial fibrillation is increasingly encountered in clinical practice, but there is limited data on secular trends of AF over time.

METHODS

Within a longitudinal case-control study of ischemic stroke, the prevalence of AF and of selected comorbid conditions among incident stroke cases and age- and gender-matched controls between 1960 and 1989 was determined.

RESULTS

The mean age +/- standard deviation for the 1,871 stroke cases (45% men) and matched controls was 75 +/- 11 years. For cases, age-adjusted estimates of AF prevalence for 1960 to 1969, 1970 to 1979, and 1980 to 1989 were 11%, 13%, and 16%, respectively, for men, and 13%, 16%, and 20% for women. For controls, the rates were 5%, 8%, and 12%, respectively, for men, and 4%, 6%, and 8% for women. Increasing AF prevalence was associated with increasing age (doubling of odds per decade of age in both cases and controls) and calendar time adjusted for age and gender (cases: odds ratio [OR] per 5 years 1.13, 95% confidence interval [CI], 1.05 to 1.22; controls: OR per 5 years 1.24, 95% CI 1.12 to 1.37). The rates of increase with calendar time were significant for cases (p = 0.001) and controls (p < 0.001) and comparable between the genders.

CONCLUSIONS

The prevalence of AF increased significantly in ischemic stroke patients and their controls from 1960 to 1989 in Rochester, Minnesota, independent of age and gender. The rate of increase did not differ significantly between men and women.

Trends in incidence, case-fatality and recurrence of myocardial infarction in the Danish MONICA population 1982-1991

BACKGROUND

Growing awareness of risk factors for myocardial infarction (MI), continuous mass campaigns on lifestyle factors, increasing use of heart rehabilitation and improved treatment should imply decreases in the incidence, case-fatality and recurrence rates of MI. The purpose of the study was to assess trends in the incidence, case-fatality and recurrence rate of MI and to analyse whether any changes seen were due to a period or a cohort effect.

METHODS

The Danish MONICA population comprises all men and women aged 25-74 years in the period 1982-1991 living in a suburban area of Copenhagen, Denmark. Fatal and non-fatal attacks classified as definite MI and non-fatal attacks classified as possible MI were included. The incidence rate was analysed by Poisson regression, the case-fatality rate by logistic regression, and the rate of recurrence by Cox regression. Age-period-cohort analyses were carried out according to a method described by Clayton and Schifflers.

RESULTS

During the 10-year period a significant decrease in the incidence rate of MI was seen for men and women and for the rate of recurrent MI. The decrease in incidence and recurrence could not unambiguously be ascribed to a period or cohort effect. The rate of case-fatality after a first MI was not changed significantly during the period, whereas men and women had different trends in case-fatality after recurrent MI.

CONCLUSIONS

In accordance with results from other Western countries we found a decline in the incidence and recurrence rate of MI. Contrary, the lack of a decrease in the case-fatality rate after a first MI was unexpected and difficult to explain.

Declining coronary heart disease mortality in Iceland: contribution by incidence, recurrence and case fatality rate

OBJECTIVE

To analyse to what extent the recent decline in coronary heart disease mortality in Iceland is due to changes in incidence, recurrence and case fatality rates.

DESIGN

A countrywide registration of myocardial infarction (MI) in people aged 25-74 was performed in Iceland during 1981-1999 according to the MONICA protocol. Possible cases were found by review of all hospital discharge records, autopsy records and death certificates.

RESULTS

MI death rate declined by 63% in males and 51% in females, most in the youngest age groups in men (86%) and least in the oldest (49%). In women there was not a significant difference in age groups. Overall the age-adjusted reduction in MI death rate was 55.4% in both sexes combined; of this 23.1% was due to incidence reduction, 22.8% to recurrence reduction and 11.6% to case fatality reduction. In the youngest age groups the decline in incidence contributed most to the decline in MI death rate (62% in men and 71% in women), but thereafter the decline in case fatality in men. In the older age groups decline in recurrence rate has greater weight.

CONCLUSION

The recent decline in MI mortality under the age of 75 years in Iceland is due to reduction in incidence and recurrence rate by about 40% each and to reduction in case fatality by 20%.

Early administration of intravenous magnesium to high-risk patients with acute myocardial infarction in the Magnesium in Coronaries (MAGIC) Trial: a randomised controlled trial

BACKGROUND

The benefits of supplemental administration of intravenous magnesium in patients with ST-elevation myocardial infarction (STEMI) are controversial. Despite promising results from work in animals and the ready availability of this simple, inexpensive treatment, conflicting results have been reported in clinical trials. Our aim was to compare short-term mortality in patients with STEMI who received either intravenous magnesium sulphate or placebo.

METHODS

We did a randomised, double-blind trial in 6213 patients with acute STEMI who were assigned a 2 g intravenous bolus of magnesium sulphate administered over 15 min, followed by a 17 g infusion of magnesium sulphate over 24 h (n=3113), or matching placebo (n=3100). Our primary endpoint was 30-day all-cause mortality. At randomisation, patients were stratified by their eligibility for reperfusion therapy. The first stratum included patients who were aged 65 years or older and eligible for reperfusion therapy, and the second stratum included patients of any age who were not eligible for reperfusion therapy. Analysis was by intention-to-treat.

FINDINGS

At 30 days, 475 (15.3%) patients in the magnesium group and 472 (15.2%) in the placebo group had died (odds ratio 1.0, 95% CI 0.9-1.2, p=0.96). No benefit or harm of magnesium was observed in eight prespecified subgroup analyses of patients and in 15 additional exploratory subgroup analyses. After adjustment for factors shown to effect mortality risk in a multivariate regression model, no benefit of magnesium was observed (1.0, 0.8-1.1, p=0.53).

INTERPRETATION

Early administration of magnesium in high-risk patients with STEMI has no effect on 30-day mortality. In view of the totality of the available evidence, in current coronary care practice there is no indication for the routine administration of intravenous magnesium in patients with STEMI.

Exploring sex differences in case fatality in acute myocardial infarction or coronary death events in the northern Sweden MONICA Project

OBJECTIVES

To investigate sex differences in reaching diagnosis, medical management and case fatality (CF) in acute myocardial infarction (AMI) in the population aged 35-64 years in northern Sweden.

METHODS

Within the framework of the World Health Organization Multinational Monitoring of Trends and Determinants in Cardiovascular Diseases (MONICA) Project, definite AMI was monitored in people aged 35-64 years from 1989 through 1995 (target population 510 000 in 1991).

SETTING

In a population based coronary register, all coronary events were recorded in nine hospitals in 1989-95.

RESULTS

The number of events included in the definite coronary myocardial infarction register was 2483 men and 669 women. On admission, a higher proportion of men with definite AMI had chest pain or ECG changes typical for AMI (P < 0.0001). Disagreement between clinical diagnosis and classification by MONICA criteria occurred more often in women (P=0.008). A significantly higher proportion of men was admitted in the coronary care unit and they were significantly more often treated with thrombolytics, nitroglycerine, beta-blockers, or antiplatelet agents. Women received significantly more diuretics, inotropics or calcium antagonists. Diabetes, conferring a worse prognosis, was more common in women (20 vs. 15%; P=0.003). Prehospital CF was significantly higher in men (24.1 vs. 18.3%; P=0.005), but in patients treated in hospital, the CF was significantly lower in men (12.7 vs. 21.2%; P < 0.001). Total CF was equal in men and women.

CONCLUSIONS

Several factors contributing to the excess in-hospital CF in women were identified, including greater problems in diagnosis of AMI in women which may be one of the reasons for less intensive treatment in women. Differences in co-morbidity, most notably diabetes and medical treatment between men and women with acute AMI may also have played a part.

[The transition from acute to chronic ischemic heart disease in Spain, 1980-1994]

BACKGROUND AND OBJECTIVES

The remarkable increase in hospital admissions from heart failure in Spain in the last few years may result paradoxical because it coincides with a decrease in ischemic heart disease mortality, the leading cause of heart failure. A plausible explanation is the increase in ischemic heart disease survival, derived from the recent therapeutic advances, which will translate into an increase in the chronic forms of disease. Thus, an analysis was made of mortality and hospital admission trends due to acute and chronic ischemic heart diseases in the 1980-1994 period in Spain.

METHODS

Population-based study of temporal trends with data of primary diagnosis of acute (CIE-9: 410-411) and chronic (CIE-9: 412-414) ischemic heart disease obtained from the National Vital Statistics and the National Survey of Hospital Morbidity.

RESULTS

The number of deaths due to acute ischemic heart disease has increased by 8.3%, from 18,559 in 1980 to 20,101 in 1994. Deaths due to chronic ischemic heart disease increased by 49.3%, from 4,703 in 1980 to 7,020 in 1994. As a result, chronic forms accounted for 20.2% of all deaths attributable to ischemic heart disease in 1980 and 25.8% in 1994. The age-adjusted acute ischemic heart disease mortality rates decreased by 20.1%, whereas those due to chronic increased by 14.6%. The number and rate of age-adjusted hospital admissions increased remarkably for both acute and chronic ischemic heart disease. Nevertheless, the increase observed with chronic form was higher, from 39.4% of all hospital admissions due to ischemic heart disease in 1980 to 58.4% in 1994. This classification of ischemic heart disease was more notorious among males and younger patients.

CONCLUSION

Currently, we are witnessing a transition from acute to chronic ischemic heart disease. That partly explains the increase in hospital care for heart diseases, particularly ischemic heart disease and heart failure.

Prevention of coronary heart disease through treatment of infection with Chlamydia pneumoniae? Estimation of possible effectiveness and costs

Evidence has been accumulating for a link between Chlamydia pneumoniae and coronary heart disease (CHD). A spreadsheet model was used to estimate the impact of different strategies for screening and treating C. pneumoniae on the incidence of myocardial infarction and cardiac mortality over a 1-year post-intervention period. It was found that screening would potentially be most cost-effective in men aged over 35 with a history of myocardial infarction (around ł2,000 per life-year saved). Cost-effectiveness would be inferior in those with established heart disease but no history of myocardial infarction (MI), and poor for people at elevated risk of CHD. If causality of the association were proven, the cost-effectiveness of treating C. pneumoniae in post-MI patients would compare favourably with, for example, statins for treating hypercholesterolaemia.

Long-term mortality among patients discharged alive after out-of-hospital cardiac arrest does not differ markedly compared with that of myocardial infarct patients without out-of-hospital cardiac arrest

The aim of our research was to study the long-term prognosis among patients discharged alive after an out-of-hospital cardiac arrest (OHCA) in comparison with patients discharged alive after acute myocardial infarction (AMI) without OHCA, and also to study the long-term influence of AMI in connection with OHCA. Our research was conducted in the municipality of Göteborg. We retrospectively studied patients discharged from hospital 1990-91 after an OHCA of cardiac aetiology and patients discharged after an AMI without prehospital cardiac arrest. During 1980-98, we studied all patients discharged alive after OHCA of cardiac aetiology, divided into groups of precipitating AMI and no AMI. The study includes 48 patients discharged alive after an OHCA 1990-91, 30 (62%) of whom had a simultaneous AMI and 1425 patients with an AMI without OHCA. Compared with AMI survivors, survivors of an OHCA of cardiac origin were younger but had more frequently a history of congestive heart failure. Their mortality rate during the subsequent 5 years was 46%, compared with 40% among survivors of an AMI (NS). The 5-year mortality rate among patients with an OHCA precipitated by an AMI was 40%. When correcting for differences at baseline, the adjusted risk ratio for death among patients with an OHCA of cardiac origin was 1.2 (95% CI 0.8-1.8) compared with patients with an uncomplicated AMI. During 1980-98, 215 patients were judged as having an OHCA precipitated by an AMI and 115 patients had an OHCA of cardiac aetiology but no simultaneous AMI. Five-year mortality was 54% and 50% respectively (NS). It is concluded that survivors of an OHCA of cardiac origin differed from survivors of an uncomplicated AMI in that they were younger and more frequently had a history of cardiovascular disease. Their 5-year mortality after discharge was similar to that of survivors of an AMI without a prehospital cardiac arrest, even after adjusting for differences at baseline.

Time trends in the occurrence and outcome of acute myocardial infarction and coronary heart disease death between 1986 and 1996 (a New Jersey statewide study)

Most reports of the decrease in age-adjusted coronary heart disease (CHD) are based on databases with upper age cut-offs that exclude approximately half of the events. We report changes in rates of acute myocardial infarction (AMI) and of out-of-hospital coronary death between 1986 and 1996 among New Jersey residents > or =15 years old. Data on patients discharged with the diagnosis of AMI from nonfederal acute care hospitals in the state (n = 270,091) and all records in the New Jersey death registration files with CHD (n = 172,175) listed as the cause of death from 1986 to 1996 (total study n = 442,266) were analyzed. The rate of hospitalized AMI cases in the state remained essentially unchanged during these 11 years, whereas in-hospital and 30-day case fatality among all age groups and both sexes declined. Age-adjusted CHD rates showed a decrease in fatal events, a smaller decrease in total events, and a slight increase in nonfatal events. The proportion of fatal CHD events occurring out-of-hospital decreased especially among men. The median age at occurrence of events increased by 1 year. Despite a decrease in CHD mortality, the rate of nonfatal events increased, especially among persons > or =75 years old. Thus, the decrease in age-adjusted CHD mortality is not all due to treatment and true prevention of CHD, but the disease simply occurs at an older age.

Indicators of myocardial dysfunction and quality of life, one year after acute infarction

BACKGROUND

There remains controversy concerning the association between myocardial dysfunction diagnosed soon after acute myocardial infarction (AMI), and subsequent quality of life.

AIMS

We searched for a correlation between criteria of myocardial dysfunction assessed within the first month after AMI, and quality of life perceived 1 year later.

METHODS

Six hundred and seventy-one patients were followed up and quality of life was assessed using the Nottingham Health Profile. Spearman correlation was used for univariate analyses. A logistic regression identified independent predictors of impaired quality of life.

RESULTS

Patients perceiving inferior quality of life were 61% for energy, 61% for sleep, 49% for physical mobility, 49% for pain, 63% for emotional reactions, and 28% for social isolation. Impaired quality of life was not associated with the initial Killip class. A low ejection fraction was associated with impaired physical mobility (OR=1.21, 95% CI=1.05-1.39). Presence of abnormally contracting myocardial segments was associated with impaired mobility (1.40, 1.09-1.80) and with increased pain (1.30, 1.02-1.66). The presence of diseased coronary vessels was associated with pain (1.25, 1.06-1.46).

CONCLUSION

Myocardial dysfunction was generally associated with impaired quality of life. This has to be considered when assessing improvement of quality of life after medical or surgical treatment of AMI.

Role of coronary interventional procedures in improved postinfarction survival in the 1990s

The contribution of increased use of same-admission percutaneous coronary interventional procedures to recent improvements in hospital survival of patients with acute myocardial infarction (AMI) remains unclear. Patients with International Classification of Diseases codes for AMI (code 410), who were admitted to the emergency coronary care unit and underwent an initial episode of treatment, were studied over the 9-year period 1990 to 1998 (n = 2,628). Three triennia between 1990 and 1998 were compared. Trends in risk, the use of procedures, and hospital outcomes were analyzed. Hospital mortality was 33% lower (p <0.02) in the third triennium (5.8%) than in the earlier 2 triennia (8.7%), equivalent to an absolute reduction of 29 hospital deaths/1,000 patients treated. The lower hospital mortality was not due to: (1) shorter hospital stays (reduction in mortality was primarily in the first 3 hospital days), (2) treatment of lower risk subjects (a risk score based on age, gender, and presence of diabetes increased between the first and third triennia), or (3) use of in-hospital interventional procedures (although the use of percutaneous coronary intervention more than doubled in the third triennium, most procedures were performed in patients with a 1% risk of hospital death). We conclude from this study that there has been a substantial improvement over a 9-year period in early case fatality after AMI, but that this cannot be attributed to the increased use of in-hospital coronary interventions, which were largely performed on low-risk patients.

Prognosis of patients with a recurrent acute myocardial infarction before and in the reperfusion era--a national study

BACKGROUND

Patients with recurrent acute myocardial infarction (AMI) are at increased risk for morbidity and mortality. We compared the outcome of patients with recurrent AMI hospitalized in coronary care units in the prereperfusion and reperfusion eras.

METHODS

The study population comprised 2 large-scale cohorts with recurrent AMI: (1) 1415 (24%) of 5839 consecutive patients with AMI hospitalized in 1981 to 1983 (Secondary Prevention Reinfarction Israeli Nifedipine Trial [SPRINT] Registry) and (2) 1093 (25%) of 4317 patients with AMI from three national surveys performed in 1992 to 1996.

RESULTS

Patients in the 1990s had significantly lower rates of heart failure and cardiogenic shock. The 7-day mortality declined from 18% in 1981-1983 to 10% in 1992-1996 (adjusted odds ratio [OR] 0.57 [0.44-0.75]), the 30-day mortality rate from 26% to 16% (OR 0.56 [0.44-0.71]), and the 1-year mortality rate from 39% to 26% (adjusted hazard ratio [HR] 0.64 [0.54-0.75]), respectively. In the 1992-1996 cohort, the adjusted risk of 7-day, 30-day, and 1-year mortality for patients with recurrent AMI treated with thrombolysis in comparison to patients without thrombolysis was OR 1.69 (1.07-2.65), 1.52 (1.03-2.23), and HR 1.18 (0.90-1.55), respectively. The mortality rate among patients treated with early percutaneous transluminal coronary angioplasty/coronary artery bypass grafting was 3% versus 12% at 7 days (OR 0.36 [0.16-0.73]), 7% versus 18% at 30 days (OR 0.45 [0.25-0.77]), and 16% versus 29% at 1 year (HR 0.64 [0.46-0.96]), in comparison to patients without revascularization.

CONCLUSION

The prognosis of patients with recurrent AMI improved significantly during the reperfusion era. Although thrombolysis may have a limited therapeutic effect among patients with recurrent AMI, an interventional approach seems more appropriate when indicated. A randomized trial of thrombolysis versus early revascularization is needed in patients with recurrent AMI.

Trends in long-term survival after myocardial infarction: less favourable patterns for patients from deprived areas

OBJECTIVE

New treatments have improved the prognosis for patients with acute myocardial infarction. However, studies on long-term survival are not unequivocally in favour of an improved long-term prognosis. This study aimed to analyse trends in 3-year survival in relation to sex, age and socioeconomic level of residential area.

SETTING

The Malmö myocardial infarction register, Sweden.

PARTICIPANTS

All men and women in the city who, between 1978 and 1995, were admitted for a first acute myocardial infarction (n = 11 226).

MAIN OUTCOME MEASURES

Age-standardized 3-year survival rates.

RESULTS

Both 28-day and 3-year survival rates improved markedly during the study period. Age-standardized 3-year survival (per 100 patients) amongst men and women who survived 28 days increased, between 1978-81 and 1991-95, from 64 to 78 in men and from 66 to 77 in women, an annual increase of 1.4% (95% CI = 1.1-1.7) and 1.2% (0.8-1.5), respectively. There were marked differences in survival between residential areas with different socioeconomic circumstances. The 3-year survival rates amongst men correlated significantly with the socioeconomic circumstances in the areas expressed in terms of a socioeconomic score (men: r = 0.60, n = 17, P = 0.01; women: r = 0.37, P = 0.15). Trends tended to be less favourable in deprived areas.

CONCLUSION

Three-year survival after first myocardial infarction has continuously improved for men and women in all age groups. Prognosis was worse and trends tended to be less favourable for patients from deprived areas.

Electrophysiologic testing to identify patients with coronary artery disease who are at risk for sudden death. Multicenter Unsustained Tachycardia Trial Investigators

BACKGROUND

The mortality rate among patients with coronary artery disease, abnormal ventricular function, and unsustained ventricular tachycardia is high. The usefulness of electrophysiologic testing for risk stratification in these patients is unclear.

METHODS

We performed electrophysiologic testing in patients who had coronary artery disease, a left ventricular ejection fraction of 40 percent or less, and asymptomatic, unsustained ventricular tachycardia. Patients in whom sustained ventricular tachyarrhythmias could be induced were randomly assigned to receive either antiarrhythmic therapy guided by electrophysiologic testing or no antiarrhythmic therapy. The primary end point was cardiac arrest or death from arrhythmia. Patients without inducible tachyarrhythmias were followed in a registry. We compared the outcomes of 1397 patients in the registry with those of 353 patients with inducible tachyarrhythmias who were randomly assigned to receive no antiarrhythmic therapy in order to assess the prognostic value of electrophysiologic testing.

RESULTS

Patients were followed for a median of 39 months. In a Kaplan-Meier analysis, two-year and five-year rates of cardiac arrest or death due to arrhythmia were 12 and 24 percent, respectively, among the patients in the registry, as compared with 18 and 32 percent among the patients with inducible tachyarrhythmias who were assigned to no antiarrhythmic therapy (adjusted P<0.001). Overall mortality after five years was 48 percent among the patients with inducible tachyarrhythmias, as compared with 44 percent among the patients in the registry (adjusted P=0.005). Deaths among patients without inducible tachyarrhythmias were less likely to be classified as due to arrhythmia than those among patients with inducible tachyarrhythmias (45 and 54 percent, respectively; P=0.06).

CONCLUSIONS

Patients with coronary artery disease, left ventricular dysfunction, and asymptomatic, unsustained ventricular tachycardia in whom sustained ventricular tachyarrhythmias cannot be induced have a significantly lower risk of sudden death or cardiac arrest and lower overall mortality than similar patients with inducible sustained tachyarrhythmias.

Marked improvement in survival after acute myocardial infarction in middle-aged men but not in women. The Northern Sweden MONICA study 1985-94

OBJECTIVES

The aim of this study was to analyse time trends in survival after acute myocardial infarction with special emphasis on sex differences.

DESIGN

Within the framework of the population-based WHO MONICA Project, all acute myocardial infarction events were recorded in the age group 25-64 years in northern Sweden during the period 1985-94. All first-ever myocardial infarction patients were followed for information on vital status.

SUBJECTS

A total of 3397 men and 860 women with acute myocardial infarction, during the period between 1985 and 1994.

MAIN OUTCOME MEASURES

Case fatality rates after first-ever acute myocardial infarction.

RESULTS

When compared with the 1985-86 cohort, the age-adjusted odds ratio for death within 1 year after acute myocardial infarction was 0.59 (95% CI 0.46-0.76) in the 1993-94 male cohort but 0.99 (95% CI 0.61-1.60) in the female 1993-94 cohort. Corresponding age-adjusted proportions of death within 1 year were 33.3% and 22.9% in men and 27.5% and 27.3% in women in 1985-86 and 1993-94, respectively. The odds ratio for 3-year case fatality amongst those who survived the first 28 days was 0.34 (95% CI 0.21-0.55) in 1991-92 compared with 1985-86 in men and 0.91 (0.43-1.94) in women.

CONCLUSION

Both short- and long-term survival after AMI have improved markedly in men over the last decade. There is a disturbing sex difference in that, during the same period, survival in women with AMI has not improved at all. This sex difference was not explained by differences in conventional prognostic factors.

Biobehavioral factors in the context of ischemic cardiovascular diseases

OBJECTIVE

We set out to examine the development of current thinking on the relationship between behavioral factors and ischemic heart disease, with the latter being viewed as an epidemic.

METHODS

The present work is a nonsystematic review of the subject.

RESULTS

Atherogenic components of the coronary-prone or type A behavior pattern (TABP), including hostility, cynicism, and suppression of anger, as well as stress reactivity, depression, and social isolation, are emerging as particularly significant behavioral characteristics, although their pathophysiology is not yet fully understood. Effective patient management, particularly for lifestyle modification, requires an appreciation of an individual's stage in their readiness to change.

CONCLUSION

The control and prevention of cardiovascular diseases depend on a multidisciplinary approach that recognizes the importance and intricacies of lifestyle behaviors.

Temporal trends in event rates after Q-wave myocardial infarction: the Framingham Heart Study

BACKGROUND

Short-term (<30 day) mortality after Q-wave myocardial infarction (MI) has declined over the decades, but it is unclear if rates of long-term sequelae after Q-wave MI have improved.

METHODS AND RESULTS

In 546 Framingham Heart Study subjects (388 men with a mean age of 60 years; 158 women with a mean age of 69 years) with an initial recognized Q-wave MI from 1950 through 1989, we investigated time trends in risk for coronary heart disease (CHD) death (n=199), all-cause mortality (n=287), reinfarction (n=108), and congestive heart failure (CHF; n=121). With 1950 through 1969 as the reference period, hazards ratios (HRs) for these outcomes were determined for the 1970s and 1980s. Trend analyses across the 3 time periods were performed for each outcome. Compared with the 1950 through 1969 reference period, the HRs for CHD death were lower in subsequent decades (1970 through 1979: HR, 0.69; 95% CI, 0.49 to 0.98; 1980 through 1989: HR, 0.48; 95% CI, 0.33 to 0.72). All-cause mortality also declined (1970 through 1979: HR, 0.70; 95% CI, 0.0.52 to 0.94; 1980 through 1989: HR, 0.59; 95% CI, 0.43 to 0.81). There were no significant temporal changes in the risks for recurrent MI or CHF.

CONCLUSIONS

Substantial reductions in risk of CHD death and all-cause mortality occurred over these 4 decades, coincident with improvements in post-MI therapies. The absence of a decline in CHF incidence may be due to improved post-MI survival of individuals with depressed left ventricular systolic function who are at high risk for CHF.

Thrombolysis with saruplase versus streptokinase in acute myocardial infarction: five-year results of the PRIMI trial

BACKGROUND

Short-term safety and efficacy of thrombolysis with saruplase in acute myocardial infarction have been shown in several trials. To assess long-term outcome of patients treated with saruplase or streptokinase for myocardial infarction, a 5-year follow-up of patients included in the Pro-Urokinase in Myocardial Infarction Trial was performed.

METHODS AND RESULTS

Follow-up data are available from 8 centers on 255 (92.4%) of 276 included patients. The 5-year mortality rate was comparable with 20.8% of patients in the saruplase group and 16.9% in the streptokinase group (odds ratio 1.29, 95% confidence interval 0.69 to 2.42). In both groups, a considerable number of fatal cardiovascular events occurred more than 1 year after study inclusion. Rates of percutaneous transluminal coronary angioplasty and coronary artery bypass grafting were comparable in both groups. Reinfarction within 5 years occurred in 19.0% of patients in the saruplase group and tended to be less frequent at 10.8% after streptokinase treatment (odds ratio 1.94, 95% confidence interval 0.98 to 3.84). In both groups, the majority of reinfarctions took place more than 3 months after study inclusion. The 5-year stroke rate was 3.6% and 7.2% in the saruplase and streptokinase groups, respectively (odds ratio 0.49, 95% confidence interval 0.16 to 1.47). Subjective symptoms of heart failure and angina pectoris were comparable in both groups.

CONCLUSIONS

Our data are consistent with a similar long-term outcome for patients treated with saruplase or streptokinase. Despite the low-risk profile of the patient cohort, there were considerable adverse event rates over a 5-year period.

[Changes in hospital mortality from acute myocardial infarction during the last 15 years. The impact of reperfusion treatments]

INTRODUCTION AND OBJECTIVES

There are not any conclusive data about the changes in in-hospital mortality in a non-selected series of patients admitted with acute myocardial infarction in different periods of time. We studied the in-hospital mortality of three extensive series of patients admitted to our Coronary Care Unit during different periods of time, the influence of reperfusion methods and their early application, as well as the changes in baseline characteristics of the three populations studied.

METHODS

The in-hospital mortality of 1,858 consecutively-admitted patients during three different periods of time (1983-1986, 1992-1994, and 1995-1998) were studied. The demographic data, the previous history and risk factors, the evolution during the acute phase and the treatment prescribed with special attention to the reperfusion methods applied and the delay on its administration were compared.

RESULTS

The differences in the baseline characteristics of the populations studied are described. In the two groups of the nineteen-nineties, an increase in the age and in the percentage of women, diabetics and hypertensives was compared. As for the characteristics of acute myocardial infarction, an increase of patients in Killip class 3 and 4 stands out besides other changes. Fibrinolitic treatment decreased during the third period due to the increment in primary angioplasty. There were no significant differences in hospital mortality among the three series studied. The treatment with thrombolysis and primary angioplasty during the first two hours showed a significant independent reduction of mortality.

CONCLUSIONS

The early application of thrombolysis and primary angioplasty showed an independent reduction of the hospital mortality in our study. Nevertheless the non-adjusted mortality rate did not show any change during the last 15 years.

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.

A two-decades (1975 to 1995) long experience in the incidence, in-hospital and long-term case-fatality rates of acute myocardial infarction: a community-wide perspective

OBJECTIVES

The purpose of the present study is to describe changes over two decades (1975 to 1995) in the incidence, in-hospital and long-term case-fatality rates associated with acute myocardial infarction (AMI) from a multihospital community-wide perspective.

BACKGROUND

Despite the magnitude of, and mortality associated with acute myocardial infarction (AMI), relatively limited population-based data are available to describe recent and temporal trends in the attack and case-fatality rates associated with AMI from a representative population-based perspective.

METHODS

The community-based study included 5,270 residents of the Worcester, Massachusetts, metropolitan area hospitalized with confirmed initial AMI in all metropolitan Worcester, Massachusetts, hospitals (1990 census population = 437,000) in 10 one-year periods between 1975 and 1995.

RESULTS

The age-adjusted incidence rates of initial AMI increased between 1975 (244 per 100,000) and 1981 (272 per 100,000), after which time these rates declined through 1995 (184 per 100,000). The crude and multivariable-adjusted in-hospital case-fatality rates exhibited a consistent decline between 1975/1978 (17.8%), 1986/1988 (17.0%) and 1993/1995 (11.7%). Although there were no statistically significant differences in the unadjusted long-term case-fatality rates of discharged hospital survivors over the periods under study, declines in the multivariable-adjusted risk of dying within the first year after hospital discharge were observed between the earliest and most recently discharged patients with AMI.

CONCLUSIONS

The results of this population-based study of patients with validated initial AMI provide encouragement for efforts directed at the primary and secondary prevention of AMI given declining incidence and case-fatality rates.

Relationship of therapeutic improvements and 28-day case fatality in patients hospitalized with acute myocardial infarction between 1978 and 1993 in the REGICOR study, Gerona, Spain. The REGICOR Investigators

BACKGROUND

The aim of this study was to analyze 28-day case fatality trends between 1978 and 1993 among hospitalized acute myocardial infarction (AMI) patients in the REGICOR registry, Gerona, Spain, and relate them to thrombolytic and antiplatelet drug use and changes in patient characteristics.

METHODS AND RESULTS

A total of 2053 consecutive patients 25 to 74 years of age with a first Q-wave AMI admitted to the reference hospital between 1978 and 1993 were registered. Clinical characteristics and patient management were recorded. Four 4-year periods were considered: 1978 to 1981, 1982 to 1985 (prethrombolytic therapy), 1986 to 1989 (thrombolytic and antiplatelet drugs introduced), and 1990 to 1993 (thrombolytic and antiplatelet drugs used routinely). The end point was death at 28 days. Case fatality at 28 days decreased 6% per year between 1978 and 1993. A logistic model adjusted for comorbidity and severity showed the last 3 periods to present a steep decrease in the OR of death at 28 days: 0.86 (95% CI, 0.52 to 1.41), 0.59 (95% CI, 0.35 to 0.99), and 0.40 (95% CI, 0.24 to 0.69), respectively, compared with the first period. After 1986, 85.7% of the 112 lives saved could be attributed to the use of antiplatelet and thrombolytic drugs. Adjusted relative risk reduction was 56.0% for antiplatelet drugs, 34.1% for thrombolytic drugs, and 77.9% for the 2 combined.

CONCLUSIONS

Our results strongly suggest that new therapies introduced since 1986 have contributed to the decrease in 28-day case fatality of patients admitted with a first Q-wave AMI. This decrease could be attributable mainly to the use of antiplatelet and thrombolytic drugs. These findings should encourage the routine use of thrombolytic and antiplatelet drugs and particularly their combination in the acute phase of AMI.

Prognostic value of dipyridamole thallium imaging after acute myocardial infarction in older patients

OBJECTIVE

To assess the utility of intravenous dipyridamole thallium testing for predicting major cardiac events following acute myocardial infarction in older patients.

DESIGN

Prospective cohort study with a median follow-up of 18 months.

SETTING

A university teaching hospital.

PARTICIPANTS

73 patients aged 65 years and older with enzymatically confirmed acute myocardial infarction (mean age 75 years, 56% male, 71% white).

MEASUREMENTS

All patients underwent a detailed clinical assessment, an echocardiogram, and an intravenous dipyridamole thallium stress test before hospital discharge. The study endpoint was death or nonfatal reinfarction during the follow-up period.

RESULTS

Overall, 24 patients (33%) died or developed recurrent myocardial infarction during follow-up. Among 44 patients with a reversible thallium defect, 19 (43%) reached the study endpoint, compared with only five of 29 patients (17%) without reversible ischemia (P = .04). On multivariate analysis, independent prognostic variables included non-use of aspirin at hospital discharge (P = .002), decreased left ventricular systolic function (P = .009), non-use of a beta-blocker at hospital discharge (P = .013), and reversible ischemia on thallium scintigraphy (P = .025). The relative risks for death or reinfarction associated with non-use of aspirin, non-use of a beta-blocker, left ventricular dysfunction, and reversible ischemia were 2.65, 2.39, 2.01, and 2.51, respectively. Patients with three or four of these risk factors had an 83% probability of death or reinfarction, compared with 41% in patients with two risk factors and 6% in patients with one or no risk factor (P < .001).

CONCLUSION

Intravenous dipyridamole thallium imaging provides independent prognostic information in older patients with acute myocardial infarction. Moreover, the combination of clinical, echocardiographic, and dipyridamole thallium variables effectively stratifies older postinfarction patients into high-, intermediate-, and low-risk categories for death or recurrent myocardial infarction.

Reappraisal of the Norris score and the prognostic value of left ventricular ejection fraction measurement for in-hospital mortality after acute myocardial infarction

A retrospective analysis of all patients admitted to an academic suburban hospital with a diagnosis of acute myocardial infarction was performed to evaluate the usefulness of the addition of left ventricular ejection fraction to the Norris score in predicting in-hospital mortality. Although both the Norris score and ejection fraction predicted mortality in univariate analysis, multivariate logistic regression analysis revealed only 3 independent variables: ejection fraction, age, and admission systolic blood pressure, which are incorporated to form a new simplified scoring system.